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Hospital Discharge Of Woman At Risk Of Stroke

Health and Disability Commissioner Morag McDowell today released a report finding a district health board (DHB) in breach of the Code of Health and Disability Services Consumers’ Rights (the Code) for failures in the care of an elderly woman.

The woman, aged in her eighties, presented to the Emergency Department (ED) of the DHB because of rectal bleeding. She had a history of atrial fibrillation, a condition that affects the heart, and was taking dabigatran (a blood thinning medication) to reduce her risk of stroke.

The following day the medical team withheld dabigatran from the woman because she was bleeding on admission. The woman was discharged from hospital with no advice about the management of dabigatran, and three days later she had a stroke.

Health and Disability Commissioner Morag McDowell was critical of the DHB for not ensuring that a clear plan for the woman’s ongoing anticoagulant (blood thinning) management was formulated or communicated to the woman and her GP when she was discharged. She was also critical of the lack of information or instructions about re-starting dabigatran in the discharge summary, which provided insufficient guidance for the woman’s GP.

Ms McDowell considered that systemic issues associated with the discharge summary template, together with the cumulative failings of several clinicians, indicated poor discharge planning processes.

"While individual staff members hold some degree of responsibility for their failings, I consider that the deficiencies indicate poor discharge planning processes, for which the DHB is responsible," said Ms McDowell.

Ms McDowell recommended that the DHB use an anonymised version of HDC’s report as a case study to provide education sessions for nurses and doctors on the importance of communication of discharge plans. She also recommended that the DHB provide education to house officers on the discharge summary, with emphasis on the importance of accuracy and the need to seek clarification if there are uncertainties.

It was recommended that the DHB provide HDC with the outcome of a review of its new electronic medical record programme and the changes to the electronic discharge summary; consider developing a multi-disciplinary approach to anticoagulation management for situations where the management may not be clear; and consider sharing the re-designed electronic discharge summary with other DHBs. Finally, Ms McDowell recommended that the DHB apologise to the woman’s family.

To read the full report on case 18HDC01085, visit the HDC website.

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