A man’s rights under the Code of Health and Disability
Services Consumers’ Rights were breached by Health New
Zealand|Te Whatu Ora Southern and a registrar, the Deputy
Health and Disability Commissioner has found in a decision
released today. Sadly, the man died of a brain
haemorrhage.
The man had an unwitnessed fall at his
care home and was taken to Southland Hospital emergency
department. A yellow envelope containing patient information
was misplaced which meant that hospital staff who were
treating the man were not aware that he was on
anticoagulants.
The man had his initial observations
taken by a registered nurse about six hours after his
arrival at hospital. He was first seen by the registrar
around nine hours after his arrival. The registrar noted it
was usual practice for her to review the information in the
yellow envelope but there wasn’t one. The registrar did
not order a CT scan because she was not aware he was on
anticoagulants.
The man was kept under observation and
was discharged back to the care home the next day. The man
became increasingly ill and was taken back to Southland
Hospital where a CT showed he had experienced an
intracranial haemorrhage and he later died.
Deborah
James said Health NZ breached the Code by not providing
services with reasonable care and
skill.
“Health NZ did not have a clear or
well understood process in place for ambulance staff to hand
over the yellow envelope when there were no available beds
in ED, resulting in the man’s yellow envelope being
misplaced,” she said.
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She added that the
man was not assessed for initial observations until around
six hours after his arrival and that several clinicians had
failed to identify he was on warfarin. These factors
combined meant Health NZ did not provide the appropriate
standard of care.
Ms James said that due to the
man’s age, fragility and because he had suffered a head
injury, a CT scan should have been completed, regardless of
whether or not he was on anticoagulants. She found that the
registrar breached the Code by not providing reasonable care
and skill in their management of the man’s care by not
ensuring a CT was completed or identifying that he was on
anticoagulants.
Health NZ says it has since increased
the number of nurses on at night shift and made sure there
is always a medical imaging technologist on site to take
scans. The registrar has also made a range of changes, which
are outlined in the report.
Ms James has recommended
both parties formally apologise to the man’s family. She
has recommended Health NZ standardise its process for yellow
envelopes to cover when there are no beds
available.
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