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Inadequate documentation resulting in inadequate care

Deputy Health and Disability Commissioner Rose Wall today released a report finding Capital and Coast District Health Board (CCDHB) in breach of the Code of Health and Disability Services Consumers’ Rights (the Code) for failing to complete and then update a care plan for a woman which meant she was not provided with adequate care to meet her changing health needs.

The woman was admitted to CCDHB where she required ongoing treatment for lymphoma and received care from numerous staff, including specialists and nurses.

A care plan was not fully completed on her admission to hospital, which meant there was no baseline of information to monitor whether her condition was deteriorating. There was also no risk assessment for falls or delirium, which meant staff were not able to provide all the care required. After the woman had a fall while in hospital, the results of assessments were inadequately recorded in her care plan and some assessments were not completed or updated.

Ms Wall said accurate health assessments were the foundation of good nursing practice and clinical decision-making.

"The district health board is responsible for ensuring that its staff provide appropriate health assessments and care. By failing to complete a care plan when this woman was admitted to hospital and to update it accurately on the days following, CCDHB did not undertake a full assessment of her condition or monitor her changing condition accurately," Rose Wall said.

In response to the deputy Commissioner’s draft report CCDHB said it would provide a letter of apology for the consumer’s family. It also noted that it had made changes to its practice. CCDHB carried out audits of staff compliance with care plan documentation and noted that compliance increased from 30% at the time of the events, to 95% in December 2018. CCDHB also made changes to staff training, by appointing a dedicated Nurse Educator, and a range of related education, to help staff complete these care plans. CCDHB indicated it will review its care plans. Ms Wall recommended that CCDHB provide her with an outcome of its review of the use of care plans.

The report for case 17HDC00187 is available on the HDC website.


A care plan is an individualised plan to guide the care required by a patient each shift.

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