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Source: MIL-OSI Submissions

Source: Health and Disability Commissioner

Deputy Health and Disability Commissioner Kevin Allan 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.
This case highlights the importance of clinicians being alert to the deterioration of patients, including when patients suffer from chronic conditions that affect their normal vital signs, and of documentation being completed to a good standard to support care and decision-making.
The man, who was in his seventies at the time, presented to the public hospital with fevers, breathlessness and a cough. He had been diagnosed with interstitial lung disease the previous year. While in hospital, the man’s condition deteriorated. On the third day, he was found to be struggling for breath and was unable to be resuscitated.
Deputy Commissioner Kevin Allan found that the man’s condition was not adequately monitored, and the response to his deterioration was inadequate. He was critical of a number of connected errors by several relatively junior clinicians in the care provided to the man. Mr Allan considered that the failures to recognise risks, escalate care appropriately, make appropriate clinical decisions, and document the clinical decisions and care provided, had a serious and cumulative impact.
“As a consequence of these errors, opportunities were missed to escalate [the man’s] care to more senior clinicians and to respond to his deteriorating condition more appropriately,” said Mr Allan. 
Mr Allan recommended that the DHB provide evidence to HDC that it has implemented a policy requiring modifications of Early Warning Score triggers to be discussed with a senior medical officer, and confirm that the reviews and audits recommended in the DHB’s own Root Cause Analysis of the man’s death have been conducted. He also recommended that the DHB review its house officer education programme; consider the merits of developing guidelines on the safe prescribing of sedatives for patients and on the appropriate timeframes for alerting patients’ families to deterioration; and apologise to the man’s family.
The Deputy Commissioner also recommended that a respiratory registrar reflect on the issues in this case and report back to HDC on the changes to his practice and learning from further training since these events, and that a house officer undertake further training on recognising clinical deterioration.
The full report on case 19HDC00017 is available on the HDC website.