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Poor pattern of care across Hawkes Bay District

Poor pattern of care across Hawkes Bay District Health Board services

Source: Health and Disability Commissioner


Health and Disability Commissioner Anthony Hill today released a report finding Hawkes Bay District Health Board (HBDHB) in breach of the Code of Health and Disability Services Consumers’ Rights for failing to provide services with reasonable care and skill.

After seeing two GP’s about abdominal pain, a consumer was assessed at HBDHB Emergency Department and admitted to the public hospital. The consumer had surgery for a perforated bowel the following day, but did not recover. Between the consumer’s admission and surgery there was a pattern of poor care. During this time:

o There were poor staffing levels in the Acute Admissions Unit and lapses in communication between services.

o The handover policy was not followed; this meant that staff were not aware of this consumer’s potential to deteriorate rapidly.

o The Early Warning Score chart, used to alert staff when patients were deteriorating, was not filled in. Observations did not trigger the escalation in care that should have occurred.

o Documentation was poor.

These factors hindered the coordination and delivery of care. While individual staff held some responsibility for their failings, overall the deficiencies indicated a pattern of poor care across services.

Mr Hill considered that DHBs are responsible for the operation of the clinical services they provide and can be held responsible for any service failures. He said "...they have a responsibility for the actions of their staff and an organisational duty to facilitate continuity of care. This includes providing adequate support to its staff in respect of the application of relevant policies, and ensuring that staff work together and communicate effectively."

Mr Hill recommended HBDHB provide a written apology to the family. He also recommended HBDHB audit its services to ensure the standard clinical tool was used to transfer consumer information between the Emergency Department and the Acute Admissions Unit. He further recommended HBDHB audit its compliance with the Early Warning System Policy in both the Emergency Department and the Acute Admissions Unit. He also asked the HBDHB to provide evidence that better education would be provided for junior doctors about how and when to contact an on-call consultant; and to provide evidence that a dedicated surgical registrar would be available at night time.

The report for case 17HDC00419 is available on the HDC website.


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