Key Takeaways
- An 83-year-old woman, Margaret Batten, died after being dropped from a hospital stretcher at Whangārei Hospital in May 2023.
- The coroner found that the cause of death was a traumatic brain injury sustained when she struck her head on concrete.
- The incident occurred due to a loss of control by the St John patient transfer service (PTS) officer, who was operating the stretcher alone.
- The coroner identified several contributing factors, including the fact that the stretcher was meant to be operated by two people and the loading ramp outside the hospital was unsuitable for the use of Stryker stretchers.
- Health New Zealand and St John have made changes to prevent similar incidents, including increased training for PTS officers and the replacement of non-powered stretchers with powered stretchers.
Introduction to the Incident
A tragic incident occurred at Whangārei Hospital in May 2023, resulting in the death of 83-year-old Margaret Batten. According to the coroner’s report, Batten suffered a head injury after falling onto a concrete floor in the ambulance loading bay when a St John officer lost control of her stretcher during her discharge. The coroner, Tracey Fitzgibbon, stated that Batten was secured on a Stryker stretcher and was in the process of being moved down a ramp by a St John patient transfer service (PTS) officer when she fell. The stretcher tipped over, causing Batten to land on her left-hand side on the concrete bay floor.
The Coroner’s Investigation
The coroner’s investigation revealed that the cause of death was a traumatic brain injury sustained when Batten struck her head on concrete. The investigation also found that the PTS officer had lost control of the stretcher, which was meant to be operated by two people. The coroner noted that the loading ramp outside Whangārei Hospital was unsuitable for the use of Stryker stretchers, and that this contributed to the incident. The ramp was used on multiple occasions for transferring patients to ambulances, but no previous incidents had been reported. The coroner concluded that the incident was an isolated one, but that it highlighted the need for improved safety measures.
Contributing Factors
The coroner identified several contributing factors to Batten’s death, including the fact that the stretcher was meant to be operated by two people. The coroner stated that if the stretcher had two operators, one at the foot and one at the head, the incident would likely not have occurred. Additionally, the coroner noted that the loading ramp outside the hospital was not suitable for the use of Stryker stretchers. The coroner also mentioned that the PTS officer had to navigate through works being conducted at the ED entrance, which may have contributed to the loss of control.
Response to the Incident
Health New Zealand and St John have taken steps to prevent similar incidents from occurring in the future. The coroner noted that Hato Hone St John had increased training for PTS officers by two days, focusing on the safe operation of stretchers as a single-use operator. The training includes manoeuvring in a range of environments and loading/unloading. Additionally, Health New Zealand has implemented changes to improve safety when transferring patients between hospital and a patient transfer ambulance. These changes include regular meetings with Hato Hone St John regarding shared use facilities, improved systems for reporting concerns or issues with facilities, and modifications to the ambulance bay ramp to improve patient safety.
Changes and Improvements
Health New Zealand and St John have made a number of changes since Batten’s death, including the replacement of non-powered stretchers with powered stretchers. The powered stretchers are viewed as a safer option for single operators. The ambulance ramp reconfiguration at Whangārei Hospital was completed in August 2023. Health New Zealand Northland group director of operations Alex Pimm stated that the organisation was "extremely sorry" about what had happened and that they had made changes to help prevent a similar event from happening again. Hato Hone St John ambulance operations general manager Debra Larsen also expressed her deepest condolences to Batten’s family and stated that the organisation remained committed to learning from the incident and improving the safety of their services.
Conclusion
The incident at Whangārei Hospital highlights the importance of ensuring that patients are transferred safely between hospital and ambulance. The coroner’s report identified several contributing factors to Batten’s death, including the fact that the stretcher was meant to be operated by two people and the loading ramp outside the hospital was unsuitable for the use of Stryker stretchers. Health New Zealand and St John have taken steps to prevent similar incidents from occurring in the future, including increased training for PTS officers and the replacement of non-powered stretchers with powered stretchers. The incident serves as a reminder of the need for ongoing vigilance and improvement in patient safety.