Latest news with #VanessaCaldwell
Otago Daily Times
2 days ago
- Health
- Otago Daily Times
Dead teen's family told they had to get his body back to hometown
A teenager's death from complications after surgery revealed troubling gaps in complex care across the South Island at the time, the Health and Disability Commissioner says. The 19-year-old died in 2015 in circumstances where his family never had the chance to say goodbye. In addition, within minutes of them being told the teen was 'brain dead' they were asked if they would like to donate his organs. The teen's family was also told by a social worker that it was up to them to organise transportation of their son's body back to where they lived. A complaint to the coroner was referred to the HDC. In a decision released today, Deputy Health and Disability Commissioner Vanessa Caldwell found that Health NZ breached a section of the Health and Disability Services Consumers' Rights code, around gaps in information and delays associated with the air retrieval team. She was also critical of why alternative transport options had not been considered for the teen who had been taken to and from various hospitals for specialised treatment and care. Health NZ had sincerely apologised for its departure from the standard of care. Death unexpected The teen died unexpectedly after suffering complications related to a postoperative wound infection. He had undergone elective surgery at a South Island tertiary hospital for the removal of benign tumours from his nervous system. Caldwell said it was complicated by postoperative infection and meningitis which required further hospitalisations at a secondary hospital and later, another tertiary hospital. The postoperative infection was treated successfully, but the teen continued to suffer complications. He was later re-admitted to hospital with ongoing headaches and vomiting but a further lumbar puncture was not done because of concerns over how the teen was coping. A decision was made to send him back to the tertiary hospital where the initial surgery was done, to insert a shunt to drain excess fluid surrounding his brain and spinal cord. Because he was considered 'neurologically stable' and there were operational delays by the air retrieval team, a decision was made to delay the transfer for a few days. While waiting, he collapsed and had a cardiac arrest. The neurosurgeon's team rushed to the hospital where he was and administered critical care but he continued to deteriorate. He was transferred back to the tertiary hospital but certified brain dead after he arrived. Outcome linked to delayed transfer Caldwell said there was dispute as to whether he would have benefited from an earlier transfer. Caldwell acknowledged the family's concerns regarding the neurosurgical care provided but she considered that Health NZ provided him with a reasonable standard of care. She said the teen's poor outcome was attributed to the delay by the air retrieval team in transferring him. However, his care was triaged and prioritised appropriately based on the information available to the team at the time, Caldwell said. An initial referral was made at 6pm and triaged by the flight coordinator with input from a senior medical consultant. Because he was considered neurologically stable and the air retrieval team was scheduled to return from another job, a collective decision was made to depart the next morning, with an expected arrival back by early afternoon. The air retrieval team stated that this was the nature of prioritisation under a resource-constrained environment, Caldwell said. On the morning of the scheduled transfer, a further delay occurred because a flight nurse had to stand down for rest after attending an overnight retrieval. Efforts were made to contact other flight nurses and intensive care nurses who were not on the roster, but none were available. At the time, the air retrieval team had been experiencing increased demands but nurse staffing levels had not increased, Caldwell said. She said between March 2015 and March 2016, there were 60 occasions when a second retrieval had been requested but could not respond. An expert's advice was that road transfer could have been considered as an alternative option but the surgeon disagreed. He said that in his experience, moving patients by road had led to a negative outcome, because of the lack of ambulance staff and inability of the ambulances to cross boundaries between healthcare districts at the time. List of changes made since The air retrieval team had since made a comprehensive list of changes, including additional nursing staff, and has introduced improved communication and operational guidelines. Caldwell said a 'significant number of changes' to the health sector had since been made. She said the amalgamation of the 20 district health boards into Health NZ had created better service integration, sharing of resources, and communication between treating teams. Health NZ Southern and Health NZ Waitaha Canterbury districts were asked to provide a formal written apology for the breaches identified in the report. Tracy Neal, Open Justice reporter
1News
2 days ago
- Health
- 1News
Dying teen transferred, family told to arrange return of his body
