Case study: Zachary Gravatt

Zachary Gravatt: misdiagnosis under stress

Med student let down by the system

"Fourth year medical student Zachary Gravatt, 22, died of meningococcal disease in Auckland City Hospital in July 2009.

[…] In findings released today, Coroner Brandt Shortland found that Gravatt's disease was not diagnosed "in a timely fashion" because of systemic failures. The report details how Gravatt made an appointment with his GP on 8 July 2009 after waking up with extreme pain, fever and headaches. His doctor referred him to the hospital after diagnosing him with influenza H1N1, or the swine flu virus, which was at the height of its epidemic and consistent with his symptoms.

The hospital emergency department and the admissions unit were both busy that day and it was over an hour before Gravatt was examined by a doctor, after his initial assessment by a nurse at triage. Gravatt was eventually moved to the High Dependency Unit (HDU), and then the Department of Critical Care Medicine (DCCM), where he died at 7.15pm.
According to the coroner's report, the hospital suspected Gravatt had swine flu until about 6pm, when a doctor in the DCCM connected his symptoms with meningococcal.

The coroner said at the time of Gravatt's death, Auckland Hospital was "effectively under siege in dealing with the overwhelming numbers of the influenza epidemic". He said Gravatt's symptoms were similar to flu symptoms, but medical staff need to be highly suspicious when diagnosing, and Gravatt should have been regularly assessed more often than he was. Shortland also concluded Gravatt should have been admitted to the DCCM hours earlier than he was, which would have given him more time in intensive care. But he stressed he was not necessarily saying Gravatt would have lived if he had received more timely treatment; which would be "pure speculation". […] The coroner suppressed the names of the doctors and nurses involved in Gravatt's care, saying they were not negligent in their duties and should not be unreasonably punished. […]

Dr Wilsher said the hospital has introduced a number of changes in the past few years as a result of Gravatt's death, including increasing education about meningicoccal to frontline staff, and an early warning score, which assists nursing staff to identify seriously ill patients and call for help earlier. […]" (Adapted from Robinson, 20111.)

1. ROBINSON Victoria (2011). Med student let down by the system. Fairfax NZ, 2011. Retrieved from on 4 November 2011.

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Jose D PEREZGONZALEZ (2011). Massey University, New Zealand (JDPerezgonzalezJDPerezgonzalez).

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