Source: Health and Disability Commissioner
The Deputy Health and Disability Commissioner has found Te Whatu Ora Te Pae Hauora o Ruahine o Tararua MidCentral (previously MidCentral DHB) breached the Code of Health and Disability Services Consumers’ Rights (the Code) for failing to provide services of an appropriate standard.
The decision relates to the care of a woman in her 50s who presented at the Emergency Department with a history of chest pain. She was assessed but discharged after five hours. She died at home later that day following a cardiac arrest.
“This case highlights the importance of clear and unambiguous communication between clinicians, as well as the critical importance of documenting such communication,” said Deborah James, who found Te Whatu Ora Te Pae Hauora o Ruahine o Tararua MidCentral had breached Right 4(1) of the Code.
The findings center on the woman’s presentation to ED after two days of transient chest pain (pain that comes and goes). The ED specialist caring for the woman told HDC he wanted the woman to be seen by the Cardiology service as an inpatient. However, there were no records of a discussion between ED and Cardiology staff at that time requesting that she be considered for admission.
Ms James also made adverse comment about the ED specialist.
“While the ED specialist had identified that the woman should have been considered for admission, he did not take sufficient steps to ensure this happened…” She said the ED specialist’s documentation of the woman’s care and related discussions did not meet the expected standard.
Ms James recommended the event be used to train staff on the importance of adequate documentation, effective communications, and referral processes for specialist services.
Te Whatu Ora Te Pae Hauora o Ruahine o Tararua MidCentral approved and implemented an action plan to ensure learning from the incident was applied consistently across the organisation.
Names have been removed from the report to protect privacy of the individuals involved in this case.