The family of a teenager who died from complications after an operation never got the chance to say goodbye. They were further distressed by being told they needed to organise his body's repatriation to his hometown. A complaint about the 19-year-old's care was referred to Health and Disability Commissioner by the coroner. The young man – who died in 2015 – had undergone an operation in January that year related to his type 2 neurofibromatosis – a genetic condition that causes benign tumours to develop on nerves, particularly those in the skull and spine. There were complications due to a post-operative infection and meningitis, which was treated successfully at a secondary hospital. ADVERTISEMENT The man – who was referred to in the commissioner's report as Mr B – continued to suffer from fluid building up around the brain and required regular release of cerebrospinal fluid through lumbar puncture. He was admitted to hospital with ongoing headaches and vomiting in April. A decision was made to hold off on further lumbar punctures due to concerns it could cause a hernia and to transfer him to another hospital via an air retrieval team. The transfer was delayed due due to staffing issues and a lack of an available air ambulance. Deputy commissioner Dr Vanessa Caldwell said Mr B was neurologically stable at the time and his transfer was scheduled for the next day. However, while waiting he collapsed and his heart stopped. He was then urgently transferred to another hospital, but his condition deteriorated and at the second hospital he was declared brain dead. ADVERTISEMENT Mr B's family told the commissioner they did not understand why he was not transferred by road when the air retrieval team was not available, and they did not understand why he was transferred to another hospital when his prognosis was poor. The transfer meant they did not have a chance to say goodbye to him before his death. The family also said they were asked if they would donate his organs only minutes after being told he was brain dead, which left them little time to consider their options. They were also told by a social worker it was up to them to organise transport of his body back to where they lived, even though he qualified for travel assistance. Health NZ apologised for the distress caused by the discussion related to organ donation and the miscommunication regarding transporting Mr B's body. Dr Caldwell said the care provided to the man was at an appropriate standard and decisions, such as the air transfer, were made appropriately based on the information available to the team at the time. Incorrect and minimal information was provided to the family once the man died and this had been particularly distressing for them, she said. ADVERTISEMENT She also had concerns about the communication between the air retrieval team and the teams treating Mr B. Health New Zealand breached the patient's right to information under the Code of Health and Disability Services Consumers' Rights, the commissioner said. A number of changes had been made since the young man's death, including the establishment of Health NZ, Dr Caldwell said. The morning's headlines in 90 seconds, including wintry blast on the way, Gloriavale leader in court, and Liam Lawson picks up points. (Source: Breakfast) "I am also mindful that providing recommendations at this stage for errors that happened some time ago is likely to have limited practical benefit." She recommended Health NZ Southern and Health NZ Waitaha Canterbury provided a formal written apology for the breaches identified in the report within three weeks.
Otago Daily Times
2 days ago
- Health
- Otago Daily Times
Teen's death exposed gaps in South Island healthcare: HDC decision
A teenager's death from complications after surgery revealed troubling gaps in complex care across the South Island at the time, the Health and Disability Commissioner says. The 19-year-old died in 2015 in circumstances where his family never had the chance to say goodbye. In addition, within minutes of them being told the teen was 'brain dead' they were asked if they would like to donate his organs. The teen's family was also told by a social worker that it was up to them to organise transportation of their son's body back to where they lived. A complaint to the coroner was referred to the HDC. In a decision released today, Deputy Health and Disability Commissioner Vanessa Caldwell found that Health NZ breached a section of the Health and Disability Services Consumers' Rights code, around gaps in information and delays associated with the air retrieval team. She was also critical of why alternative transport options had not been considered for the teen who had been taken to and from various hospitals for specialised treatment and care. Health NZ had sincerely apologised for its departure from the standard of care. Death unexpected The teen died unexpectedly after suffering complications related to a postoperative wound infection. He had undergone elective surgery at a South Island tertiary hospital for the removal of benign tumours from his nervous system. Caldwell said it was complicated by postoperative infection and meningitis which required further hospitalisations at a secondary hospital and later, another tertiary hospital. The postoperative infection was treated successfully, but the teen continued to suffer complications. He was later re-admitted to hospital with ongoing headaches and vomiting but a further lumbar puncture was not done because of concerns over how the teen was coping. A decision was made to send him back to the tertiary hospital where the initial surgery was done, to insert a shunt to drain excess fluid surrounding his brain and spinal cord. Because he was considered 'neurologically stable' and there were operational delays by the air retrieval team, a decision was made to delay the transfer for a few days. While waiting, he collapsed and had a cardiac arrest. The neurosurgeon's team rushed to the hospital where he was and administered critical care but he continued to deteriorate. He was transferred back to the tertiary hospital but certified brain dead after he arrived. Outcome linked to delayed transfer Caldwell said there was dispute as to whether he would have benefited from an earlier transfer. Caldwell acknowledged the family's concerns regarding the neurosurgical care provided but she considered that