Source: Health and Disability Commissioner
The need to ensure tests are followed up, and examinations and tests are undertaken to determine the extent of an illness to support timely diagnosis and management, was highlighted in a decision by Health and Disability Commissioner Morag McDowell.
This case concerns services provided to a man by a GP and medical centre, relating to the diagnosis and management of his kidney disease, until the man was diagnosed with Stage 4 kidney failure.
In her decision Ms McDowell found the GP in breach of the Code of Health and Disability Services Consumers’ Rights (the Code) for a number of deficiencies in care provided to the man, which collectively represented a failure to provide services with reasonable care and skill. She also found the GP in breach of the Code for not adequately informing the man of his deteriorating renal function test results in a timely manner and the risk of ongoing use of certain medication in the context of impaired renal function.
Ms McDowell emphasised “the importance of good communication and robust clinical documentation”.
She considered that “a number of oversights in the man’s care contributed to a delay in his diagnosis with Stage 4 kidney disease”.
Ms McDowell noted clinical advice received that “overall management of the man’s renal disease, particularly the failure to undertake appropriate investigations early on to enable staging of the disease and an appropriate structured management and surveillance plan, departed from accepted practice to a moderate degree”.
“I accept that the medical centre had appropriate policies in place at the time of these events, and consider the errors made by the GP were individual failings and do not indicate broader systems issues at the medical centre.
“However, I have identified some deficiencies in the medical centre’s complaint management on this occasion,” says Ms McDowell.
Ms McDowell recommended the GP provide a written apology to the man and his family, and conduct an audit to ensure clinical documentation is of an appropriate standard according to the Medical Council of New Zealand (MCNZ) practice guidelines. She also recommended MCNZ consider whether a review of the GP’s competence is warranted.
Ms McDowell further recommended the medical centre provide a written apology to the man and his family, conduct a further audit to ensure that patients are classified appropriately in terms of whether they have kidney disease, and undertake communication and complaints management training for staff.
The medical centre accepted the findings of this report, and following the events of this case undertook a range of actions and made changes to improve its processes and policies. HDC were also advised by the GP that he has reflected on, and learnt from this complaint, and made changes to his systems and practice.
“Complaints provide a learning opportunity which can lead to system improvements. I am pleased to see the changes made since these events by the GP and medical centre, which will result in improved standards of care and may prevent other families going through a similar situation in the future,” says Ms McDowell.
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.
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