Woman left to die after Hollywood Hospital staff incorrectly believed patient had ‘do-not-resuscitate’ order

A Perth woman was left to die for several minutes before doctors frantically restarted CPR after her patient file was mixed up with one that had a ‘do-not-resuscitate’ order. The woman, aged in her 50s, had gone into cardiac arrest at Hollywood Hospital prompting a resuscitation effort. It was then halted when a staff member believed her patient file had a ‘do-not-resuscitate’ order. The file, however, belonged to a woman in her 80s in the same Ramsay Health Care facility who had a similar name. Both women shared the same first name and first letter of their surnames. The West Australian understands it took approximately four minutes for staff to realise the blunder. They then swiftly restarted their resuscitation efforts. The women was able to be revived, but was placed in an induced coma. After a fortnight in recovery, supported by her partner, she was discharged. The case of mistaken identity is believed to have come after a staff member took the wrong paper-based file into the room. A ‘do-not-resuscitate’ order — or DNR order — is a medical order written by a doctor which instructs health-care providers not to perform CPR if a patient’s heart or breathing stops. A Hollywood Private Hospital spokeswoman said the incident would be thoroughly reviewed. She said the hospital has been in contact with the patient. “Hollywood Private Hospital can confirm that it is thoroughly investigating an incident that occurred,” she said. “The hospital understands the patient, who has since been discharged, is recovering well. “We will await the outcome of the investigation and implement any recommendations that arise as a result.” The hospital said it prides itself on providing “high quality and accessible health care” to the community. Australian Medical Association WA branch president Mark Duncan-Smith described the event as “bizarre” and said foundation identity and consent checks, like looking at the patient’s name tagged on their wrist band, should have picked up the error. “It’s a routine medical check. Private or public, they’re the same protocols with subtle variations,” he said. “Every hospital must do analysis of the event and find out the errors or weakness and correct those system to ensure they never happen again. Has it fallen down at a system level? Or has it fallen down at an Individual level.” It comes as the entire health system is under pressure with calls for a royal commission after the death of seven-year-old Aishwarya Aswath. The coroner’s report into her death also recommended Perth Children’s Hospital end the practice of drawing nurses and doctors from the ED floor in the event of emergency resuscitation events, instead rostering additional staff for those roles.