A tragic case at Wellington Hospital

A tragic case at Wellington Hospital

Health and Disability Commissioner Ron Paterson has found serious failings in the care a 50-year-old patient received in Wellington Hospital in September 2004, over the 40 hours prior to his death.

Mr Paterson has just completed an investigation into a complaint from the man's family. In a report released today, Mr Paterson states:

"The primary focus of my report is on the failure of Capital and Coast District Health Board to provide safe and appropriate care for a very unwell patient. In addition to the clear systems failure, several individual doctors and nurses must accept responsibility for their failure to provide appropriate medical and nursing care."

"Before and after the chest infection was diagnosed, clinical staff provided a poor standard of care. There was inadequate communication, documentation, and monitoring of [the patient's] condition. [He] was deprived of the opportunity to benefit from simple interventions that might have saved his life."

Mr Paterson also criticises the attitude of some members of the clinical staff to the patient and his family:

"The tragedy of this case is compounded by the fact that during his fatal illness, Mr [X] was denied the basic respect that ethics and the law require to be accorded to all patients."

Mr Paterson says the case should be a "wake-up call to all district health boards". He has sent a copy of the report to the CEO of every DHB, requesting that they review their own systems to prevent a similar event happening in their hospitals:

"That the same tragedy could unfold at another hospital in New Zealand should not obscure the fact that what happened at Wellington Hospital is inexcusable. It is vital that lessons are learnt from this tragic case, and that steps are taken at Wellington Hospital and around the country to ensure that patients receive the competent and co-ordinated care they need and deserve, and that they and their families are treated with compassion."

Key facts from report
A 50-year-old man was admitted to Wellington Hospital in September 2004 with classical signs of a chest infection. His chest X-ray and blood tests were not reviewed for almost 30 hours, despite an assessment during that time by a senior registrar and a consultant physician. He was inadequately monitored by nursing staff, with virtually no clinical observations performed during the last 12 hours of his life. He was found dead by nursing staff at 6am, just over 40 hours from when he was admitted to hospital. At post-mortem, the cause of death was found to be respiratory failure and pneumonia.

Summary of findings
Capital and Coast DHB
The Commissioner found that Capital and Coast DHB (CCDHB) breached the Code of Health and Disability Services Consumers' Rights (the Code) by:

- a lack of care planning, ineffective communication, and discontinuity of care
- an inadequate response to shortages in nursing and medical staffing
- allowing an enrolled nurse to work outside her scope of practice
- not treating the patient and his family with respect and compassion
- failing to respond appropriately to the patient's nicotine addiction.

The Commissioner also criticised CCDHB's response to queries from the patient's relatives after he had died. Mr Paterson states:

"Hospital management and clinicians owe families a duty of candour in such circumstances — to openly discuss and honestly disclose what has happened, and to apologise for any shortcomings in care. The conduct of CCDHB in this case fell woefully short of the standard of open and honest disclosure expected of a hospital in such circumstances."

Doctors and nurses
The Commissioner found that a number of CCDHB doctors and nurses also breached the Code, as follows:

- Medical registrar failed to review the X-ray (or arrange for it to be reviewed) and did not commence antibiotic treatment in the presence of clear signs of infection.
- Consultant physician did not ensure that the X-ray was reviewed, failed to review blood test results, and failed to commence treatment for chest infection.
- Registered nurse failed to monitor the patient's condition adequately and gave an inadequate handover to the night staff.
- Enrolled nurse failed to undertake any clinical observations.

Key recommendations
- CCDHB to review the management of patients who require treatment in hospital, but are addicted to nicotine, and advise the Commissioner by 30 June 2007.
- CCDHB to review its systems of care for physiologically unstable patients at Wellington Hospital, and to report what actions are to be taken to improve the quality of care for such patients to the Commissioner by 30 June 2007.
- All DHBs to advise the Commissioner by 30 June 2007 what safeguards are in place to prevent a similar event occurring at their hospitals.

Referral to Director of Proceedings
The Commissioner has referred CCDHB to the Director of Proceedings, for the purpose of determining whether any further proceedings should be taken. Mr Paterson states:

"All too often, the public of New Zealand is told that failings in the health service (or other public/private services) are attributable to 'the system'. … Education and quality improvement are laudable goals, but there must also be accountability for systems failures. The buck must stop somewhere."

This is the first time the Commissioner has specifically referred a district health board to face a potential civil claim before the Human Rights Review Tribunal.

No individual doctor or nurse has been referred to the Director of Proceedings.

Copies of report
A copy of the report has been sent to the Minister of Health, the Director-General of Health, the Medical Council of New Zealand, all District Health Boards, Quality Health New Zealand, the Mental Health Commission, the New Zealand Nurses Organisation, the New Zealand Medical Association, the Resident Doctors Association, the Association of Salaried Medical Specialists, and the National Health Epidemiology and Quality Assurance Advisory Committee.

The full (partially anonymised) report may be viewed at: www.hdc.org.nz/files/HDC/Opinions/05HDC11908dhb.pdf

Background
What is the Code of Consumers' Rights?
The Code of Health and Disability Services Consumers' Rights is a regulation under the Health and Disability Commissioner Act 1994. It confers a number of rights on all consumers of health and disability services in New Zealand, and places corresponding obligations on the providers of those services, including hospitals and district health boards.

What is the function of the Director of Proceedings?
The Director of Proceedings is an independent statutory officer under the Health and Disability Commissioner Act 1994. The current Director is Ms Theo Baker. The Director has responsibility for deciding whether to issue proceedings on matters referred by the Commissioner.

What happens next?
If the Director decides to issue proceedings, a claim will be drafted and filed with the Human Rights Review Tribunal. Under the Health and Disability Commissioner Act 1994, the proceedings are at the suit of the Director of Proceedings. Therefore she is the plaintiff, but seeks remedies on behalf of the aggrieved person(s) — in this case, the patient's immediate family.

What remedies are available?
Under the Health and Disability Commissioner Act, the Tribunal, on being satisfied that any action of a defendant is in breach of the Code, the Health and Disability Commissioner may grant any one or more of the following remedies:

- A declaration that the action of the defendant is in breach of the Code:
- An order restraining the defendant from continuing or repeating the breach, or from engaging in, or causing or permitting others to engage in, conduct of the same kind as that constituting the breach, or conduct of any similar kind specified in the order
- Damages for pecuniary loss, loss of any benefit, humiliation, loss of dignity and injury to feelings
- Exemplary damages (for any action that was in flagrant disregard of the rights of the aggrieved person)
- An order that the defendant perform any acts specified in the order with a view to redressing any loss or damage suffered by the aggrieved person as a result of the breach
- Such other relief as the Tribunal thinks fit.

What further comment can the Director of Proceedings provide to the media?
For legal reasons the Director of Proceedings will make no further comment at this time.

ENDS

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