Source: MIL-OSI Submissions
Source: Health and Disability Commissioner
Deputy Health and Disability Commissioner Deborah James today released a report finding numerous healthcare providers in breach of the Code of Health and Disability Services Consumers’ Rights (the Code) for multiple failures in rural sexual health services provided to a man before and after he was diagnosed with an STI.
A man in his twenties presented to a rural sexual health clinic with symptoms of an STI. Ms James found that throughout the man’s sexual health journey, he engaged with six different (rural) healthcare providers and, along the way, each provider let him down.
“While the individual omissions or errors in this case by each provider may seem small in isolation, they had the cumulative effect of delaying the man’s diagnosis and treatment,” said Ms James.
He was not given all the requisite tests at his initial appointment with a nurse, and subsequently attended a follow up appointment with a GP. The GP (who was juggling a personal crisis along with sole-charge responsibilities in an understaffed centre), failed to do the outstanding tests, arrange repeat tests, or examine the man at this appointment.
Deputy Commissioner, Deborah James was critical of the care provided by the GP at the sexual health clinic whose omissions contributed to the man not receiving care that met accepted practice. However, she considered that primarily the failings identified at the first clinic were the result of a wider systemic issue. In particular, the District Health Board responsible for the sexual health clinic the man initially visited, failed to have in place an adequate system to support its staff.
A month later the man presented at another medical centre with further symptoms, where he experienced more failures in his care.
In addition, there were delays in test results from the medical laboratory due to errors in the laboratory’s test management system.
Ms James further considered that the registered nurse at the second medical centre, which is separate from the DHB, failed to undertake all the tests required, failed to obtain the man’s abnormal blood test results from the system, and failed to hand over the man’s positive test result or put in place an action plan before going on leave. The nurse also inadequately documented the care provided.
A second DHB, which the medical laboratory was part of, was also found to have failed to process and report the man’s two test results within the standard turnaround time.
Ms James recommended that the first DHB provide HDC with an update on the changes being undertaken in its sexual health services; develop a process for formalised yearly performance reviews for all staff; complete a review of the staffing levels at the sexual health clinic; and consider recruitment of more staff to provide leave cover for current staff when needed. She also recommended the DHB provide a written apology to the man.
Ms James recommended that the registered nurse at the medical centre organise a review of his documentation, and write an apology to the man. She also recommended that the New Zealand Medical Council consider whether a review of the nurse’s competence is required.
The second DHB was asked to undertake an audit of its process regarding the analysis of tests.
