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Deputy Health and Disability Commissioner Dr Vanessa
Caldwell has found Te Whatu Ora – Nelson Marlborough (NMD),
formerly Nelson Marlborough District Health Board in breach
of the Code of Health and Disability Services Consumers’
Rights (the Code).
A man underwent surgery to remove a
bladder tumour at Nelson Hospital. After the surgery, a
postoperative plan was made for the man to have a follow-up
consultation with the urologist in 2-3 weeks’ time.
However, administrative staff at NMD failed to action the
man’s appointment, and, as a result, he did not receive
timely management of his care, and his histology results
were not communicated to him.
Over a year later, the
man presented to Nelson Hospital after experiencing
discomfort and blood in his urine. During this consultation,
it was discovered NMD had failed to book the follow-up
appointment after his surgery in the previous year. The man
underwent further investigations and was diagnosed with
terminal bladder cancer, which may have been preventable had
the man received timely follow-up and appropriate treatment
postoperatively.
In her decision, Dr Caldwell
considered NMD did not have in place robust systems to
minimise the risk of errors in arranging important follow-up
care in accordance with the New Zealand Health and
Disability Services Standards. Dr Caldwell also considered
the results of tumour biopsies was information a reasonable
consumer would expect to receive.
Dr Caldwell says,
“it is the responsibility of healthcare providers, such as
NMD, to ensure there are robust systems in place to minimise
the risk of errors in arranging important follow-up
care.”
“The New Zealand Health and Disability Services
(CORE) Standards states that each stage or service provision
(assessment, planning, provision, evaluation, review, and
exit) is to be provided within timeframes that safely meet
the needs of the consumer.
“NMD has accepted it
‘clearly failed’ to provide appropriate follow-up care
to the man after his procedure by failing to make an
outpatient appointment with the urologist,” says Dr
Caldwell.
Dr Caldwell was also critical the man was
not notified about his histology results which contained
serious findings of the fast-spreading cancerous
tumours.
“Failure to notify the man of the histology
results was a systems failure. Had the follow-up appointment
been booked by NMD, the man would have been informed of the
results. I consider a reasonable consumer in the man’s
circumstances would expect to receive the results of his
tumour biopsies,” says Dr Caldwell.
Dr Caldwell
recommended NMD provide a written apology to the man. She
also recommended NMD outline the progress made in
implementing discharge summaries for all Day Stay Unit
patients and the effectiveness of the stickers placed on the
patient’s chart; monitor the new system implemented in
relation to referrals created in the electronic system; and
consider further changes to ensure patients are informed of
the need for a follow-up appointment.
Dr Caldwell will
also ask the Ministry of Health to seek confirmation from Te
Whatu Ora of the activities and expected outcomes under the
New Zealand Health Plan that will improve electronic booking
systems and administrative processes to improve patient
outcome by reducing multiple handling of
information.
As a result of the events in this case,
NMD made a number of changes to its discharge and follow-up
processes, including a review of policies, procedures, and
guidelines to ensure they are adequate to prevent patients
falling through the gaps. NMD have also implemented software
which will allow clinicians to complete electronic operation
notes that are automatically uploaded to clinical records,
and directly notifies the respective secretaries of the need
for follow-up. NMD confirmed the service upgrade was
completed on 30 December 2021 with all services
onboard.
“Patients are trained to consider ‘no
follow-up as no issue’ with test results so it is vital
that good systems are in place to ensure patients are
followed up when test results show anomalies.
“I am
pleased to see the systems improvements and changes made by
NMD to its procedures and processes. This will lead to
positive change and improved service delivery for future
patients at Nelson Hospital,” says Dr
Caldwell.
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