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Health & Disability Commissioner Decision - Service Failures

Date: 1 July, 2013


Today the Health and Disability Commissioner released the results of his investigation into the death of a 75-year-old Patient (Mr A) who underwent a total knee joint replacement at Whangarei Hospital in February 2010.

Mr A first sought knee joint replacement in 2006. At that time the anaesthetists involved in his care considered it was not safe for him to have surgery because of his severe heart disease.

As well as severe aortic stenosis Mr A also suffered from type II diabetes, ischaemic heart disease, congestive heart failure, moderate renal impairment, and paroxysmal atrial fibrillation.

Mr A’s GP referred him back to the orthopaedic team in 2009 because knee pain was severely affecting his quality of life. Mr A was advised by the surgeons and anaesthetists that there was a significant risk he would not survive the surgery but he remained determined to undergo the operation and it was performed on 15 February.

While his initial recovery was less complicated than expected his heart and kidney function deteriorated on the third post operative day and he died on 20 February.

The Commissioner found that a combination of poor documentation and poor communication led to the failure of both the Orthopaedic and Nursing Teams to recognise and act promptly on Mr A’s deteriorating condition.

The Commissioner has found that the failures of the Orthopaedic and Nursing teams were service failures and so Northland DHB breached Right 4(1) of the Health and Disability Services Consumers’ Rights. Northland DHB also breached Right 4(4) of the Code by failing to communicate Northland DHB profoundly regrets what happened in 2010 and accepts that the care this patient received was not to a high enough standard. The DHB has expressed profound apologies to the patients’ family.

The Commissioner has acknowledged that following internal enquiries Northland DHB quickly implemented corrective actions and has thus already complied with the recommendations made in his report. In summary these include; Nurses and junior doctors working on the Orthopaedic ward are required to attend a course which teaches a structured approach to the assessment of patients so that any deterioration in their condition is quickly recognised and then receives appropriate management.

Educational sessions for nurses on the Orthopaedic ward have been conducted to reinforce understanding about cardiac and renal failure. A new Clinical Nurse Educator was appointed to the Orthopaedic ward in 2012. She continues to provide education to improve the accuracy of note keeping and quality of clinical handovers. Bedside handovers now occur at the beginning and end of every shift.

Communication tools first developed in military and aviation settings has been taught to theatre and ward staff to improve quality of handovers between them.

An outreach service is now run from the intensive care unit and ICU registrars are available 24 hours a day to review unwell patients anywhere in the hospital.

Junior doctors now have extra time for handover when they pass on the responsibility for patient care at the end of their shifts and a paper record of the handover is completed to ensure that at risk patients are not missed.

Junior doctors are encouraged to contact their seniors for advice at any time if they feel this would benefit patient care.

Chief Medical Officer Dr Mike Roberts commented, “This sad case has led to many changes within the hospital. Standards of quality and safety within the organisation are much higher now. This is confirmed by data from the Ministry of Health which compares hospital mortality rates across the country and show that we have a significantly lower mortality rate than would be expected given the number and type of patients we treat”.


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