Woman, 96, died of sepsis after test results went unchecked

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Norma Barton died in Hawke’s Bay Hospital in November, 2018.

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Norma Barton died in Hawke’s Bay Hospital in November, 2018.

A 96-year-old woman died from sepsis after her GP and nurses failed to check test results that showed she had a potentially deadly infection in a poorly treated wound.

Norma Barton, died on November 22, 2018 at Hawke’s Bay Hospital from sepsis that developed in a cut she suffered to her lower leg when she fell in her home a month earlier.

She was treated at the hospital and had her wounds dressed.

In the weeks after she was discharged from hospital Barton was visited at home by the district nurse team. Because the team works on rotation, it was usually a different nurse that saw her each time.

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On November 11, one of the nurses noticed that Barton’s wound was smelling bad, so the nurse took a swab from the wound and sent it for testing.

The test was undertaken the next day and revealed a “heavy growth of streptococcus group A (pyogenes) and heavy growth of staphylococcus aureus”.

Tests revealed Barton had a “heavy growth of staphylococcus aureus” in her wound. (File photo)

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Tests revealed Barton had a “heavy growth of staphylococcus aureus” in her wound. (File photo)

Staphylococcus aureus can be deadly if it enters the bloodstream.

The results were reported to Barton’s GP.

The GP visited Barton on November 13, but was not aware of the test results and did not inspect the wound.

Different district nurses visited Barton at home on November 15 and 19 to attend her wound. When a nurse visited on the morning of November 22 she found Barton in a distressed state. She was taken to hospital but died that day.

Barton’s death was referred to the coroner’s office. Coroner Alexander Ho made findings on Barton’s death after seeking expert advice from Dr Lynette Murdoch, an expert in GP related matters, and from nurse practitioner, Julie Betts, in relation to the level of care Barton received from her GP and the district nurses.

In findings recently made public Ho said it was clear that neither the GP nor the district nurses had reviewed the test results. This was due to various factors, including that the GP hadn’t been aware that a test had been ordered, and when the test result was reported to the GP they appeared to have overlooked it.

Ho noted that the nurse who ordered the test did not record in the clinical notes that a test had been ordered, meaning other nurses didn’t know a test result was outstanding.

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He also noted that the electronic system used by the district nurses did not notify them when test results were completed. In order to see if the results were available, the nurses had to search the system to find them.

And he said the different ways in which the nurses had recorded details of Barton’s wound meant it was difficult for them to track how it was progressing.

He also said that failing to change the wound’s dressing between November 15 and 19 was inappropriate.

He said there were missed opportunities to closely monitor Barton’s wound and that there was confusion among the nurses and GP whether the district nursing team or the GP, or both, were responsible for the care of Barton’s wound.

This confusion extended to the experts and organisations Coroner Ho consulted on the matter, he said.

He recommended that in situations where the same professional is not attending consecutive visits of a patient then objective information about a wound should be recorded in a consistent manner.

He also recommended that Te Whatu Ora districts have clear policies, procedures and guidelines in place setting out the process for district nurses to follow when they submit a diagnostic test on behalf of an authorised provider, including the communication required between the nurses and the authorised provider that a test has been submitted.

“It is apparent from the evidence I received that there was significant confusion between the district nurse team and the GP about who was responsible for Mrs Barton’s wound care and the points at which responsibility switched or needed to be jointly assumed,” he said.

Ho said the Te Whatu Ora districts should consider implementing a system that meant district nurses received electronic notification of test results, and encouraged Te Whatu Ora Health New Zealand and other stakeholders “to continue to work towards effective ways of ensuring that patient records are appropriately accessible and/or easily able to be shared among health professionals”.

Barton’s family could not be reached for comment.

Te Whatu Ora Health New Zealand and Te Whatu Ora Te Matau a Māui Hawke’s Bay have been contacted for comment.

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