A woman in her 50s died of a cardiac arrest hours after being sent home from the emergency department (ED) at Palmerston North Hospital with chest pain.

The care provided to the woman in 2018 was so concerning it was referred to the Health and Disability Commissioner [HDC] by the coroner.

The woman had been experiencing chest pain for two days when she presented at the public hospital ED via ambulance, and although she had no history of a heart condition, three of her siblings had suffered a heart attack in their mid-50s.

After five hours, two electrocardiograms [ECGs], and two tests for a protein found in the blood when the heart muscle has been damaged due to a heart attack, Mrs A was discharged from the ED.

She suffered a cardiac arrest that night at home and died.

An investigation by Deputy Health and Disability Commissioner Deborah James found MidCentral DHB, now Te Whatu Ora - Health New Zealand MidCentral District, breached the woman’s right to services of an appropriate standard.

Mrs A’s husband and daughter, Mr A and Ms C, told the HDC “a sequence of unfortunate events” led to their wife and mother’s death, which they felt could have been avoided if sufficient due diligence had been carried out.

Deputy Health and Disability Commissioner Deborah James.

On the day she arrived at the hospital about 7am, Mrs A was triaged by a nurse who noted chest pain and left arm pain and weakness throughout the night but that she was currently pain-free.

The nurse noted breathlessness at 5am that day and the ambulance care summary noted the family history of heart attacks and that the patient was on medication for high cholesterol.

An emergency medicine specialist, Dr B, noted Mrs A’s ECG was “unremarkable” and allocated the case to a final-year medical student, Mr D, to examine Mrs A.

Mr D noted Mrs A’s risk factors as a history of smoking, high cholesterol, and a family history of cardiovascular disease.

Mr D, a trainee intern, also noted on examination the woman had an irregular heart rate and a heart murmur.

He told this to Dr B, who told the HDC he saw a cardiology consultant, Dr E, and a cardiology registrar, Dr G, as they were reviewing another patient in the ED at that time.

Dr B said he spoke with Dr E and his team about Mrs A, with a view to asking them to review Mrs A and admit her to the cardiology service.

“I have a clear memory of [Dr E] and his team then speaking amongst themselves in order to triage their patient load that day and, as a group, deciding not to see [Mrs A] at that time because of the lack of blood results.”

Dr B said he was not surprised by this decision, because in his experience it was a relatively common occurrence for review requests to cardiology to be declined, and he was aware that cardiology was operating under significant resource constraints at the time.

He told the coroner that cardiology did not review Mrs A at the time of his request, instead recommending waiting for a standard emergency department evaluation using the Accelerated Chest Pain Pathway [ACPP], which includes ECG and troponin [protein] testing.

The HDC said there was no record or notes of Dr B’s discussion with Dr E or request for review, though Dr B said it wasn’t common practice for him to make a note of such a discussion.

Dr E said it was standard practice that an oral or written request was made for admission and that because the first troponin measure was not known, he decided to wait for a consultation request.

Dr E acknowledged later that he should have documented his conversation with Dr B in the clinical notes at the time, as would have been his usual practice, but said on reflection the circumstances were “not normal and at that time [he] did not think of doing that”.

“When I learned from [Dr B], three weeks after the death of [Mrs A], that she had positive troponins and an episode of a chest pain in the ED before her discharge home, I realised that there was an issue.”

There were also discrepancies about when the discussion took place but at 8.39am Mrs A’s first blood test came back showing an elevated troponin level and Dr B said he asked the trainee intern to make another request of cardiology for review.

Mr D said that wouldn’t be normal practice and he made no reference to it in his statement to the HDC.

Because no notes were taken, it was unclear who ordered a repeat blood test but this was done around 10am, at the same time Mrs A began experiencing chest pain again and was given medication by a nurse.

However, Dr B said he was not made aware of the pain.

When the second blood test showed elevated troponin again, Dr B said cardiology would have been contacted again by Mr D - but the HDC found no evidence of this.

Dr B said the repeat discussion resulted in cardiology directing “us to refer [Mrs A] to outpatient clinic for follow-up testing as a routine chest pain patient who had two troponins, both elevated but not rising”.

Mrs A was discharged at 12.18pm.

In finding Te Whatu Ora in breach of the Code of Health and Disability Services Consumers’ Rights, James said there were several instances of poor documentation by a number of hospital staff who were involved in Mrs A’s care, and practices in place at the time resulted in her receiving less assessment and fewer clinical investigations than appropriate, based on her clinical results.

“This case highlights the importance of clear and unambiguous communication between clinicians, as well as the critical importance of documentation of any such communication,” she said.

The deputy commissioner considered Te Whatu Ora Te Pae Hauora o Ruahine o Tararua MidCentral’s system allowed for clinical decisions to be made with too much weight given to resourcing capacity considerations, and not enough to the clinical needs of patients.

James also made adverse comment about Dr B, but did not find him in breach of the Code.

“While the ED specialist had identified that the woman should have been considered for admission, he did not take sufficient steps to ensure this happened”

She said his documentation of the woman’s care and discussions did not meet the expected standard.

James recommended Te Whatu Ora and Dr B apologise to the woman’s family and that the event be used to train staff on the importance of adequate documentation, effective communications, and referral processes for specialist services.

Natalie Akoorie is the Open Justice deputy editor, based in Waikato and covering crime and justice nationally. Natalie first joined the Herald in 2011 and has been a journalist in New Zealand and overseas for 27 years recently covering health, social issues, local government, and the regions.