Source: MIL-OSI Submissions
Source: Health and Disability Commissioner
Health and Disability Commissioner Morag McDowell 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 in the care of a man admitted to hospital with pneumonia and pleural effusion.
The man, aged in his sixties at the time of the events, presented to the DHB with multilobar pneumonia and pleural effusion (a build-up of fluid around the lungs). The pleural effusion was treated with a chest drain.
A number of oversights in the man’s care relating to a lack of communication and handover, and subsequent lack of assessment and monitoring, resulted in his deterioration not being detected in a timely manner. This contributed to a delay in commencing resuscitation, and sadly the man died.
Health and Disability Commissioner Morag McDowell was critical that communication and handover from doctor to nurse was lacking after the chest drain was removed; a plan for monitoring was documented but not verbally communicated to nursing staff; there was no assessment and monitoring of the man after the chest drain was removed; and the DHB’s policy on observations was not followed.
She was critical that two doctors did not check the man’s anticoagulant status before removing his chest drain and that they did not verbally communicate the plan for monitoring with nursing staff. Ms McDowell was also critical that a nurse did not assess the man before administering IV opiates, when he had respiratory compromise and had been administered opiates for severe pain an hour earlier.
“While acknowledging that it cannot be determined to any degree of certainty that [the man’s] outcome would have been any different had there been appropriate communication, handover, and monitoring and assessment, I conclude that an opportunity to maximise [the man’s] survival was lost,” said Ms McDowell.
Ms McDowell recommended that the DHB use an anonymised version of HDC’s report as a case study; consider updating their Bedside Handover Policy; and consider including a strategy on communication and handover in their Adverse Event Investigation Action Plan.
She also recommended that the DHB provide an update on the implementation of the draft Intrapleural Haemorrhage Guidelines Policy; consider updating the Respiratory Chest Drain Policy; require registered nurses who care for patients with chest drains to demonstrate competency in all aspects of chest drains; and provide a formal written apology to the man’s family.
The full report for case 18HDC01266 is available on the HDC website.