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Management of IV device & communication on discharge

Health and Disability Commissioner Anthony Hill today released a report finding Auckland District Health Board in breach of the Code of Health and Disability Services Consumers’ Rights (the Code) for the care provided to a young woman.

The woman was admitted to a public hospital for postoperative treatment and tests. A device to draw blood and give treatments (a PIVC) was inserted in her arm on her first day in hospital. Throughout the woman’s stay, staff repeatedly failed to document observations of her PIVC site, including the swabbing of a substance found near the site after the PIVC was removed. Staff did not document verbal advice given to the woman and did not communicate to her GP, who was outside the DHB catchment area, that the swab had been taken, meaning the GP did not know to follow up on test results. One day after her discharge from hospital, the laboratory reported that the swab showed heavy growth of a type of bacteria that is a common cause of skin infection.

Two days after her discharge, the woman presented to her GP. Her GP assessed her as needing urgent care and sent her by ambulance to hospital where she was diagnosed with septicaemia. While the woman was at the hospital, the swab result from the previous day was viewed for the first time. Sadly, the following day the woman died from a cardiac arrest caused by septicaemia.

Mr Hill considered that the PIVC check documentation fell below the standard of care, especially at the time of taking the swab. Mr Hill was critical that verbal instructions given to the woman were not documented either in the clinical record or in the discharge summary, that the discharge summary did not reference the swab and expected test results, that the GP was not told to follow up the test results if consulted by the woman and nor were they informed of the test results. Accordingly, Mr Hill found that the DHB did not provide services with reasonable care and skill and breached Right 4(1) of the Code.

Mr Hill commented that policies and practices need to ensure that the right information gets to the right providers regardless of where a patient lives.

Mr Hill recommended that the DHB apologise to the woman’s family and that it implement and review a number of policies relating to PIVC. Mr Hill made a number of other recommendations including that the DHB use the report for staff training, implement recommendations in its own report into this case and consider what further changes could be made to improve the co-ordination of care for people involved with multiple services and follow up of abnormal test results particularly for people discharged outside of its catchment area.

The full report for case 17HDC01589 is available on the HDC website.


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