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Source: Health and Disability Commissioner

The Deputy Health and Disability Commissioner has found a district health board (DHB) (now Te Whatu Ora) failed to provide an appropriate standard of care in its management of risks relating to a woman’s surgery for a broken ankle.
Sadly, the woman died from a pulmonary embolism five days after being discharged from hospital following her surgery for the fracture.
Dr Caldwell found the DHB’s assessment procedures for venous thromboembolism (VTE), where a blood clot or thrombus occurs in a deep vein, on admission were inadequate and that the woman’s specific risk factors, were not considered by staff appropriately. She found that as a result, the management of the woman’s discharge was inadequate.
“There were missed opportunities for staff to assess Ms A’s condition critically and put in place a management plan to address the risks appropriately… I consider this to be a service delivery failure for which, ultimately, Te Whatu Ora is responsible.”
She recommended the organisation formally apologise to the woman’s family for the failings identified. She also recommended it review its policy on assessing and managing VTE risk, and its recommended preventative measures on admission and discharge.
Other recommendations included:
– Te Whatu Ora to provide training to all current staff who were involved in the woman’s care on awareness of VTE’s, assessment processes for VTEs and risks associated with foot and ankle surgery.
– Completion of an audit following the review of Te Whatu Ora’s updated VTE Policy of at least 15 patients to determine compliance with the new policy.
Evidence of these recommendations being carried out is to be provided to HDC within six months of her report.
Te Whatu Ora has made several changes since this report. This includes creating a mandatory field for VTE assessment in electronic admission documents, reinstating mandatory online learning on VTEs for all resident medical officers (RMO), ensuring VTE risk and assessment is included in the RMO orientation and teaching, and reviewing its preoperative process in the use of the Acute Theatre Health Questionnaire.
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