Unexpected deaths nearly double at DHB

Serious adverse events at the Capital & Coast District Health Board nearly doubled to 61 in the year ended June.

Seventeen patients died, and other adverse events included a premature baby being fed formula instead of breast milk, resulting in surgery, and one patient being permanently harmed by delays to their surgery.

In the previous year, 36 adverse events – unintended or unexpected events causing serious harm – were reported, including the deaths of nine patients.

Adverse medication events increased from one to seven in the last year. A woman was given an incorrect intravenous medication during labour and had to have her baby via emergency delivery, while two patients had reduced consciousness after reacting to opioids.

Six babies had to be admitted to the neonatal intensive care unit at Wellington Regional Hospital following failures in their process of care.

Two people caught infections from the hospital, including a premature baby whose condition then deteriorated. As a result, the hospital installed bacterial filters on all water taps in the unit.

The board is investigating 65 per cent more cases this year, according to its report. Improvements would follow its reviews.

But the jump also shows an improved reporting culture among staff, the board’s chief medical officer, John Tait, said.

He was not available for an interview but in a statement said the harm was low in relation to how many people used the DHB.

‘‘Capital & Coast DHB funds and provides health services for 300,000 people in Wellington, Porirua and Ka¯piti,’’ he said.

‘‘We provide a range of tertiary and specialist services for the upper South and lower North islands – a population of around 900,000 people.

‘‘As a DHB we discharge an average of 60,000 patients from our hospital facilities, perform an average of 19,000 surgeries, and have more than 3000 babies born each year.

‘‘We are confident that the vast majority of our patients receive safe, timely and high quality service.’’

The DHB had also bought a donor milk pasteurisation and storage facility to have its own supply of donor milk, following issues with its supply during the Covid-19 lockdown.

Across the country’s 20 district health boards, 627 adverse events were reported.

Auckland topped the list with 81 events compared with 59 last year, whereas Canterbury had 77. Southern had 66 adverse events. The Wairarapa DHB recorded six adverse events, while Hawke’s Bay had 26.

Sarah Dalton, from the Association of Salaried Medical Specialists, said public reporting of adverse events encouraged an open culture.

‘‘It is a sign of a mature, reflective health system,’’ she said.

‘‘We support the promotion of open cultures that encourage review which, in the end, result in better care for patients and their families.’’