Life at risk when IT system failed
Documents reveal how treatment of young girl hindered
A12-year-old girl who suffered a serious liver injury in a car accident could have died because an urgent radiology report did not show up in a hospital’s electronic records system, according to documents obtained by the Herald.
The alleged near-miss was one of several incidents that Dr Bryan Wolf, a senior doctor at Hawke’s Bay Hospital’s radiology department, claimed were evidence of deep-rooted technical and cultural problems that endangered staff and patients at the hospital until last year.
Wolf submitted at least five detailed reports to senior executives at Te Whatu Ora-Health New Zealand which highlight one of the major challenges thrown up by the biggest public restructuring in New Zealand history. In merging 20 regional health authorities, Te Whatu Ora has inherited thousands of IT systems that are often outdated and severely flawed.
In one report, which has not been made public, Wolf claimed that an unnamed child was taken to Hawke’s Bay Hospital after a vehicle collision in November 2022. The 12-year-old was sent by emergency department doctors for a CT scan, which showed that she had a lacerated liver and a small lung contusion.
A radiologist advised that the girl needed to be examined by a surgeon but their report did not show up in the hospital’s clinical records portal. Surgical staff only learned about the recommendation hours later when a junior doctor independently looked at the scan results.
“The 12-year-old slept through the night, accompanied by their wha¯nau at her bedside, under the false assumption she was safe and receiving care with reasonable skill,” Wolf claimed in the report. “At any moment, the patient could have decompensated and died, as some do with liver lacerations.”
By “luck and chance” the girl’s liver stopped bleeding on its own without needing surgery, Wolf wrote. Her family was oblivious to their near-miss until Wolf told them about it later. (Wolf declined to comment and the girl’s family could not be reached.)
The incident was not isolated, Wolf claimed, but representative of widespread safety risks at the hospital arising from flawed IT systems. He claimed that similar problems were happening routinely in other hospitals across the country.
In response to Wolf’s disclosures, Te Whatu Ora ordered a review of Hawke’s Bay’s radiology service. In April 2023, the reviewers issued a damning report which found that years of poor performance and unsafe practices had forced staff to adopt risky workarounds, fostered a culture of “learned helplessness”, and caused documented harm to patients.
At the heart of the problems was an IT system that was plagued with technical problems, including that prior patient studies were not visible, scans for different body parts of the same patient were not linked, and reports were not delivered to the clinicians who requested them.
Te Whatu Ora initially refused to release the findings of the April 2023 review. Wolf was furious at that decision and wrote to the Chief Ombudsman Peter Boshier accusing Te Whatu Ora of a “conspiracy” to avoid disclosing safety risks to the public. Te Whatu Ora denied there had been a deliberate attempt to mislead the public and said it acted on legal advice.
Te Whatu Ora reconsidered in August after the Herald revealed that
Wolf had escalated the issue to the Ombudsman and it published the reviewers’ full findings and recommendations. Since then, Wolf’s disclosures have reverberated across the health service, prompting scrutiny from external agencies and a flurry of activity among senior executives.
Te Whatu Ora says it has taken Wolf’s concerns extremely seriously and committed significant resources to address the problems he raised. But months later there has yet to be a full public accounting of the extent of patient harm caused by the problems at Hawke’s Bay Hospital over the past decade and the impact they had on individual patients.
The reports obtained by the Herald add substantially to the information in the April 2023 review, including details of several incidents in which patients were harmed or experienced close calls.
In one example, Wolf claimed that an orthopaedic surgeon was about to perform emergency surgery on a teenager who had suffered major fractures but had to wait because a computer in the operating theatre did not have enough memory to open CT images. The emergency procedure was delayed by up to 15 minutes while the surgeon went around other rooms trying to open the scans.
In an email quoted by Wolf, the surgeon later said that the hospital’s IT system “presents a serious risk to patients and in my opinion, it is only a matter of time before someone comes to serious harm or worse still results in a death”.
In other incidents cited by Wolf, a 27-year-old patient allegedly experienced a delay in care of more than 400 days and “will suffer permanent