Rise in hospital adverse events

A baby being kidnapped from hospital and a patient dying after an improper handover are among 21 blunders from the Midcentral District Health Board in the past year.

Ten people also suffered broken limbs after needless falls and a patient suffered internal damage after a piece of equipment was activated while it was still being inserted into them.

Across the country, 542 adverse events – unintended or unexpected events that result in a patient being harmed – were recorded by district health boards in the 12 months to June this year, up slightly on the 520 for the previous year.

Seven adverse events in Midcentral involved people dying, although not necessarily because of mistakes. There were two of people dying unexpectedly at home after being discharged from hospital, and one where someone deteriorated unexpectedly and died in hospital. In one incident, a patient died after being taken to the emergency department by St John ambulance. The patient was not assessed or treated for suspected acute coronary syndrome and the ambulance handover information was not reviewed by ED staff. This sparked a new process where St John care summaries are viewed by emergency staff and documented in clinical notes. Another incident was the kidnapping of a baby from Palmerston North Hospital. Jamie Rowena Henry, 37, smuggled her 2-day-old daughter out of the neonatal unit with the help of two other women.

Henry gave birth to her youngest child on December 12, and Child, Youth and Family obtained a custody order the next day, placing the child in its care.

Te Arohanui Taputoro, 21, and Tara Jade Taputoro, 28, signed into the hospital with fake names and smuggled the baby out, wrapped in a jacket, before later being caught.

Midcentral said a review of all systems and processes that relate to child safety, child abuse and child supervision across child and women’s services had been undertaken.

Policies, procedures and security were all reviewed and strengthened.

There had been 17 adverse events at Midcentral in 2015-16.