The Deputy Health and Disability Commissioner has noted several failings that led to a man's death following an incorrect intubation – where a tube was inserted into his oesophagus instead of his trachea.
The error was not picked up for 15 minutes and, during that time, the man sustained a fatal brain injury.
Following a successful intubation, the man was placed in the intensive care unit for 15 days until his ventilation was removed and he died.
Now, following an investigation by the commissioner, Dr Vanessa Caldwell, it's been revealed the Hawke's Bay District Health Board (now Te Whatu Ora Te Matau a Māui) breached the Code of Health and Disability Services Consumers’ Rights.
The breach relates to its failure to provide services of an appropriate standard.
The man had been taken to Hawke's Bay Fallen Soldiers' Memorial Hospital for the treatment of two wounds to his back. As the impact of his wounds was unknown, a decision was made to perform a series of CT scans to check for internal injuries.
But because of his agitated state, the man was anaesthetised to be able to insert a breathing tube into his trachea.
During the procedure, performed in the emergency department, the tube was incorrectly placed in the man's oesophagus instead of his trachea.
Dr Caldwell identified several factors that contributed to the man's death, including a lack of standardised equipment, superior equipment not being made available and staff members believing that certain equipment was not functioning properly.
"I am critical that Te Whatu Ora did not ensure that there was suitable equipment for difficult airway management available in the ED, and that there was a lack of standardised equipment across the hospital," she said.
"I am also critical that the staff were not made aware of the equipment that was available, and that the staff were not reassured that the equipment was functional and being maintained adequately. In my view this contributed to the delay in diagnosing the oesophageal intubation."
However, in response to his whanau questioning consent not being obtained prior to the procedure, Dr Caldwell said that "given the emergency situation following [the man's] arrival in the ED, the decision to intubate was necessary, and in these circumstances it is reasonable that [his] consent could not be sought at the time."
Te Whatu Ora Te Matau a Māui has made several changes since the death, including purchasing new equipment and forming an airway committee comprising anaesthetics, ICU, ED and ear, nose and throat departments. The committee has reviewed and standardised airway equipment between ED, ICU and the operating theatre.
It has also established an equipment testing and checking regime, developed difficult intubation, and airways checklists, and reviewed the ED red alert response. Interdepartmental simulation training has also been put in place.
Dr Caldwell also recommended Te Whatu Ora provide a written apology to the man's whānau and put in place regular training for all current staff in ED and ICU on the standard practice in emergency airway management.
