Death of newborn among incidents

The death of a newborn baby sharing a bed with their mother, the loss of an eye from a delayed appointment, and a sepsis infection from swabs left in after surgery were among the serious adverse events reported in Canterbury in the past year.

The Canterbury District Health Board (CDHB) reported 82 serious adverse events for the 2017-18 year, an increase from 73 events (or 12 per cent) on the previous year.

Adverse events were those that resulted in ‘‘significant additional treatment, major loss of function, are life-threatening or have led to an unexpected death’’, the CDHB’s report says. Of the total events reported by CDHB, 50 were caused by falls in hospital, and 14 from hospital-acquired pressure injuries, or bed sores.

The CDHB report did not say what injuries the falls resulted in.

Other events included a cardiac arrest ‘‘potentially’’ caused by aspiration of oral medication and a head injury to a palliative care patient who was being transferred from a chair to a bed by hoist.

The report says the patient ‘‘slid out of hoist due to incorrect use and insufficient training with hoist equipment’’.

Two incidents of ‘‘babies born in poor condition’’ were reported, but reviews were not completed.

A medication omission for one patient resulted in a blood clot on the brain and ‘‘associated seizures’’.

In another case,a woman who haemorrhaged after a C-section was given a hysterectomy. A review has not yet been completed.

Incidents including the wrong placement of an implant, and the wrong site for surgery were also included in the report.

Nationally 631 adverse events were reported to the Health, Quality & Safety Commission by district health boards (DHBs) and 351 by other providers, a 16 per cent increase on the 2016-17 year.

This year 232 mental health adverse events were reported to the commission by DHBs, including 208 suspected suicides.

The majority of these (196) happened in the community. Other events included ‘‘self-harm’’ and ‘‘serious adverse behaviour’’.

CDHB chief medical officer Sue Nightingale said staff had reported more events because DHBs had worked diligently to increase their ability to recognise and report adverse events.

Each of the events was investigated and reviewed so staff could ‘‘learn and improve our systems and processes to make them safer’’, she said.

‘‘While we aim for zero harm, having a culture where staff are encouraged and supported to report adverse events is vital to ensure the quality and safety of our treatment and care is constantly improving.’’