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Monitoring of a patient on a personal breathing machine

Monday 22 July 2019

Health and Disability Commissioner Anthony Hill today released a report finding Hutt Valley DHB in breach of the Code of Health and Disability Services Consumers’ Rights (the Code) for failures relating to the care provided to a man admitted to hospital with a personal breathing device.

The man, who had motor neurone disease, was admitted to hospital overnight because of respiratory difficulties. He had a device to assist with his breathing that he brought into hospital with him. Repeat observations were taken but at 4am a nurse found the man unresponsive, with his ventilation mask removed, and he could not be revived.

Mr Hill found the man received inadequate monitoring and medical review by the DHB. While repeat observations were taken and early warning scores (EWS) calculated, these should have triggered more frequent monitoring. EWS are a tool to help staff recognise and appropriately respond to an acutely ill patient who is at risk of deteriorating.

Mr Hill criticised the DHB for inconsistencies between its EWS policy and EWS chart, as this created a lack of clarity about how the scores should be calculated and what actions should be taken as a result. Mr Hill was also critical that the DHB did not have a policy for monitoring personal breathing devices.

"It is the responsibility of Hutt Valley DHB to have in place adequate systems to ensure that an acceptable standard of care is provided to consumers. This includes having appropriate policies, having working documents that accurately reflect those policies, and ensuring that the policies are complied with," Mr Hill said.

Mr Hill recommended that the DHB apologise to the man’s wife for its breach of the Code. He also recommended that the DHB amend its EWS policy and EWS chart to ensure they were consistent and clear, and develop a policy for the management of patients who are using a personal breathing device.

The full report for case 16HDC00823 is available on the HDC website.


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