Blame for ‘poor standard of care’ lies with health board

Medical staff and systems failed a man who died at Whanganui Hospital after knee surgery, the Health and Disability Commissioner says.

The 74-year-old man has not been named, but died in 2014 after he was found unresponsive in a surgical ward two days after a knee replacement, commissioner Anthony Hill said in a report released this week.

Care for him was ‘‘sub-optimal’’ in three ways, Hill said. The system used before the operation to assess the patient’s risks in recovery was not good enough. Nurses did not monitor and assess him regularly while he recovered in hospital after the surgery, and his relief plan was not reviewed when his condition changed.

‘‘The commissioner found that Whanganui DHB failed to provide services [to the patient] with reasonable care and skill, and breached ... the Code of Health and Disability Services Consumers’ Rights.’’ The surgery was uneventful but the patient’s blood-oxygen levels were low in the days afterwards, triggering an ‘‘early warning score’’.

But this did not lead to a senior staff member being notified to assess him in the next two shifts.

There was uncertainty about how much fluid the man had drunk, and he had not been given enough intravenous fluid after the surgery.

He was later found to have developed sudden ‘‘kidney injury’’.

During this time he was given an opiate for pain relief that the Whanganui DHB has has since said should have been adjusted ‘‘once it was known the patient was developing acute kidney injury’’.

A nurse found the man unresponsive and a team tried to resuscitate him for 40 minutes.

Hill said individuals were partly responsible for the failures but the primary responsibility for the poor standard of care rested with the district health board because of the systems and number of staff involved.

Whanganui DHB had also done an investigation.

As a result it has undergone a programme of staff retraining, changed guidelines for monitoring patients after operations and for responding to changes in condition.