DHB re­leases de­tails of ad­verse and men­tal health death events

Six­teen deaths as a re­sult of care re­gret­table, DHB ad­viser says

Bay of Plenty Times - - LOCAL NEWS - Scott Yeo­man

Six­teen peo­ple died as a re­sult of un­in­tended, un­ex­pected or un­planned events and men­tal health-re­lated in­ci­dents in the Bay of Plenty Dis­trict Health Board area in the lat­est re­port­ing pe­riod.

Two of those deaths, one an el­derly in­pa­tient and the other a foe­tus, were among a to­tal of 13 ad­verse events in 2017/18 — out­comes the dis­trict health board has de­scribed as “re­gret­table”.

There were also 14 deaths re­lated to men­tal health events over a pe­riod of 18 months in the Bay of Plenty Dis­trict Health Board area, which in­cludes Tau­ranga and Whakata¯ne hos­pi­tals.

The 13 ad­verse events re­lated to clinical process (as­sess­ment, di­ag­no­sis, treat­ment and gen­eral care) and in­cluded eight falls.

One of the falls, in­volv­ing an el­derly in­pa­tient, was fa­tal. The pa­tient suf­fered a head in­jury and sub­se­quently died.

The other ad­verse event fa­tal­ity was a “pla­cen­tal abrup­tion re­sult­ing in foetal demise”.

No fur­ther de­tails were pro­vided on those two deaths.

Ad­verse events are over­seen na­tion­ally by the Health Qual­ity and Safety Com­mis­sion, which de­fines them as events with neg­a­tive re­ac­tions or re­sults that are un­in­tended, un­ex­pected or un­planned.

The com­mis­sion says ad­verse events are of­ten re­ferred to as in­ci­dents or re­portable events and in prac­tice, are most of­ten un­der­stood as events which re­sult in harm to a con­sumer.

Deb­bie Brown, the Bay of Plenty Dis­trict Health Board’s se­nior ad­viser of gov­er­nance and qual­ity, said: “Over 62,000 pa­tients are dis­charged from our hos­pi­tal sites each year and when The Bay of Plenty Dis­trict Health Board area in­cludes Tau­ranga and Whakata¯ ne hos­pi­tals. a per­son has an ad­verse out­come as a re­sult of their care with the BOPDHB it is re­gret­table.”

She said when care did not go as planned, the dis­trict health board thor­oughly re­viewed it and worked closely with the pa­tient’s fam­ily through that process.

“We then im­ple­ment any re­sult­ing rec­om­men­da­tions, to en­sure no other per­son and their fam­ily/wha¯nau has the same ex­pe­ri­ence.”

The in­ci­dent in­volv­ing the el­derly in­pa­tient was in­ves­ti­gated and found to be “an un­for­tu­nate ac­ci­dent and there­fore no fur­ther rec­om­men­da­tions were made”.

The pla­cen­tal abrup­tion case is cur­rently un­der re­view and the find­ings are not yet avail­able.

Brown said na­tion­ally the num­ber of ad­verse events re­ported to the Health Qual­ity and Safety Com­mis­sion in 2017/18 rose com­pared to the pre­vi­ous years.

“This in­crease is likely due to changes in re­quire­ments for re­port­ing along with bet­ter re­port­ing within DHBS. Even with in­creased re­port­ing the ad­verse events num­bers at the BOPDHB for 2017/18 have If you are wor­ried about your or some­one else’s men­tal health, the best place to get help is your GP or local men­tal health provider. How­ever, if you or some­one else is in dan­ger or en­dan­ger­ing oth­ers, call po­lice im­me­di­ately on 111. Or if you need to talk to some­one else:

Life­line: 0800 543 354 or text HELP (4357) for free (avail­able 24/7)

Sui­cide Cri­sis Helpline: 0508 828 865 (0508 TAUTOKO) (avail­able 24/7)

Youth­line: 0800 376 633 or text 234

Kid­sline: 0800 543 754 (avail­able 24/7)

What­sup: 0800 942 8787 (Mon-fri 1pm to 10pm. Sat-sun 3pm-10pm)

De­pres­sion helpline: 0800 111 757 or text 4202 (avail­able 24/7) Rain­bow Youth: (09) 376 4155 Sa­mar­i­tans: 0800 726 666 Need to talk? Call or text 1737 come down from 2016/17.”

The Bay of Plenty Dis­trict Health Board area had 15 ad­verse events in 2016/17.

Mean­while, there were a to­tal of 15 men­tal health events re­sult­ing in death or se­ri­ous harm over a pe­riod of 18 months in the dis­trict health board area — 13 com­mu­nity and two in­pa­tient.

Four­teen of those 15 cases re­sulted in a death.

The dis­trict health board would not com­ment on the men­tal health cases and would not clar­ify de­tails about the fig­ures it pro­vided.

There were also seven “Al­ways Re­port and Re­view Events” in 2017/18.

This is a new cat­e­gory for pre­ventable events which, re­gard­less of whether any harm has oc­curred, should be re­ported and re­viewed in the same way as an ad­verse event.


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