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Source: MIL-OSI Submissions

Source: Health and Disability Commissioner

The Office of the Health and Disability Commissioner 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 failures relating to the care of a man admitted to hospital with acute pancreatitis.
The man, aged in his late sixties, was admitted to hospital following a sudden onset of abdominal pain. He was given oxygen and pain relief, and assessed as having mild to moderate acute pancreatitis. An ultrasound scan was planned for the following day to investigate the cause of the pancreatitis further.
Overnight, the man’s condition deteriorated, but staff failed to recognize this and to escalate his care in a timely manner. He was transferred to the Intensive Care Unit (ICU) 36 hours after his admission to hospital, and it was only at this point that he was seen by a consultant. Sadly, he developed sepsis and suffered a cardiac arrest, and he could not be resuscitated.
Former Commissioner Anthony Hill found that there was a lack of clarity about who had overall responsibility for the man’s care, and a lack of effective communication between the different teams responsible for the man’s care. He was critical that the DHB did not have systems in place to support staff in their clinical decision-making, including escalation of concerns and communication between teams. As a result of these failings, there was a delay in transferring the man to ICU and, consequently, a missed opportunity for him to receive treatment for his deteriorating condition at an earlier time. Mr Hill also considered that staff did not communicate information to the family adequately about the risks associated with acute pancreatitis.
“[This case] highlights the importance of effective communication between nursing and surgical staff and with the consumer’s family, and of ensuring that senior doctors provide guidance and leadership to junior doctors, and that documentation is completed to a good standard,” said Mr Hill.
Mr Hill recommended that the DHB update HDC on the changes made as a result of their Adverse Event Review. He also recommended that the DHB provide HDC with a copy of the updated pancreatitis and fluid management guidelines; details of the escalation pathway when a patient is reviewed more than once during a shift; the outcome of the review of the Early Warning Score framework (a system to track signs of acute clinical deterioration); and a report on how the current system is working.
Mr Hill recommended that the DHB use an anonymised version of the report as a case study to provide continuing education to staff on the use of the Early Warning Score system and escalation of care, and provide a formal written apology to the man’s wife.
The full report for case 17HDC02364 is available on the HDC website.