DHB criticised after death
Taranaki District Health Board has been heavily criticised after a patient who was admitted to hospital with chest pain died two days later after falling while unsupervised and suffering a brain bleed.
The widow of the 68-year-old man complained to the Health and Disability Commissioner following her husband’s death in 2015 at Taranaki Base Hospital.
In his newly released report, Commissioner Anthony Hill found the level of care the man received to be very poor and well below the standard expected.
There was poor judgment and lack of critical thinking by staff, poor communication between handovers, and inaccurate recording of medication.
‘‘Attention to the most basic aspects of monitoring, assessment, communication, and critical thinking were noticeably absent,’’ he said.
The man arrived at the emergency department around 8pm with chest pain, later found to be a heart attack.
Five hours later he was admitted to a ward and given several sprays of glyceryl trinitrate, medication used to treat and prevent chest pain.
It requires patients to be monitored afterward as it carries a risk of falling over.
But at 3.10am he went to the bathroom alone and passed out, knocking his head. After coming to he made his way back to bed.
At 9.15pm nursing staff found he had vomited, was breathing abnormally and was nonresponsive.
He had suffered a large brain bleed and died at 2.30am.
Commissioner Hill found the DHB had breached the Code of Health and Disability Services
Consumers’ Rights.
Information regarding the man’s fall and head injury was not communicated properly among staff.
‘‘Blood thinning medication continued to be administered to the man by some nursing staff, despite knowing that he had sustained a head injury, and without ensuring that he had been reviewed by the medical team,’’ the report said.
‘‘When the man began to deteriorate, medical review was not sought with clarity, and decisions about the medical review were not recorded.’’
DHB staff looking after the patient said they were in a busy environment at the time.
One nurse said she had to manage four new patients that evening, the death of a second patient, and was responsible for 11 patients overall.
But Hill said while staff may have been busy, they had the opportunity to consider the care of this patient and simply failed to do so adequately.
The incident was a collective failure of the system and the people operating in it, rather than the fault of one individual, the report said.
The commissioner made a number of recommendations including a review to ensure accurate shift handovers, new alert systems to flag patients on blood-thinning medications, an audit to assess whether heart attack patients have been appropriately transferred to critical care, and another audit to assess the electronic notification tool used to contact medical staff.
The DHB recorded the incident in its Serious Adverse Events 2015-2016 report.
In an emailed statement, DHB chief medical adviser Dr Greg Simmons said the board deeply regretted what happened and apologised to the family.
‘‘These multiple failings led to a series of events that have been deeply distressing to the wha¯ nau and have, I am sure, increased their pain, suffering and grief. We remain truly sorry for this.’’
Simmons said the public could be assured the DHB had implemented the recommendations, completed internal reviews and was making ongoing improvements.
‘‘We want to reassure people we take this breach extremely seriously and our teams have learnt a great deal from this case. We have made changes to systems and processes to reduce the chances of similar failings happening again.’’
The DHB has been referred to the Director of Proceedings – a step reserved for the most serious breaches of the code.
The Director of Proceedings will review the information provided by the commissioner and in some cases take further action.