A 46-year-old woman suffered a brain injury and permanent memory loss after receiving an excessive combination of opioid painkillers during a busy night at Middlemore Hospital in 2021, according to a report released by the Health and Disability Commissioner (HDC).
According to a report by RNZ, the HDC criticised Health New Zealand Counties Manukau, stating that the hospital failed to provide adequate staffing, monitoring, and documentation on the night of the incident.
The woman, who had a complex medical history including post-traumatic stress disorder, anxiety, chronic pain disorder, and sleep apnoea, arrived at Middlemore’s emergency department on March 4, 2021, complaining of severe abdominal and back pain. Doctors suspected gastroenteritis and administered fentanyl intravenously, followed by oxycodone and her regular sedative medications, RNZ reported.
Despite receiving multiple types of pain relief, she continued to report significant discomfort. A junior doctor noted that her pain appeared “out of proportion” to the clinical findings.
Shortly after midnight on her second night in hospital, the woman was found unresponsive and not breathing properly. Although staff administered oxygen and medication to counter the opioid overdose, she had already sustained a brain injury due to oxygen deprivation.
The HDC’s investigation found that while the opioids were given within recommended dosage limits, the lack of close monitoring and inadequate documentation contributed to the adverse outcome. The report stated that the woman was supposed to be checked every 30 minutes, but there was no record confirming that this occurred.
“I am critical that despite Ms B receiving multiple doses of opioids over 24 hours, her pain score was documented only five times,” the Commissioner said. “I am also concerned that her vital signs were not recorded when she was on the ward,” as quoted by RNZ.
Health NZ acknowledged that its ward had been “very busy and short-staffed” at the time, with junior staff managing a heavy patient load. The organisation admitted it should have considered limiting admissions or bringing in additional staff.
Since the incident, Middlemore Hospital has implemented several measures to improve patient safety, including enhanced documentation practices, updated opioid protocols for adults, and improved co-prescribing alerts to guide staff in managing patients with complex medication needs.
Health NZ Counties Manukau acting chief medical officer Dr Geoff Green said the organisation accepted the Commissioner’s findings and had apologised to the woman and her whānau.
“We take the safety and well-being of every person in our care extremely seriously,” Dr Green said. “We have made a number of changes to ensure such an event does not happen again,” RNZ quoted.
The case underscores ongoing concerns about staffing pressures and patient monitoring standards in New Zealand’s hospital system.