The importance of having clear systems in place to ensure
emergency department (ED) clinicians are aware of which
consultant has responsibility for each patient, and
processes for consultant handovers was highlighted in a
decision published by Deputy Health and Disability
Commissioner Dr Vanessa Caldwell.
Dr Caldwell also
emphasised the importance of resident medical officers
recording and communicating a patient’s symptoms
accurately, and recognising when care should be escalated to
a senior medical officer (SMO).
A woman, in her
eighties at the time of the events went to an ED with acute
kidney failure and obstruction of her single functioning
kidney, but was discharged five hours later with a diagnosis
of a kidney stone. She re-presented to the ED three days
later and sadly passed away.
In her decision, Dr
Caldwell considered the adequacy of the care provided to the
woman by the ED at her first admission, including whether
the discharge was appropriate, and the system in place at
the hospital regarding overall consultant
responsibility.
Dr Caldwell concluded the consultant
handover processes in place at the ED were inadequate, with
no clear identification and delineation of which consultant
had oversight of care for the woman. She therefore found
Taranaki District Health Board (TDHB), now Te Whatu Ora
Taranaki, in breach of the Code of Health and Disability
Services Consumers’ Rights (the Code) for failing to
provide services with reasonable care and skill.
Te
Whatu Ora Taranaki was referred to the Director of
Proceedings for consideration of further
proceedings.
Dr Caldwell further concluded a senior
house officer (SHO) should have recognised the seriousness
of the woman’s condition and admitted her to hospital, and
therefore also found the SHO in breach of the Code.
“I
consider the failures in this case were the result of both
an individual error in clinical decision-making, and an
inadequate system within the ED, for which TDHB had
responsibility.
“At the time of events, TDHB ED did
not have a system that clearly identified or allocated a
supervising consultant for each patient. TDHB had overall
responsibility for these system failures that contributed to
the tragic consequences of this case.
“Actions and
omissions of the SHO to recognise the seriousness of the
woman’s condition contributed to her being discharged from
the ED inappropriately. While the SHO was a junior doctor at
the time of events, I note her significant prior experience.
I consider my criticisms of her care for the woman were well
within her capabilities,” says Dr Caldwell.
Te Whatu
Ora Taranaki and the SHO were both asked to provide a
written apology to the family.
Dr Caldwell made
multiple recommendations to Te Whatu Ora Taranaki including;
developing a more formal system for consultant handover in
ED, providing training to all ED SHOs on the revised
guidelines/system for handover, and highlighting the
importance of communication between nurses and senior
medical officers.
Dr Caldwell recommended the SHO
undertake further training and also recommended the Medical
Council of New Zealand consider whether a review of the
SHO’s competence is warranted.
Following the events,
Te Whatu Ora Taranaki have implemented changes to its
processes including the use of an electronic whiteboard to
record and identify the consultant with responsible
authority, and ensure that one senior doctor is clearly
focused on the patient’s care, changes to the consultant
staffing model for the ED, and changes to its escalation
procedures by nurses.
“I am pleased to see the
significant work and changes undertaken in the hospital to
improve patient care to prevent a similar occurrence in the
future,” says Dr Caldwell.
Notes
The full report
of this case can be viewed on HDC’s website – see HDC’s ‘
Latest
Decisions‘.
Names have been removed from the
report to protect privacy of the individual involved in this
case. We anticipate that the Commissioner will name DHBs and
public hospitals 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. 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).
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