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DHBs Response to HDC Capital & Coast DHB Inquiry

Responses of DHBs to HDC Capital & Coast DHB Inquiry Report

Health and Disability Commissioner Ron Paterson is calling for greater national collaboration and faster progress on efforts to improve patient safety systems in public hospitals.

In April 2007 the Commissioner asked all district health boards: “What safeguards are in place to prevent a case like the tragic death of a 50-year-old patient at Wellington Hospital in September 2004, occurring at your hospitals?” This followed an investigation into the man’s death, which found serious failings in his care.

The Commissioner has now reviewed the district health boards’ responses to his question. All but one DHB have indicated that a similar case could occur at their hospitals, and they have outlined the steps they are taking to improve their organisation of care. Mr Paterson comments:

“The responses from DHBs indicate that there is a lot of excellent work in progress to improve the safety and quality of hospital care for patients. But currently the efforts are not well coordinated and there appears to be a lot of unnecessary duplication.”

An independent expert, Dr Mary Seddon, reviewed the DHB responses for the Commissioner. She notes:

“There appear to be several obvious areas where national collaboration would hasten systematic improvements. These are highlighted in the detailed DHB responses, but briefly some are:

    1. Development of Early Warning Scores
    2. Standardised sentinel event investigation training
    3. National open disclosure policy and training
    4. Standardised initial communication process with the Coroner
    5. Standardisation of both nursing and medical handover practices”

Mr Paterson hopes the Minister of Health will seize the opportunity offered by this review to ensure that current efforts are well coordinated, with national leadership from the Ministry of Health and the Quality Improvement Committee, to achieve real improvements for patients.

“The Capital and Coast DHB case was a wake-up call to all district health boards. It is vital that lessons are learnt from that case. It is encouraging to see the steps being taken at Wellington Hospital and around the country to ensure that patients receive the competent and coordinated care they need and deserve, and that they and their families are treated with compassion. The challenge now is to coordinate efforts nationally to keep hospital patients safe, and to speed the rate of progress,” says the Commissioner.


Dr Seddon’s review of DHB responses
Dr Mary Seddon is a physician and quality improvement expert who reviewed all the DHB responses on behalf of the Commissioner. Her overview report, “Safety of Patients in New Zealand Hospitals: A Progress Report” may be viewed at:

Key facts from CCDHB report
A 50-year-old man was admitted to Wellington Hospital in September 2004 with 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 extensive pneumonia.

In a report published in April 2007, the Commissioner found serious failings in the care provided over the 40 hours prior to the man’s death.

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 lack of candour with the patient’s family and the Coroner.

CCDHB was referred to the Commissioner’s Director of Proceedings, leading to a confidential settlement. The Commissioner’s CCDHB inquiry report may be viewed at:

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, who has responsibility for deciding whether to issue proceedings on matters referred by the Commissioner.


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