Health NZ provided him with a reasonable standard of care. She said the teen's poor outcome was attributed to the delay by the air retrieval team in transferring him. However, his care was triaged and prioritised appropriately based on the information available to the team at the time, Caldwell said. An initial referral was made at 6pm and triaged by the flight coordinator with input from a senior medical consultant. Because he was considered neurologically stable and the air retrieval team was scheduled to return from another job, a collective decision was made to depart the next morning, with an expected arrival back by early afternoon. The air retrieval team stated that this was the nature of prioritisation under a resource-constrained environment, Caldwell said. On the morning of the scheduled transfer, a further delay occurred because a flight nurse had to stand down for rest after attending an overnight retrieval. Efforts were made to contact other flight nurses and intensive care nurses who were not on the roster, but none were available. At the time, the air retrieval team had been experiencing increased demands but nurse staffing levels had not increased, Caldwell said. She said between March 2015 and March 2016, there were 60 occasions when a second retrieval had been requested but could not respond. An expert's advice was that road transfer could have been considered as an alternative option but the surgeon disagreed. He said that in his experience, moving patients by road had led to a negative outcome, because of the lack of ambulance staff and inability of the ambulances to cross boundaries between healthcare districts at the time. List of changes made since The air retrieval team had since made a comprehensive list of changes, including additional nursing staff, and has introduced improved communication and operational guidelines. Caldwell said a 'significant number of changes' to the health sector had since been made. She said the amalgamation of the 20 district health boards into Health NZ had created better service integration, sharing of resources, and communication between treating teams. Health NZ Southern and Health NZ Waitaha Canterbury districts were asked to provide a formal written apology for the breaches identified in the report. Tracy Neal, Open Justice reporter
RNZ News
09-06-2025
- Health
- RNZ News
Commission criticises dentist after woman suffers tooth infection for eight months
Deputy Health and Disability Commissioner Vanessa Caldwell says from the time of the initial procedure on 4 December 2019, Ms A had concerns. Photo: 123rf A woman whose dental implant and bone-graft failed and who suffered an undiagnosed infection for eight months says she still has pain, headaches and brain fog four years on, and ended up losing her job as a result. In a report released on Monday, the Health and Disability Commission has criticised the dentist for failing to adequately explain the risks of the procedure, and for poor record-keeping and medication management. The complainant, known as "Ms A", had an implant supported crown placed in her upper left central incisor by a specialist periodontist in 2009. However, after two years of problems with the implant starting in 2017, she consulted the dentist in July of 2019. He suggested a treatment plan involving a bone graft to support a new implant and crown, which was approved by her insurance provider. Ms A told HDC that in discussing risks, the dentist "mentioned only that infection was a possibility, but he said that he had performed the procedure many times and only one other person had had an infection, which had healed well". She said he made the procedure sound very low risk and "all very fixable", and never mentioned anything about the possibility of it failing. "I really didn't think I was going to have a problem and I trusted [the dentist]." However, in the days following the procedure, she began feeling unwell and had "a burning sensation". Between 4 and 19 December, the dentist saw Ms A four times to assess the healing. He could see no sign of infection but prescribed antibiotics. On 16 December, he reported there was slight puffiness at the site of the graft, but no pus or other evidence of infection. At 6.55am on 19 December, Ms A texted the dentist asking him to call her. He ended up seeing her after hours and removing the "membrane" (a special wound dressing made from the patient's own blood), at her request. "He stated that he discussed the possible complications of re-opening the site, but she was very insistent that the membrane be removed. Dr B stated: 'In the end I abided by her wishes'. "In response to the provisional opinion, Ms A told HDC: 'This is not correct … It was his only suggestion he gave me to remedy the issue.'." On 20 December, Ms A went to a public hospital Emergency Department with swelling to her upper lip and left cheek, but an X-ray was normal and there was no sign of infection. She went back to the dentist on 23 December, who reassured her the site was healing well. He gave her a medical certificate. The patient told the HDC she asked him to write out an insurance claim but he declined, saying she was "Okay [and there was] no need to do that." "She said that she told him that she had no more sick leave and had started to use up her annual leave, but he did not seem to care and shrugged everything off, seemingly ignoring her. "Dr B said that the process was that she should have downloaded and completed the relevant form, which he would then have countersigned." She phoned the clinic again on Christmas Eve, and reception staff advised her to either go to the hospital or she could see another dentist at the practice on the following Friday. On Boxing Day, she went to the ED again with pain in her face, and was given painkillers and discharged. She