The Deputy Health and Disability Commissioner, Dr Vanessa
Caldwell has found Te Whatu Ora – Whanganui (formerly
Whanganui DHB) breached the Code of Health and Disability
Services Consumers’ Rights (the Code) following its
treatment of a man who did not receive coordinated care in
his leg being amputated below the knee.
The man went
to Whanganui Hospital eight times over three months for
treatment of an ingrown toenail and an unresolved infection.
He had a complex medical history with a number of chronic
conditions.
The man’s infection progressed over the
three months and his right toe was amputated in an attempt
to stop its spread. However, this was unsuccessful and six
days later the leg amputation proceeded.
In her
decision, Dr Caldwell said she was concerned that, despite
the repeated presentations and unplanned admissions, a
coordinated care plan directed by a senior staff member was
not put in place, nor was there a multidisciplinary team
approach. Instead, his presentations and admissions to ED
were managed in isolation of each other.
Dr Caldwell
found WDHB breached Right 4(5) of the Code, being the right
to services of an appropriate standard, specifically that
every consumer has the right to co-operation among providers
to ensure quality and continuity of services.
“A
hospital system would be expected to operate in such a way
that a patient who has attended numerous times with the same
issue would be afforded continuity of services, for example
by having a dedicated team assigned to oversee, monitor and
plan the patient’s care.”
“I would expect WDHB’s
system to operate in this manner, and consider this should
have been the case with Mr A.”
Dr Caldwell also
criticised aspects of the man’s care provided by three
doctors and commented on the care provided by two further
doctors.
WDHB has since established a high-risk foot
clinic to focus on education and awareness, assessment,
diagnosis and care plan development, initiation of
treatment, follow up, and onward
referral.
ENDS
Editors notes
The full
report of this case (20HDC00914) will be available on
HDC’s website.
Names have been removed from the report to protect privacy
of the individuals involved in this case.
The
Commissioner will usually name providers 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.
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).
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