Source: MIL-OSI Submissions
Source: Health and Disability Commissioner
The importance of robust systems for ordering and acting on test results, and communication with consumers about their results was highlighted in a decision published by Deputy Health and Disability Commissioner Dr Vanessa Caldwell.
In her decision, Dr Caldwell found the Department of Corrections (Corrections) in breach of the Code of Health and Disability Services Consumers’ Rights (the Code) for not informing a woman of her abnormal test result until over two years later. She also found that Corrections’ processes for ordering tests and follow up of abnormal results was inadequate and their systems failed to ensure the health service was informed of the woman’s release, or that the woman was informed of the need for her to see a doctor on her release.
A woman (aged in her thirties), who was a resident at Auckland Region Women’s Corrections Facility (ARWCF) attended a nursing appointment at ARWCF after submitting a Health Request Form for “blood in her stool”.
An abnormal result from a test was not actioned, either by way of a further nursing assessment or referral to a medical officer, and the woman was not informed of the result, despite a subsequent nursing assessment. The medical officer saw the positive test result in her inbox on the day it was returned and booked the woman for the first available clinic appointment, but she was released from ARWCF prior to the appointment. The health service was not informed of the woman’s release, and the woman was not told of her outstanding test result or of the importance of seeing a doctor in the community for her symptoms.
The health service became aware of the woman’s release about a week later. Corrections did not contact the woman about her test result and she was not provided with her abnormal test result until over two years later. The woman was subsequently diagnosed with advanced colorectal cancer.
The Code requires Corrections, as a healthcare provider, to ensure health services are provided to prisoners in their care of an appropriate standard.
Dr Caldwell noted there were multiple issues with the woman’s care, which stemmed in part from inadequate policies and procedures at Corrections.
“There was a lack of effective communication between the different teams within Corrections, namely the health service and custodial staff. As a result, the health service was unaware the woman was to be released, and therefore an earlier appointment was needed.
“Had the health service been informed of the woman’s release, at the very least she would have been provided with a discharge summary noting her abnormal result and the importance of follow-up in the community.
“It is clear Corrections did not provide medical treatment that was ‘reasonably necessary’ for the woman, and the standard of health care she received at ARWCF was not ‘reasonably equivalent’ to the standard of health care available to the public. I therefore consider there was an overarching service failure in this case,” says Dr Caldwell.
Dr Caldwell recommended Corrections provide the woman with a written apology. She also recommended they provide HDC with an update on the changes made since these events, including the review and development of its policies; report on the current wait times in the health service at ARWCF and the further actions taken to ensure patients’ health needs are prioritised appropriately; and undertake an audit of prisoners who have been released, to check whether the appropriate steps were taken in relation to their discharge summaries and health information.
We anticipate that the Commissioner will name providers found in breach of the Code, unless it would not be in the public interest, or would unfairly compromise the privacy interests of an individual provider or a consumer.
More information for the media and HDC’s naming policy can be found on our website here.
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