texted the dentist, asking him to call her urgently. He called her that afternoon and she said blood tests were normal but clinicians suspected inflammation as the probable cause. On 27 December Ms A was seen by the dentist, who extended her medical certificate to 3 January 2020 and recorded that her gum looked "ok". The sutures were removed on 13 January by another dentist, who noted there were no signs of infection. On 20 January and again on 18 February, she was seen again by the dentist, who assured while the site looked normal and was healing well. Ms A was upset and worried that the infection was back. On 15 May Ms A's general practitioner (GP) referred her to an oral and maxillofacial surgeon at a public hospital, querying whether Ms A had an infected dental cyst. Meanwhile, she had several more appointments over 2020 with the dentist , who uncovered the implant and put a temporary crown in place. "I felt like he wasn't listening, [and I was] at a loss to know what was happening to my body.'" On 17 August 2020 Ms A was seen by the maxillofacial service at the public hospital. The specialist noted the presence of a soft tissue pocket, peri-implantitis and bone loss, and that there was "large force put on [the] implant due to incorrect crown/implant ratio". She was referred to oral and maxillofacial surgeon, who removed both the implant and crown on 13 October 2020. Ms A told HDC that when the infected implant and surrounding bone in her jaw was removed, it left her with gum and bone shrinkage and stained teeth. She said the bacterial infection had been left undiagnosed for over eight months, and it had taken a toll on her health. "Today I still have burning, swelling and discomfort around the area where the implant use to be. I suffer from headaches, brain fog and concentration issues. Coupled with very bad fatigue. I also couldn't go back to work and I ended up losing my employment. "Four years on from then my life has never been the same." In response to the HDC provisional opinion, the dentist said it was "unfortunate Ms A has had to go through this". "No one likes to see a patient struggle and their treatment not go to plan." Two other dentists, two hospital visits and two X-rays had not found any evidence of infection either, he said. "It seems there was a low grade bone infection… We are all disappointed and sorry for [Ms A] that she got an infection and did not get the desired outcome." Deputy Health and Disability Commissioner Vanessa Caldwell said from the time of the initial procedure on 4 December 2019, Ms A had "concerns". She said while the dentist pointed out the infection was only detected in December 2020 - when the hospital specialist conducted a CBCT (cone beam CT scan) - Ms A's GP had been "sufficiently concerned in May 2020 to refer her to a maxillofacial specialist". "And when Ms A was seen at the public hospital on 17 August the maxillofacial service identified a soft tissue pocket, peri-implantitis and bone loss. "Further, on 19 December 2019, the dentist had recorded 'infection tissue removed'." A dental expert who reviewed the clinical record for the HDC found the dentist "demonstrated considerable skill". "Although the procedure failed, the treatment was within his scope." Caldwell said however, the dentist failed to provide Ms A with the information she needed to make informed choices about her treatment, and his records were "incomplete in several respects". Dr B stopped practising dentistry in June 2021 due to a medical condition, but he said after receiving the complaint, he and the dental practice reviewed all clinicians' note-taking, and consent forms were being reviewed and updated. The HDC has recommended that the dentist apologise to Ms A for the criticisms in the report, and before returning to practice he undertake additional education on record-keeping, informed consent, person-centred care and effective communication with health consumers. Sign up for Ngā Pitopito Kōrero , a daily newsletter curated by our editors and delivered straight to your inbox every weekday.
RNZ News
09-06-2025
- Health
- RNZ News
Comission criticise dentist after woman suffers tooth infection for eight months
Deputy Health and Disability Commissioner Vanessa Caldwell says from the time of the initial procedure on 4 December 2019, Ms A had concerns. Photo: 123rf A woman whose dental implant and bone-graft failed and who suffered an undiagnosed infection for eight months says she still has pain, headaches and brain fog four years on, and ended up losing her job as a result. In a report released on Monday, the Health and Disability Commission has criticised the dentist for failing to adequately explain the risks of the procedure, and for poor record-keeping and medication management. The complainant, known as "Ms A", had an implant supported crown placed in her upper left central incisor by a specialist periodontist in 2009. However, after two years of problems with the implant starting in 2017, she consulted the dentist in July of 2019. He suggested a treatment plan involving a bone graft to support a new implant and crown, which was approved by her insurance provider. Ms A told HDC that in discussing risks, the dentist "mentioned only that infection was a possibility, but he said that he had performed the procedure many times and only one other person had had an infection, which had healed well". She said he made the procedure sound very low risk and "all very fixable", and never mentioned anything about the possibility of it failing. "I really didn't think I was going to have a problem and I trusted [the dentist]." However, in the days following the procedure, she began feeling unwell and had "a burning sensation". Between 4 and 19 December, the dentist saw Ms A four times to assess the healing. He could see no sign of infection but prescribed antibiotics. On 16 December, he reported there was slight puffiness at the site of the graft, but no pus or other evidence of infection. At 6.55am on 19 December, Ms A texted the dentist asking him to call her. He ended up seeing her after hours and removing the "membrane" (a special wound dressing made from the patient's own blood), at her request. "He stated that he discussed the possible complications of re-opening the site, but she was very insistent that the membrane be removed. Dr B stated: 'In the end I abided by her wishes'. "In response to the provisional opinion, Ms A told HDC: 'This is not correct … It was his only suggestion he gave me to remedy the issue.'