The importance of robust systems for ordering and acting
on test results, and communication with consumers about
their results was highlighted in a decision published by
Deputy Health and Disability Commissioner Dr Vanessa
Caldwell.
In her decision, Dr Caldwell found the
Department of Corrections (Corrections) in breach of the
Code of Health and Disability Services Consumers’ Rights
(the Code) for not informing a woman of her abnormal test
result until over two years later. She also found that
Corrections’ processes for ordering tests and follow up of
abnormal results was inadequate and their systems failed to
ensure the health service was informed of the woman’s
release, or that the woman was informed of the need for her
to see a doctor on her release.
A woman (aged in her
thirties), who was a resident at Auckland Region Women’s
Corrections Facility (ARWCF) attended a nursing appointment
at ARWCF after submitting a Health Request Form for “blood
in her stool”.
An abnormal result from a test was not
actioned, either by way of a further nursing assessment or
referral to a medical officer, and the woman was not
informed of the result, despite a subsequent nursing
assessment. The medical officer saw the positive test result
in her inbox on the day it was returned and booked the woman
for the first available clinic appointment, but she was
released from ARWCF prior to the appointment. The health
service was not informed of the woman’s release, and the
woman was not told of her outstanding test result or of the
importance of seeing a doctor in the community for her
symptoms.
The health service became aware of the
woman’s release about a week later. Corrections did not
contact the woman about her test result and she was not
provided with her abnormal test result until over two years
later. The woman was subsequently diagnosed with advanced
colorectal cancer.
The Code requires Corrections, as a
healthcare provider, to ensure health services are provided
to prisoners in their care of an appropriate
standard.
Dr Caldwell noted there were multiple issues
with the woman’s care, which stemmed in part from
inadequate policies and procedures at
Corrections.
“There was a lack of effective
communication between the different teams within
Corrections, namely the health service and custodial staff.
As a result, the health service was unaware the woman was to
be released, and therefore an earlier appointment was
needed.
“Had the health service been informed of the
woman’s release, at the very least she would have been
provided with a discharge summary noting her abnormal result
and the importance of follow-up in the community.
“It
is clear Corrections did not provide medical treatment that
was ‘reasonably necessary’ for the woman, and the
standard of health care she received at ARWCF was not
‘reasonably equivalent’ to the standard of health care
available to the public. I therefore consider there was an
overarching service failure in this case,” says Dr
Caldwell.
Dr Caldwell recommended Corrections provide
the woman with a written apology. She also recommended they
provide HDC with an update on the changes made since these
events, including the review and development of its
policies; report on the current wait times in the health
service at ARWCF and the further actions taken to ensure
patients’ health needs are prioritised appropriately; and
undertake an audit of prisoners who have been released, to
check whether the appropriate steps were taken in relation
to their discharge summaries and health
information.
Editors notes
The full
report of this case can be viewed on HDC’s website –
see HDC’s ‘ Latest
Decisions‘.
We anticipate that the Commissioner
will name providers found in breach of the Code, unless it
would not be in the public interest, or would unfairly
compromise the privacy interests of an individual provider
or a consumer.
More information for the media and
HDC’s naming policy can be found on our website here.
HDC
promotes and protects the rights of people
using
health and disability services as set out in the Code
of Health and Disability Services Consumers’ Rights (the
Code).
© Scoop Media
Discussion about this post