The sad story of the death of diabetic Mrs. Maureen Pineki is the subject of an even sadder report released by the Auckland DHB today. The reason it is sad is because it comes to almost the entirely wrong conclusions about this poor lady’s death. The report urges:
Review systems to ensure timely testing, especially of samples prone to rapid chemical breakdown.
Give more explicit guidance on response to critically abnormal results.
THE MEDICAL CENTRE:
Review systems for contacting patients with critically abnormal results.
Talk to District Nursing Service and Diabetes Centre to improve co-ordination of patients who repeatedly miss appointments.
ST JOHN AMBULANCE SERVICE:
Write guidelines on communicating with GPs when patients seen but not taken to hospital.”
However, the actual story of this lady tells another tale. The story starts with Mrs. Pineki having “limited understanding of her diabetes” and repeatedly canceling Diabetes Centre appointments “because of pain and mobility difficulties”. This is therefore the story of a lady severely at risk for diabetic complications – ignorance, immobility and insulin are also known as the trio of death.
On September 7th she phones her GPs practice nurse and tells her of hypoglycaemic (low blood sugar) episodes. Inexplicably the nurse orders a routine home blood glucose instead of insisting Mrs. Pineki see the doctor immediately. She does not tell the doctor.
I hope she has a seriously good reason for doing this because this seems to me to be a major error of judgement; the sort the nursing council take a very dim view of. One does not order home blood tests for hypoglycaemia – one tells the patient to come in immediately or go to hospital. Anybody see any mention of this in the recommendations above? No, nor do I. Just some waffle about “co-ordination” and “systems”.
On September 8th, a Labtest tech takes some blood from this “routine” patient. Because the test is a routine home sample, it is done as a “batch”, not as an urgent result. The result is then faxed through to the GP, as it is very abnormal. Labtests should probably have phoned the GP for an unexpected abnormal like this. Weirdly, Labtests are not criticised for not phoning the result through. I say weirdly, because it is clear from the article’s tone that the Herald is trying to make this story look like a Labtests botch up, whereas Labtests contribution to this poor lady’s demise is very minor.
Instead of the absent phone call, Labtests are criticised for the speed of their processing (a fair, but somewhat irrelevant, comment). They are also criticised for their “guidance on response to critically abnormal results”, which is simply absurd. This is a poorly controlled diabetic lady with a hypoglycaemic result. Any GP with a degree not derived from K-mart would know that this lady needs urgent assessment. Frankly, Labtests could have written “we are incompetent and you can’t trust this result” on the form and it would still be incumbent on the GP to arrange immediate assessment. Explicit guidance is not required and a request for it is just so much drivel.
The GP’s response to this critically abnormal result?
“Mrs Pineki’s GP tried once to phone her, but got no answer.”
The DHB recommendation?
“Review systems for contacting patients with critically abnormal results.”
MacDoctor’s recommendation is a steel toecap to the rear-end of both said GP and said nurse. Twice.
That same morning the GP and nurse were sitting on their hands, an ambulance was called for Mrs. Pineki following a fall. I have simply no idea what the ambulance officer’s rationale was for not transporting an immobile insulin-dependent diabetic to hospital for a review. His lack of judgement here is rivaled only by the the GP’s practice nurse. And, of course, the DHB, whose recommendation for the ambulance service was “Write guidelines on communicating with GPs when patients seen but not taken to hospital”. Unbelievable.
This lady was a very poor risk patient with extremely poor compliance who is likely to have expired from her diabetes sooner, rather than later. But this does not excuse the extremely poor decision making of the nurse, GP and ambulance officer involved. Nor does it excuse the Auckland DHB whose report can only be described with the adjectives “wishy” and washy”. I suspect this episode will be winging its way to the HDC by now and, from there, to the nursing and medical council.
And, once again, I have to award the crap journalism of the week prize to the Herald for attempting to castigate Labtests again, despite their extremely peripheral role in this. Congratulations, guys, MacDoctor would like to recommend steel toecap therapy to your journalist as well.