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Handover instructions for care after discharge

Handover instructions for care after discharge 17HDC00572

Source: Health and Disability Commissioner


Deputy Health and Disability Commissioner Rose Wall today released a report finding Waikato District Health Board in breach of the Code of Health and Disability Services Consumers’ Rights (the Code) for failures relating to poor co-ordination of care and communication.

After an 81-year-old woman fractured her right leg, she was admitted to a public hospital where a range of motion (ROM) brace was fitted and she was placed on 12 weeks’ bed rest. A doctor directed that she be monitored for pressure sores but this was not recorded in her Patient Care Plan, which serves as a guide to nursing care. The doctor also asked for the woman to be referred to the Pain Clinic, but this was not done.

When she was discharged to a rest home after approximately three weeks, the DHB did not provide the rest home with clear instructions for the care of the brace or the skin beneath it. She was readmitted to the hospital a few days later with an infection, severe pain and delirium. A doctor noted the woman had a pressure area on her knee and sacrum and instructed that the brace be removed and the wound be reviewed daily. Those instructions were again not entered into the woman’s Patient Care Plan.

She was transferred back to the rest home but the discharge documents did not adequately record the abrasion beneath the brace, or the care required for it. The brace was not removed for approximately two weeks at which time a necrotic area of skin was discovered. The woman was transferred back to the hospital and died the next day.

Ms Wall considered that the handover information provided to the rest home was poor and that this information, or lack of it, may have affected the care provided to the woman by subsequent healthcare providers. She found that while individual staff hold some degree of responsibility for their failings, the deficiencies indicate a pattern of poor co-ordination and communication, both within Waikato DHB and with the rest home.

"I am concerned that numerous staff at Waikato DHB did not record key information about the woman’s care in the appropriate documents, and when it was recorded it was not actioned," Ms Wall said.

Ms Wall recommended that Waikato DHB apologise to the woman’s family. She also recommended that the DHB conduct an audit of staff compliance with the discharge policy; update HDC on the results of the investigation into the development of the deconditioning plan for selected patients; and update HDC on the review of its process for referral to the Pain Clinic.

A copy of the full report for case 17HDC00572 is available on the HDC website.


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