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Co-ordination of care in neurosurgery ward

Health and Disability Commissioner Anthony Hill today released a report finding Capital & Coast District Health Board in breach of the Code of Health and Disability Services Consumers’ Rights for its care of a woman in her mid-fifties.

The woman presented to the Emergency Department of a public hospital with right-sided weakness in her face, arm and leg. A CT scan showed a large intracerebral haematoma, a life-threatening type of stroke. She was transferred to another hospital, where she was admitted to the Intensive Care Unit and had surgery. She was later discharged to the neurosurgery ward. A week later, her condition deteriorated significantly. After a delay, she was identified as needing further urgent surgery.

Mr Hill found that the standard of communication within the neurosurgery department was very poor, and had adversely affected the quality and continuity of services provided to the woman.

Mr Hill was critical of communication failures that had led to the consultant in charge not being adequately informed about the woman’s condition during the morning of her deterioration. There had also been serious nursing communication failures that meant she was not reviewed by doctors as part of the morning ward round.

"Teams need to communicate well, and ensure that concerns are escalated appropriately," Mr Hill said.

Mr Hill also found that documentation of the woman’s deteriorating condition, and communication with her family and other members of the clinical team, was poor.

"This Office has continually stressed the importance of clear and accurate documentation. In my view, the poor documentation contributed to the poor communication within the clinical team and the lack of continuity of care."

Mr Hill recommended that the DHB provide a written apology to the woman, provide training to clinical staff on communication pathways and record-keeping, review its Early Warning Score and handover policies, develop an escalation process for situations in which clinical care is impeded by concerned relatives of patients, and carry out an audit on compliance with its Early Warning Score policy.

The full report for case 17HDC00690 is available on the HDC website.


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