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Source: MIL-OSI Submissions

Source: Health and Disability Commissioner

Deputy Health and Disability Commissioner Rose Wall today released a report finding a district health board (DHB) and a rest home provider in breach of the Code of Health and Disability Services Consumers’ Rights (the Code) for failures in the care of an elderly man following a stroke.
The man, aged in his eighties at the time of events, was admitted to the DHB with slurred speech and a left facial droop. He was transferred from the DHB to the rest home, and required hospital-level care.
At the rest home, his agitation and pain were not assessed and managed adequately, Te Ara Whakapiri end-of-life planning was not initiated, and hospice or other services were not contacted for guidance. Sadly, he passed away three months after being transferred to the home.
Deputy Commissioner Rose Wall found that the DHB’s review of the man’s deteriorating condition was inadequate. There was a lack of consideration for thrombolysis treatment and escalation to a senior doctor, a lack of documentation, and the DHB’s policies and systems to support staff to provide adequate after-hours care and treatment were inadequate.
Ms Wall was critical of the rest home’s overall assessment of the man’s agitation and the management of his pain, and the lack of discussion with his family and his GP. She was also critical of the rest home’s documentation and follow-up of UTIs, and that Te Ara Whakapiri end-of-life planning was not initiated nor the hospice consulted when the man’s condition deteriorated.
“I strongly emphasise to health providers the importance of initiating end-of-life conversations and instigating end-of-life protocols once a patient has been assessed for palliative care and prior to a patient’s deterioration, to enable the person to have a voice (if able) along with their family,” said Ms Wall.
Ms Wall recommended that the DHB use an anonymised version of HDC’s report as a case study; consider updating its stroke thrombolysis protocols and reviewing its stroke management pathway; evaluate its mechanisms to identify and manage spikes in workload after-hours; and provide a written apology to the family.
She recommended that the rest home develop a guideline for the timing of end-of-life conversations and protocols; review its current process for end-of-life care; provide training on end-of-life care; and provide a written apology to the family. She also recommended that the rest home provide its registered nurses with education on the assessment of patients following a stroke; document a plan for regular reassessment of patients who require increased surveillance; and consider training staff on the correct documentation and communication regarding specimens sent for analysis.
To read the full report on case 18HDC02364, visit the HDC website