Trevor Flood continues to fall after Auckland hospital’s overdose error causes brain injury

A cancer patient who suffered irreversible brain damage after receiving a morphine overdose during his hospitalization has continued to decline since the life-changing incident.

“He can’t do anything. He can’t turn on the TV, change the channel or use a phone,” Kylie Flood said of her husband Trevor Flood’s current condition.

“He’s pretty much dependent on caregivers and myself, and our daughter.”

Before the 2019 accidental overdose at Auckland City Hospital, Trevor from Dargaville was an active builder who loved fishing, motorcycling and socializing.

“Now he doesn’t do anything all day. He just sits there and watches TV,” Kylie told NZME this week.

“It’s almost like dementia. He forgets things and asks the same question a hundred times a day.”

While Trevor, now 61, has beaten the throat cancer he was battling, his cognitive health has deteriorated over the past five years since the brain injury.

Kylie said it would come to a point where he would have to move into a retirement home.

“I feel sorry for Trevor… and I feel sorry for our daughter, who has missed these years with her father.”

Kylie spoke to NZME following a decision by the Human Rights Review Tribunal (HRRT) which confirmed that Health New Zealand Te Whatu Ora had breached Trevor’s rights as a patient.

The case had been referred to the HRRT by the procedural director after the Health and Disability Commissioner (HDC) determined that system failures at the Auckland District Health Board (ADHB), now Te Whatu Ora Te Toka Tumai Auckland, contributed to the morphine overdose and a lack of adequate monitoring of Trevor.

The HDC was also critical of a nurse involved in his care.

Te Whatu Ora Te Toka Tumai Auckland told NZME it acknowledged and accepted the HRRT’s decision and said it “deeply regrets” “the shortcomings” in the care it provided to Trevor.

While the HRRT’s recent decision doesn’t change anything for the family, Kylie said it has given them closure.

“It makes them more accountable for what they’ve done, but it doesn’t mean anything different to us as such. I think it just closes a chapter.

“It’s all done and dusted (the grievance process) and it’s just a matter of moving on with everything.”

The HRRT has the authority to declare that a healthcare provider has breached the Code of Health and Disability Services Consumers’ Rights (the Code), which it did in Trevor’s case.

In some cases, it may also order the healthcare provider to stop the conduct that was part of the claim and make orders regarding compensation.

The Floods, who receive ACC, did not receive nor request compensation from the HRRT.

“When I first complained to the HDC it was not for financial reasons, but to gain responsibility for what happened to Trevor.”

Kylie said she was angry after the incident but has now moved past that.

“It’s our life now and we can’t live in the past,” she said.

“We have to stay focused on what the future holds and keep moving forward.”

A code red

Trevor was admitted to Auckland City Hospital’s oncology unit in February 2019 for pain and dehydration treatment following radiation therapy for throat cancer.

He was initially prescribed oral morphine to reduce his pain, but due to his symptoms he was unable to tolerate oral medications.

Instead, he was given morphine through a syringe driver, a pump that provides continuous delivery of medication.

The morphine infusion had to take place under constant monitoring of vital functions, including four-hour checks of the injections to prevent overdose.

Two days later, the hospital was understaffed and a nurse, a nurse who works in different departments when one department is short-staffed, was called in to work the night shift.

She told the HDC that she checked on Trevor at midnight and noted that he was sleeping and breathing normally, but his vital signs were not recording.

The nurse checked him again at 2 a.m., documented his vital signs, and then performed hourly checks but did not take his vital signs.

She told the HDC that when she saw Trevor at midnight, she checked the pump, which was working, but did not do the full check required because she was busy with other patients. She then checked at 1:30am and 6am and documented it.

At 6:55 a.m. the nurse noticed that he was snoring loudly. She became concerned and left the room to contact the day shift and alert the charge nurse, who called a code red and stopped the syringe driver.

Trevor had low blood oxygen levels and was unresponsive. He was transferred to the intensive care unit (ICU) where he was treated for opioid anesthesia.

He was given another medication to reverse the effects of the morphine, including respiratory depression.

Trevor was discharged a week later, but Kylie noticed he was beginning to show signs of confusion, decreased coordination and altered speech.

It later emerged that the morphine overdose had caused him irreversible brain damage, with tremors at rest, increased muscle stiffness and limb weakness.

Insufficient care

A few months later, Kylie filed a complaint with the HDC.

In February last year, HDC deputy Dr Vanessa Caldwell found that the ADHB and the assistant nurse had breached the HDC code by failing to provide Trevor with adequate care.

Caldwell discovered that the nurse had not performed all necessary vital checks overnight, which contributed to his morphine overdose.

She said the nurse also left Trevor to seek help rather than staying with him and immediately assessing his consciousness, breathing and circulation and raising the alarm.

In the findings, health experts said there were systemic problems at the ADHB due to a lack of clear policies and guidelines, as well as an overburdened workforce, with a ratio of one nurse for every nine patients.

Along with several recommendations, Caldwell told the nurse and Te Whatu Ora to formally apologize to Trevor and his family.

Margaret Dotchin, acting group director of Te Toka Tumai Auckland, told NZME that Health NZ has formally apologized to Trevor.

“We continue to recognize the deep and lasting impact our care has had on him and his family,” she said.

“In 2023, we accepted the findings of the Deputy Commissioner for Health and Disability regarding breaches of the HDC Code and associated recommendations, all of which have been acted upon.”

Dotchin said several other changes have also been made, including improved support for nurses, the way opioid medications are administered to non-palliative patients receiving radiotherapy, and training and guidance.

“We would like to reassure the public that we are confident that the changes we have made will reduce the chance of an incident like this happening again.”

A friend of the Floods has set up a Givealittle page to help them with ongoing costs associated with Trevor’s care.

This story originally appeared in the New Zealand herald.