." On 20 December, Ms A went to a public hospital Emergency Department with swelling to her upper lip and left cheek, but an X-ray was normal and there was no sign of infection. She went back to the dentist on 23 December, who reassured her the site was healing well. He gave her a medical certificate. The patient told the HDC she asked him to write out an insurance claim but he declined, saying she was "Okay [and there was] no need to do that." "She said that she told him that she had no more sick leave and had started to use up her annual leave, but he did not seem to care and shrugged everything off, seemingly ignoring her. "Dr B said that the process was that she should have downloaded and completed the relevant form, which he would then have countersigned." She phoned the clinic again on Christmas Eve, and reception staff advised her to either go to the hospital or she could see another dentist at the practice on the following Friday. On Boxing Day, she went to the ED again with pain in her face, and was given painkillers and discharged. She texted the dentist, asking him to call her urgently. He called her that afternoon and she said blood tests were normal but clinicians suspected inflammation as the probable cause. On 27 December Ms A was seen by the dentist, who extended her medical certificate to 3 January 2020 and recorded that her gum looked "ok". The sutures were removed on 13 January by another dentist, who noted there were no signs of infection. On 20 January and again on 18 February, she was seen again by the dentist, who assured while the site looked normal and was healing well. Ms A was upset and worried that the infection was back. On 15 May Ms A's general practitioner (GP) referred her to an oral and maxillofacial surgeon at a public hospital, querying whether Ms A had an infected dental cyst. Meanwhile, she had several more appointments over 2020 with the dentist , who uncovered the implant and put a temporary crown in place. "I felt like he wasn't listening, [and I was] at a loss to know what was happening to my body.'" On 17 August 2020 Ms A was seen by the maxillofacial service at the public hospital. The specialist noted the presence of a soft tissue pocket, peri-implantitis and bone loss, and that there was "large force put on [the] implant due to incorrect crown/implant ratio". She was referred to oral and maxillofacial surgeon, who removed both the implant and crown on 13 October 2020. Ms A told HDC that when the infected implant and surrounding bone in her jaw was removed, it left her with gum and bone shrinkage and stained teeth. She said the bacterial infection had been left undiagnosed for over eight months, and it had taken a toll on her health. "Today I still have burning, swelling and discomfort around the area where the implant use to be. I suffer from headaches, brain fog and concentration issues. Coupled with very bad fatigue. I also couldn't go back to work and I ended up losing my employment. "Four years on from then my life has never been the same." In response to the HDC provisional opinion, the dentist said it was "unfortunate Ms A has had to go through this". "No one likes to see a patient struggle and their treatment not go to plan." Two other dentists, two hospital visits and two X-rays had not found any evidence of infection either, he said. "It seems there was a low grade bone infection… We are all disappointed and sorry for [Ms A] that she got an infection and did not get the desired outcome." Deputy Health and Disability Commissioner Vanessa Caldwell said from the time of the initial procedure on 4 December 2019, Ms A had "concerns". She said while the dentist pointed out the infection was only detected in December 2020 - when the hospital specialist conducted a CBCT (cone beam CT scan) - Ms A's GP had been "sufficiently concerned in May 2020 to refer her to a maxillofacial specialist". "And when Ms A was seen at the public hospital on 17 August the maxillofacial service identified a soft tissue pocket, peri-implantitis and bone loss. "Further, on 19 December 2019, the dentist had recorded 'infection tissue removed'." A dental expert who reviewed the clinical record for the HDC found the dentist "demonstrated considerable skill". "Although the procedure failed, the treatment was within his scope." Caldwell said however, the dentist failed to provide Ms A with the information she needed to make informed choices about her treatment, and his records were "incomplete in several respects". Dr B stopped practising dentistry in June 2021 due to a medical condition, but he said after receiving the complaint, he and the dental practice reviewed all clinicians' note-taking, and consent forms were being reviewed and updated. The HDC has recommended that the dentist apologise to Ms A for the criticisms in the report, and before returning to practice he undertake additional education on record-keeping, informed consent, person-centred care and effective communication with health consumers. Sign up for Ngā Pitopito Kōrero , a daily newsletter curated by our editors and delivered straight to your inbox every weekday.
