Source: Health and Disability Commissioner
Deputy Health and Disability Commissioner Dr Vanessa Caldwell has found Te Whatu Ora – Nelson Marlborough (NMD), formerly Nelson Marlborough District Health Board in breach of the Code of Health and Disability Services Consumers’ Rights (the Code).
A man underwent surgery to remove a bladder tumour at Nelson Hospital. After the surgery, a postoperative plan was made for the man to have a follow-up consultation with the urologist in 2-3 weeks’ time. However, administrative staff at NMD failed to action the man’s appointment, and, as a result, he did not receive timely management of his care, and his histology results were not communicated to him.
Over a year later, the man presented to Nelson Hospital after experiencing discomfort and blood in his urine. During this consultation, it was discovered NMD had failed to book the follow-up appointment after his surgery in the previous year. The man underwent further investigations and was diagnosed with terminal bladder cancer, which may have been preventable had the man received timely follow-up and appropriate treatment postoperatively.
In her decision, Dr Caldwell considered NMD did not have in place robust systems to minimise the risk of errors in arranging important follow-up care in accordance with the New Zealand Health and Disability Services Standards. Dr Caldwell also considered the results of tumour biopsies was information a reasonable consumer would expect to receive.
Dr Caldwell says, “it is the responsibility of healthcare providers, such as NMD, to ensure there are robust systems in place to minimise the risk of errors in arranging important follow-up care.”
“The New Zealand Health and Disability Services (CORE) Standards states that each stage or service provision (assessment, planning, provision, evaluation, review, and exit) is to be provided within timeframes that safely meet the needs of the consumer.
“NMD has accepted it ‘clearly failed’ to provide appropriate follow-up care to the man after his procedure by failing to make an outpatient appointment with the urologist,” says Dr Caldwell.
Dr Caldwell was also critical the man was not notified about his histology results which contained serious findings of the fast-spreading cancerous tumours.
“Failure to notify the man of the histology results was a systems failure. Had the follow-up appointment been booked by NMD, the man would have been informed of the results. I consider a reasonable consumer in the man’s circumstances would expect to receive the results of his tumour biopsies,” says Dr Caldwell.
Dr Caldwell recommended NMD provide a written apology to the man. She also recommended NMD outline the progress made in implementing discharge summaries for all Day Stay Unit patients and the effectiveness of the stickers placed on the patient’s chart; monitor the new system implemented in relation to referrals created in the electronic system; and consider further changes to ensure patients are informed of the need for a follow-up appointment.
Dr Caldwell will also ask the Ministry of Health to seek confirmation from Te Whatu Ora of the activities and expected outcomes under the New Zealand Health Plan that will improve electronic booking systems and administrative processes to improve patient outcome by reducing multiple handling of information.
As a result of the events in this case, NMD made a number of changes to its discharge and follow-up processes, including a review of policies, procedures, and guidelines to ensure they are adequate to prevent patients falling through the gaps. NMD have also implemented software which will allow clinicians to complete electronic operation notes that are automatically uploaded to clinical records, and directly notifies the respective secretaries of the need for follow-up. NMD confirmed the service upgrade was completed on 30 December 2021 with all services onboard.
“Patients are trained to consider ‘no follow-up as no issue’ with test results so it is vital that good systems are in place to ensure patients are followed up when test results show anomalies.
“I am pleased to see the systems improvements and changes made by NMD to its procedures and processes. This will lead to positive change and improved service delivery for future patients at Nelson Hospital,” says Dr Caldwell.
The full report of this case will be available on HDC’s website. Names have been removed from the report to protect privacy of the individuals involved in this case.
The Commissioner will usually name providers and public hospitals 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.
HDC acknowledges the significant pressure the health and disability system is currently under with limited capacity to respond to the demands placed upon it. However, notwithstanding these challenges, people’s rights under the Code continue to apply.
