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Source: Health and Disability Commissioner

The Deputy Health and Disability Commissioner has found Waitematā District Health Board DHB (now Te Whatu Ora Waitematā) breached the Code of Health and Disability Services Consumers’ Rights (the Code) in its care of a man with a severe and progressive lung condition. Sadly, the man, in his sixties, passed away as a result of the condition.
Deborah James found Te Whatu Ora breached Right 4 (1) of the Code – the right to services of an appropriate standard provided with reasonable care and skill.
The breach concerns the assessments, communication and support referrals made for the man who wished to receive palliative treatment at home by two hospitals of the Waitematā DHB in 2020.
Ms James was critical of the way the man’s discharge and palliative care was managed.
“Mr B was not reviewed by an occupational therapist or physiotherapist prior to discharge …. A physiotherapy and occupational therapy assessment, including a home visit prior to discharge, would have allowed for the necessary equipment to be in place to allow [Mr B] to be as comfortable as possible in his last days of life,” she said.
Ms James noted the man’s partner of many years was unclear about the oxygen delivery plan and about the oxygen saturation settings for the palliative oxygen care at home. She said overall communication with the man and his partner was poor, leaving his partner feeling confused about the progress of the man’s condition while he was in hospital, and about the timeframe for appropriate hospice support after discharge.
Ms James’ report notes that the man would have benefitted from hospital palliative care involvement and, under the man’s circumstances, inpatient palliative care assessment should have been standard care. She noted that if all the appropriate assessments prior to discharge had been done, the man and his partner would have received more support at home.
Te Whatu Ora has advised HDC that since the complaint it has ensured medical wards have access to inpatient palliative care services to refer patients to, if needed. It has made sure there are multi-disciplinary team meetings on the ward and that family can meet with these teams. It also now recomm