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Dialysis Discussion => Dialysis: News Articles => Topic started by: okarol on September 24, 2011, 02:34:40 PM
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They gave our mother a man's name tag, then she died
September 25, 2011
The state's largest hospital is under investigation after an identity mix-up and accusations of a cover-up, writes Eamonn Duff.
On the night of her admission to Westmead Hospital, a dialysis patient, Anka ''Annie'' Dukich, saw something disturbing. ''I'm a man!'' she said to one of her daughters, pointing to her identity wristband.
Mrs Dukich, 80, had somehow been tagged as Kevin Wyatt, a 58-year-old cancer patient.
''Oh, my God!'' replied her daughter, adding: ''Did they ask you your name when they put your wristbands on [in emergency]?''
''No, they didn't ask anything,'' was the reply.
Earlier that day, a ''young female registrar'' had given Mrs Dukich medication.
The next morning, Thursday, June 30, Mrs Dukich complained to her family that something felt wrong.
Unusually, she had experienced trouble sleeping, she felt nauseous and was convinced she was either allergic to the medication or it had been too strong.
On Friday, the family says, they were told that Mrs Dukich's condition was ''critical''. By Saturday morning, she was dead.
The circumstances of the death of Mrs Dukich are being investigated by the state Health Care Complaints Commission, which confirmed it was ''looking closely at the complaint''.
Mrs Dukich's three daughters, Milly, Nada and Jelena, have also asked the NSW Coroner to review their mother's cause of death, accusing some members of the hospital staff of ''concealing the truth''.
In a complaint to the HCCC, the daughters claim they received four separate explanations in the hours before their mother's death, including an admission from one doctor that the prescribed medication had been ''too strong''.
They also want answers as to why Mrs Dukich's medication chart allegedly went missing, and how staff could not have noticed the obvious identity mix-up.
The middle daughter, Nada Dacich, said: ''Our poor mum was a private [health insurance] patient who got transferred into a public hospital that tagged her as a man, treated her with an unknown medicine and then tried to hide the evidence.''
Mrs Dacich, 55, also expressed ''deep concern'' about the recognised problem of employing health workers from other countries where English is a second language.
''It has the clear potential to impact on oral communication and interpreting or checking written words. In a hospital of all places, you can't afford such basic mistakes,'' she said.
''Despite a clear mix-up and our repeated complaints, we were offered no autopsy or toxicology tests that would have conclusively determined the true cause of death.
''At a time when we were completely shell-shocked, the hospital should have done the decent thing and explained this was an option,'' Mrs Dacich said.
''But it was only after mum's funeral and a meeting with NSW Police that we discovered our rights.''
The Sun-Herald can reveal Mr Wyatt was on blood-thinning medication and, at one stage, Mrs Dukich's family were informed she had suffered massive internal bleeding.
But a senior specialist at Westmead said the wristband mix-up did not lead to Mrs Dukich being given inappropriate treatment.
''It had no influence on our therapy,'' the specialist said. ''As soon as we saw it, we changed it.''
When The Sun-Herald pointed out that she had already been given medication before the mix-up was realised, the specialist replied: ''She was administered the drugs she was appropriately prescribed.''
Asked why, in that case, no autopsy nor toxicology tests were offered after the family raised concerns, he said: ''I'm not aware of that.''
The NSW Health Minister, Jillian Skinner, said: "As with all HCCC investigations, I'm unable to comment until a finding has been determined, but my thoughts are with the Dukich family at this difficult time.''
Although Mrs Dukich had been a dialysis patient since she was diagnosed with polycystic kidney disease 11 years ago, it never prevented her from living a normal life.
Said to be ''bright as a button'' by her daughters, she was a crossword and sudoku fanatic who enjoyed outings with several community groups near her Castle Hill home and seeing her 12 grandchildren.
On the morning of June 29, she was at Norwest Private Hospital for her weekly dialysis session when a doctor noted she was displaying signs of an elevated heart rate.
She was transferred to Westmead Hospital to finish her treatment.
After arriving through the emergency department, she completed her dialysis in Westmead's acute dialysis department.
She ate a sandwich with her daughters, then settled into the renal unit for routine monitoring. Later that night, Mrs Dukich and Mrs Dacich found she had been wrongly tagged with the name and allergy wristbands of Kevin Gerard Wyatt.
In the complaint to the HCCC, Mrs Dukich's family alleges the hospital gave a range of explanations about their mother's condition during a six-hour period the day before her death. During that time, they also claim, they were barred from seeing her.
''I begged them to take me to mum so I could just hold her hand but they deliberately kept us away from her,'' Mrs Dacich said. ''At first it was, 'No, you can't see her, she's in radiology,' which didn't add up because she'd completed that the day before. Then I was told, 'No, you can't see her, she's in the operating theatre' - yet, apparently, there was never an operation.
''At one stage, we were informed [by a doctor] that the medication given to our mother was too strong for her; it had put her heart rate into a very low and critical state, and that there had also been massive bleeding behind the stomach.
''We were then told there was no bleeding at all and that, somehow, a test had provided a 'false read'.''
The Sun-Herald asked the doctor if he told Mrs Dukich's family that her administered drugs had been too strong.
''This is the subject of a HCCC complaint. There has been a formal response, and it is still in progress,'' the doctor said.
Mr Wyatt died on August 28 and had made several visits to Westmead after being diagnosed with lung cancer. It is unknown whether he crossed paths there with Mrs Dukich, was tagged with her wristband or received wrong medication.
He was, however, on blood-thinning medication for blood clots, said his brother, Paul, who spoke to The Sun-Herald from his home in Auckland.
''I'm shocked,'' he said. ''You would have to think it's almost impossible for a hospital to mix up the identities of a 58-year-old man and a lady more than 20 years older. They couldn't have been paying much attention.''
Mr Wyatt said that, while his brother, a design engineer from Parramatta, was resigned to losing his battle with cancer, he had at one stage ''suffered an adverse reaction to either the drugs or the treatment he'd received''.
''It would have been between June and July but I don't know actual dates,'' he said.
''All I know is that when I arrived [in Sydney] on August 10 to talk to him, I took one look at him and said, 'Right, we're taking you to hospital.' I got him to the cancer ward, they said, 'Shit, he's had a reaction to the pills or the radiation treatment.'''
At 5.30pm on the day before Mrs Dukich died, her daughters wept as she was finally wheeled into the high-dependency ward, in a comatose state.
''Upon arrival, a doctor casually turned to us and asked what medication had been administered to mum - because her medication chart was missing,'' Mrs Dacich said.
Moments later, Mrs Dukich's eyes flickered, and she began pulling at her mask in what seemed a desperate attempt to tell them something.
Mrs Dacich said: ''I honestly believe in my heart and soul that mum was trying, with all her will, to give us answers, but she never got her words out. We still have no idea what they were attempting to do to her that day.''
Mrs Dacich added: ''Mum may have lived a full life but this was not the ending she deserved.''
eduff@sunherald.com.au
Read more: http://www.smh.com.au/nsw/they-gave-our-mother-a-mans-name-tag-then-she-died-20110924-1kqmg.html#ixzz1YuMYX1ck