JMO Supervision An Essential Safety Ingredient

Case history

On Sunday 22 January 2006, Ms Olga Krivitch, 81 years  of age, presented to Royal Adelaide Hospital (RAH) with a several day history of a cold and painful right foot. A diagnosis of an ischaemic right leg was made. An angiogram and subsequent thrombolytic therapy was performed by a senior radiologist in the Department of Radiology on the afternoon of her presentation to hospital, but this was unsuccessful in improving the perfusion of her leg. The patient was then admitted to the Vascular Surgery Unit at RAH. There was no surgical option available to achieve re-vascularisation of the patient’s right leg. In order to try to maintain the viability of her leg, the admitting vascular surgeon decided to commence the patient on an anti-coagulation regime, involving the RAH Heparin Protocol.

At the time of the patient’s admission to the Vascular Surgery Unit in January 2006, there were no registrars working in the unit. Instead there were two “relieving” RMOs, working in conjunction with two interns in the unit.

During her admission, the patient’s APTT and haemoglobin were checked on 22, 23 and 24 January 2006. On 22 January 2006, her haemoglobin was 119. On 23 January 2006 it was 100 and on 24 January 2006 the haemoglobin was 98. On 24 January 2006, the patient was also diagnosed as suffering from a non-traumatic haematoma of her left shoulder. No haemoglobin was ordered or performed on 25 and 26 January 2006, although her APTT levels were checked on both of these days.

At 10:55am on Friday 27 January 2006, blood tests revealed a haemoglobin of 54 and an APTT of 109. Later that day, the RMO was contacted by the unit intern and informed of these results. The intern explained to the RMO that he had been unable to obtain any further blood for cross-matching. At about 3pm on 27 January 2006, the RMO examined the patient, but the source of bleeding was unable to be identified. The RMO obtained blood for cross-matching and ordered a CT abdomen and pelvis to try to identify if there was an intra-abdominal bleed. The RMO attempted to contact the admitting and also the on-call vascular surgeons, without success. The RMO left a message for both of the vascular surgeons, outlining his concerns about the patient’s deteriorating condition and his plan for a blood transfusion and CT scan. The heparin infusion was also ceased. The RMO went off duty at about 5:30pm and handed over the patient’s care to the other unit RMO who was on-call from 5pm until 8am the following morning. The patient’s blood transfusion did not commence until about 8:20pm on 27 January 2006. The CT scan revealed a massive haematoma of the right thigh. The admitting vascular surgeon was eventually contacted and the patient was taken to theatre in the early hours of the morning on Saturday 28 January 2006, where a bleeding point in the right femoral artery was oversewn. Postoperatively, the patient was admitted to the ICU. However, she had developed respiratory failure, renal failure, ischaemic hepatitis and an acute myocardial infarction. Her condition continued to deteriorate over the next 24 hours and eventually treatment was withdrawn. The patient died at 9:30am on 29 January 2006 and her death was reported  to the Coroner.

Medico-legal issues

A Coronial Inquest was held in June 2009 and the Coroner’s findings were handed down on 4 February 2010. The Coroner found that the patient had died as a result of hypovolaemic shock following bleeding from the site of a femoral angiogram. Expert evidence was provided at the Inquest by an Intensive Care Specialist, Professor J Cade. The admitting vascular surgeon and the unit RMO also gave evidence at the Inquest.

Professor Cade had two main concerns about the patient’s management: Firstly, that the patient’s anti-coagulation regime was not stabilised in a timely manner, and she was over anti-coagulated for some period of time. Secondly, he was concerned that the significant bleeding from the site of Ms Krivitch’s original thrombolytic therapy had not been identified in a timely manner with the result that the patient experienced severe blood loss, hypovolaemia and significant coagulopathy from which she did not recover.

Professor Cade opined that a number of things urgently should have followed the discovery on 27 January 2006 that the patient’s haemoglobin was 54. At the Inquest, he gave the following evidence:

“This is a red flag that needs immediate attention…Firstly it needs to be checked that it is correct, it may have been an erroneous sample….Then you need to urgently look  at the patient, see if they are pale, see if they have got some bleeding and see what their general state is like.  If it was believed on all those grounds that the reading is correct then two things have to happen from that: one is urgent repair of the haemoglobin with a blood transfusion; and secondly urgent investigation of the (bleeding) site....Where is all the bleeding?”

He concluded that Ms Krivitch would have survived if appropriate interventions including an early identification of her haemoglobin levels and a blood transfusion on the morning of 27 January 2006 had been commenced. The Coroner stated that the fact that the patient’s haemoglobin levels had not been checked on 25 or 26 January 2006 “was a significant oversight that was to have a direct bearing on Ms Krivitch’s decline and death. The fact that no specific instruction was given to junior staff to monitor Ms Krivitch’s haemoglobin levels on 25 and 26 January 2006 was to my mind a misjudgement given that there was already in existence evidence of spontaneous bleeding (into the shoulder) that was the product of over anticoagulation”. He went on to state that “I find that there was a significant and unacceptable delay in appropriate action being taken after Ms Krivitch’s haemoglobin level was revealed to be 54. The haemoglobin test sampling was undertaken at  10:55am on 27 January 2006. There was no evidence as to when the result of that test would have been available for the first time, but it was not reported to… one of the two RMOs on the ward until shortly before 3pm that day. Even then there was considerable delay in administering the necessary blood transfusion…I conclude that the shortcomings in Ms Krivitch’s treatment at the RAH were due to the inexperience of junior practitioners who were staffing the Vascular Surgery Unit at that time and the lack of supervision of those staff members. It is hard to imagine experienced registrars, had they been employed within the unit at the time, not ensuring that appropriate monitoring was in place, particularly in relation to Ms Krivitch’s haemoglobin levels. Similarly, in my view the delays experienced during the afternoon of 27 January 2006 could have been avoided if more experienced and senior medical staff had been on hand. If appropriate medical expertise had been available within the Vascular Surgery Unit at the relevant time, I find on the balance of probabilities that Ms Krivitch’s outcome could have been avoided. Having regard to the inexperience of the medical staff who were employed at the Vascular Surgery Unit from 22 to 27 January 2006, there is no evidence to warrant the criticism of any individual junior medical practitioner. They should have been more closely supervised and, in particular, it should have been made clear to them that there was a fundamental need for Ms Krivitch’s haemoglobin levels to be closely monitored and evaluated on 25 and 26 January 2006.”

Risk management strategies

The Coroner’s recommendations included the following:

• “That the Minister for Health draw to the attention of the Chief Executive Officers of all public hospitals the desirability of identifying in advance of the commencement of anti-coagulation therapy, the relevant blood grouping of the patient so as to facilitate the more timely delivery of a blood transfusion should the necessity for the same arise;
• That the Minister for Health draw my findings in respect of the necessity to monitor haemoglobin levels in circumstances such as those that pertained to Ms Krivitch to the attention of all the relevant persons at all medical schools in South Australia;
• That the Minister for Health take the necessary steps to ensure that wards in all public hospitals are at all times appropriately staffed.”

Reference

Inquest into the death of Ms Olga Krivitch, Coroner’s Court of South Australia, Inquest number 13/2009 (0154/2006).