A fatal overdose wasn’t reported quickly enough, leading to a disabled woman’s death.
A woman with multiple sclerosis died in a care facility after a nurse gave her the wrong medication and failed to properly report it, delaying help until it was too late.
Details of the woman’s 2017 death can only be made public now, after a complaint and two-year investigation by the Ombudsman.
Previously, the Ministry of Health refused to release any information about the death and the investigation undertaken by the care home, citing privacy reasons.
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But following the Ombudsman’s intervention it was forced to release a summary of events, including the fact the registered agency nurse on duty did not follow basic nursing protocols and was reporting to the Nursing Council.
It also revealed that ACC had reported the incident to the Director-General of Health on the basis it presented a degree of “risk of harm” to the public.
The summary states how on the night of 19 December, the nurse administered the wrong medication to a 46-year-old woman with end-state multiple sclerosis, at the St John of God care facility in Karori, Wellington.
The medication had been intended for another resident. The woman who received it instead died the next day, after being transferred to an intensive care unit at a hospital.
An investigation found the primary cause of the medication error was the performance of the agency nurse. When she reported the medication error to a supervising nurse off site, the agency nurse did not accurately describe all of the medication, or the doses wrongly administered.
“Consequently, the potential impact of the medication error was not fully appreciated, and an ambulance was not called for at that time,” the summary said.
“Instead [the woman] was monitored, and an ambulance was only called when her condition deteriorated.”
As a result of the investigation, senior executive made a “comprehensive” series of recommendations around the administration of medication, staff communications and orientation, and access to medical staff and staffing at the facility.
The facility took steps to implement the recommendations, and reported the error to the Nursing Council and the ministry.
After the receipt of that notification and the ACC notification, the ministry closed the reports on the basis no further action was necessary.
The death remains under investigation by the Coroner.