Woman ‘disappointed’ by Manukau DHB counties died of sepsis from pressure injuries

A woman in her sixties developed sepsis from pressure injuries and died after she was “disappointed” by staff at the Manukau County Board of Health, according to an investigation.

A report released by the Health and Disability Commissioner on Monday found that DHB violated the patients’ rights code for failures in the care provided to the woman, known as Ms. A.

Ms A was initially admitted to the hospital in 2016 after suffering a severe stroke, with a history of ischemic heart disease and type 2 diabetes. Her prognosis was “poor,” according to the report.

Ms. A was assessed as being at high risk of developing pressure injuries due to her age, increased BMI, type 2 diabetes, and the fact that she was bedridden and developed pressure injuries three days after admission.

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Pressure injuries (bedsores) usually develop on “bony” parts of the body due to sustained pressure or pressure combined with friction.

Ms. A spent several weeks in the hospital for four months and was discharged to a nursing home for ongoing care in between.

The HDC found that the documentation in Ms. A’s nursing care plan at DHB was “inconsistent” and did not reflect the “significance” of her pressure injuries.

The injuries also did not appear to have increased medical staff “as expected,” he found.

Ms. A had been given an air mattress to help prevent pressure injuries, but the mattress was not working properly and staff did not investigate or escalate the problem, according to the report.

Ms. A’s pressure wounds and general condition deteriorated, and she was diagnosed with sepsis, also known as blood poisoning, from an infected pressure injury, which was odorous and “oozing”.

Surgery was performed to try to remove the infected tissue, but she continued to deteriorate and palliative care was started. She died 10 days after surgery.

Former Health and Disability Commissioner Anthony Hill criticized the delay in assessment and mismanagement of Ms A’s risk factors, saying “closer monitoring” of her injuries was necessary.

Hill was also instrumental in that wound care or palliative care specialists were not involved in her care earlier, and that the hospital discharged her to the nursing home without providing enough information about the status of her wound or instructions to monitor her injuries. .

“In my opinion, [the woman] various aspects of the care provided to you by numerous members of the [the DHB].

“As a consequence, his pressure injuries were not properly managed and opportunities were missed to prevent further pressure injuries from developing,” he said.

Hill said it was important to ensure that a patient’s end-of-life care is provided in a way that mitigates “disturbing” circumstances for both the patient and his family, and “in this case, that did not happen.”

He recommended that DHB apologize to the woman’s family and improve its processes around pressure injury care.

Dr. Peter Watson, Manukau Counties DHB Medical Director, said the DHB accepted the findings and “sincerely regrets that we have not provided the high level of care that we expect of ourselves.”

The DHB apologized and extended its “deepest condolences” to Ms A’s family, Watson said.

It also introduced a series of measures in the wake of Ms A’s case that “would significantly reduce the likelihood of a similar incident happening again,” he said.

These include individual pressure injury education sessions, which address skin assessment and risk level assessment for patients, and weekly pressure injury management audits.