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Source: MIL-OSI Submissions

Source: Health and Disability Commissioner

Health and Disability Commissioner Anthony Hill today released a report finding a District Health Board (DHB) in breach of the Code of Health and Disability Services Consumers’ Rights (the Code) for providing poor care to a man in his seventies after brain surgery. The Commissioner was also critical of a neurosurgeon who handed the man’s care over to the District Health Board from a private hospital. 
The man had surgery for a brain tumour at a private hospital. Soon after his brain surgery, he developed a deep vein thrombosis and was transferred to a public hospital for further care. His neurosurgeon told the public hospital doctor to arrange a CT scan of the man’s head, and medication to prevent blood clots. The man was at risk of a brain bleed, so he should have been given a low dose of the medication. However the public hospital’s protocol for administering that medication was unclear and a junior doctor gave the man a high dose. The man suffered a brain bleed and died.
Anthony Hill was critical of the DHB for providing inadequate support for junior staff, and for the poor communication from senior to junior clinicians regarding the man’s plan for treatment. The CT scan should have happened before any medication was administered, but due to a misunderstanding and the unavailability of the CT scanner, the scan was not prioritised and the medication was given to the man first.
“[The DHB] is responsible for ensuring an appropriate level of supervision for its junior staff, and for providing adequate training on clinical matters where junior staff may be expected to make decisions without supervision,” Mr Hill said.
“[T]here should have been better systems in place for coordination and decision-making.”
Anthony Hill recommended that the DHB review its processes for requesting and prioritising Radiology scans, and develop a clear and agreed pathway to provide specialist input and support for complex patients. Mr Hill also recommended that the DHB audit junior and senior clinicians in neurosurgical services in respect of the use of the medication prescribed in this case, and that the DHB apologise to the man’s family.
The full report for case C18HDC01361 is available on the HDC website.