Lack of adequate follow up of nerve injury
Monday 30 September 2019
Deputy Health and Disability Commissioner Rose Wall today released a report finding Capital and Coast District Health Board in breach of the Code of Health and Disability Services Consumers’ Rights (the Code) for failures relating to the care of a woman with a nerve injury.
The woman presented to the Emergency Department with an injury to her lower leg and numbness in her foot. She was assessed by a doctor and discharged with the possibility of returning for surgery the next day. The doctor discussed her case with a senior doctor the following morning, and based on that discussion it was decided that surgery was not required and that further care would be with her general practitioner (GP).
The woman did not have any reassessment or follow-up by a senior clinician on the day of her admission or at any stage afterwards by the DHB’s orthopaedic team.
Over the next few months her wound became infected, the pain worsened and she subsequently had surgery and nerve grafting. It transpired that the nature of the nerve injury had not been correctly identified. The lack of follow up by the DHB’s orthopaedic team was a missed opportunity to reassess the woman and have her examined by a more senior doctor.
Ms Wall said it is important for junior staff to have adequate support to enable the provision of safe care to patients, and in failing to have such a system in place, she found the DHB in breach of the Code. At the time of these events, there was no policy, suggested pathway, or common practice, that such injuries should be reviewed by a senior clinician.
Ms Wall recommended that the DHB apologise to the woman and use the report for training about missed diagnoses. She also recommended that the DHB consider whether its systems can be improved to ensure that appropriate supervision is in place and emphasise to orthopaedic staff that these type of injuries should be assessed by a senior doctor.
The full report for case 16HDC01557 is available on the HDC website.