Three deaths could have been avoided

A flight delay, a missed diagnosis and an unexpected complication during dialysis contributed to the deaths of three Midcentral Health patients during the 2017-18 year.

They were among 20 serious and adverse events the district health board reported to the Health Quality and Safety Commission.

Chief medical officer Ken Clark said every one of the events was taken ‘‘incredibly seriously’’ and staff worked hard to reflect on what could have been done better, and to identify where processes could be improved.

Some of the issues were difficult, including dealing with the increasing age and frailty of hospital patients.

Of the patients who died, one was waiting to be flown to another hospital for specialist care.

Another had been discharged from the emergency department, collapsed at home and was brought back, but then died.

A third patient had been carrying out haemodialysis when they had an unrelated, unexpected medical event, lost consciousness, and later died.

Although the number of events at Midcentral Health had remained stable over the past five years, the most recent national figures masked improvements that had been made, as the reporting included serious bedsores for the first time.

Nine patients were included in that category, and another five had falls.

One frail patient had two dislocated hips.

While that problem was being treated, they developed a bedsore.

The hospital’s own investigation found improved staff training was needed to identify the risk of pressure injuries and try to prevent them.

The review of the serious falls, which resulted in broken bones, showed there were generally good measures in place to reduce risks.

However, simple measures such as removing the clutter in wards and corridors could have helped.

There was just one medication problem, when a patient was not prescribed the medicines they needed when transferring between care services.

Chief medical officer Ken Clark said every event was taken ‘‘incredibly seriously’’.