Woman forced to wait five hours for heart attack diagnosis

A woman suffering a heart attack had to wait five hours for a diagnosis after healthcare staff failed to acknowledge her symptoms, the health and disability commissioner has found.

The woman, in her 50s, presented to a Pegasus health facility with symptoms of a heart attack.

Health and Disability Commissioner Morag McDowell said doctors and nurses focused for five hours on the possibility that she was suffering from a negative reaction to an antibiotic, before finally diagnosing her with a heart attack .

The woman had a clinical history that put her in the high-risk category for ischemic heart disease, but staff still did not recognize a heart attack, McDowell said.

McDowell concluded that Pegasus Health violated the Health Services Consumer and Disability Code of Rights for failing to provide services with reasonable care and skill.

She found that Pegasus Health had failed to properly triage the woman and that medical staff had failed to correctly identify her symptoms or reconsider the labor diagnosis.

McDowell also concluded that the conversations between the nurses were not documented, the woman’s symptoms were not recorded in Pegasus Health’s electronic records, and the nursing staff did not refer care to doctors.

“I am particularly concerned that the woman’s chest pain was known to the nursing staff, but apparently not to the two doctors who examined her. This raises questions, not only about the quality of the medical examinations, but about the level of communication between nursing and medical staff.

“Given the whole context, a cardiac cause for the woman’s presentation should have been considered. This may have prompted further questioning of the woman, an earlier ECG, and possibly earlier diagnosis and treatment. “McDowell said.

McDowell said the blame lies with Pegasus Health following an investigation that identified deviations from the standard of care by staff.

“Pegasus Health has a responsibility, through its people and processes, to provide a reasonable standard of care to consumers. They must also have a system that supports good clinical decision-making, as well as communication and cooperation between different individual health providers.

“Throughout the woman’s presentation to Pegasus Health, several staff demonstrated a lack of effective written and verbal communication that was not supported by Pegasus Health’s expectations for staff adherence to standards. and relevant policies.

“Overall, the gaps that have been identified in the care provided to the woman highlight poor teamwork and a lack of critical thinking among several staff members,” McDowell said.

The HDC recommended that Pegasus Health write a letter of apology to the woman, provide evidence of attendance of all triage nurses at the College of Emergency Nurses New Zealand national triage course, and use this investigation as a case study. .