Preventing 'avoidable' deaths: Too expensive? Or too expensive not to?

You don't want the holes in the Swiss cheese to line up.

First off, I don’t have any information other than what I read on Stuff, same as you. Nor would I ever (of course!) share any information that wasn’t already available to the wider public. But I do think these media health stories, however limited, provide an opportunity to discuss general medical concepts that might be quite useful to readers. If you find this useful or worthwhile, please share it widely. Feel free to leave a comment. Unlike on Twitter, on my Substack, I read all subscriber comments.

A brief excerpt from the Stuff article, followed by a bit of analysis below:

https://www.stuff.co.nz/nz-news/360513497/heads-have-roll-sick-taranaki-mum-visited-ed-twice-two-days-then-died-home

A coroner has found the “fit, young” 38-year-old died of pneumonia, due to a Type A influenza infection and beta haemolytic streptococcus infection, which can cause pharyngitis.

The report is a Te Whatu Ora Serious Incident Review. It shows Janelle presented to the emergency department on the night of July 16 and the morning of July 18, when three other patients were present.

Janelle tested positive for Influenza A on July 16. By July 18, her parents say she’d been experiencing symptoms for about four days. The report adds she had developed diarrhoea and vomiting.

It goes on to reveal a series of failures in relation to Janelle’s care, specifically a failure to recognise she was deteriorating, not appreciating the gravity of her illness and a failure to escalate her care.

Documentation reviewed by the report’s authors did not describe Janelle’s response to the “limited treatment she received", the report shows. It goes on to note a "significant lack of documentation” in relation to her care.

It also states further investigations would have been "advisable", including consideration of an antibiotic, investigations to rule out sepsis, a chest x-ray, a blood test and a urine test. Additionally, no oxygen was given in response to low levels.

The report also reveals an initial primary assessment was not completed, incomplete risk assessments and adds Janelle was not reassessed by medical staff at the time she was discharged.

Her Early Warning Score (EWS), a tool used to assess deterioration, was six prior to being discharged, but the report suggests this was inaccurate.

“It is likely that this would have been a higher score but her temperature was not taken and so was not included in the calculation,” it found.

“It would have been advisable to keep her in for further observations and tests as opposed to discharge.”

Some general (educational) points that I’d make, prompted by the article’s topic of patient safety, but not based on this specific and tragic event.

1. ‘Mild’ illnesses like the flu and Covid can actually kill people. Not just the elderly or infants or the debilitated, but sometimes even the seemingly random, unlucky ‘fit and well’ person. To the extent these infections can be prevented, for the sake of all patients, they should. Preventing ‘preventable’ deaths should be a given. Clean, ventilated indoor air. Vaccinations. Throat swabbing programmes in schools. Sick students and employees not coming to school or work to unwittingly spread illness. It all helps reduce suffering.

2. Viral illnesses, like influenza, can co-exist with bacterial infections like Strep. Some viral infections weaken your immune system enough for another viral or a bacterial infection to take hold. Some people in a hospital for let’s say, a bacterial pneumonia, may pick up a viral infection due to close proximity with infected people in hospital.

   I wish we had a top-notch industrial hygiene programme in all hospitals to ensure nosocomial (hospital-acquired) infections, especially respiratory ones, were reduced, through good hospital design, individual rooms, and modern filtration and ventilation systems. I’ve only rarely been in such institutions in the West—you’d need a level of attention to detail and optimisation that just isn’t in play in most public institutions—but it would be nice. Might save money and lives too.

   I wish more politicians spoke up about this. But merely ‘hoping’ never cured a single case of strep throat. Where are the well-being governments?

   'The cuts will continue until the economy improves'

   Health and productivity go hand-in-hand. You’d think all political parties would want to advocate for that. I was in Germany last year, where even the most lefty and rightwing governments BOTH advocated for great public health services, reasoning correctly that healthy people are an asset for a nation. Whether for pragmatic or compassionate reasons, supporting a healthy populace is a win-win.

3. Some viruses can remain dormant in us for years (herpes virus, which causes shingles, is one example). Strep and menincococcus are two bacteria that can sometimes (infrequently) lie dormant in our throats or elsewhere, popping up after months to cause infection, or sometimes leaving us completely alone, and instead infecting only those we come in contact with. Quite fickle. Requiring ongoing vigilance and great screening programmes. The kind that may be harder to operate when one’s National Public Health service was just cut by 25%.

   

4. Screening and secondary prevention programmes, like school nursing programmes with strep throat swabbing are one example of wise investments in our health. Every school should have regular access to a school nurse, a dental therapist, and a psychological counselor. It’s money well spent; a form of preventive care that ultimately benefits families and the community.

   Once again, I’ve only seen a handful of places that do this well, but it’s a no-brainer. We allow kids to descend into illness at our own peril. Save a dollar, but harm society in the long run. It’s obviously not just inhumane to let kids (or others) suffer, but it’s also financially irresponsible.

5. Vital signs are vital. Every doctor should feel a little chill down their spine when they discharge a patient with abnormal vital signs, especially a rapid heart rate or rapid breathing rate above standard norms. Early warning systems and other such vital sign-based metrics are only useful to the extent that the person interpreting them is competent, aware, and also empowered and resourced to act on them.

6. Nationally, a huge push towards less trained medical professionals (read: cheaper and more plentiful) providing clinical care, coupled with overwhelmed hospitals and primary care, creates an increasing risk of sending patients home prematurely.

7. Options exist for patients to get cases looked at more closely. Hospitals have administrators that can take complaints. At a higher level, so can the Health and Disabilities Commissioner. Some cases get reviewed by the Coroner’s Court as well. All of these are meant to get at the core ‘misses’ that led to the problem, which is often multifactorial. (In rare cases criminal malfeasance occurs, which is handled separately, in the criminal court system.)

8. Lastly, suggestions on improvements have to be implemented, not just written down. Problems that remain chronic create apathy. It’s rarely one person’s fault, but usually a Swiss-cheese model of failures throughout a patient’s journey, with the holes in the slices lining up, and bad things happening through a series of unfortunate but often preventable, or at least modifiable, misses.

-Gary Payinda