Deficiencies In Southern District Health Board Follow-up Care Of Patient After Repeated Visits To Emergency Department

The Health and Disability Commissioner (HDC) has today published the following decision relating to a breach of the Code of Health and Disability Services Consumers’ Rights (the Code).

Health and Disability Commissioner, Morag McDowell, has recommended Southern District Health Board (SDHB) share with staff an anonymised case involving a woman who presented to the SDHB emergency department (ED) three times with rectal bleeding. The woman was later found to have rectal cancer.

The case highlights the importance critical assessment when patients present to hospital on multiple occasions with the same symptoms within a relatively short period of time. It also highlights the importance of undertaking adequate examinations; maintaining patient records that reflect care provided at each consultation; taking an adequate family history; and to critically assess patients who present on multiple occasions.

Ms McDowell also recommended SDHB encourage opportunities for teaching junior staff on what constitutes an appropriate rectal examination, and its importance and limitations. She further recommended SDHB instigate a process to inform specialty doctors of patients under active care who present to the ED for any reason.

In her report Ms McDowell considered there were a number of deficiencies in the care of the woman across three ED visits. She found there was no specific follow-up to identify the cause and source of her bleeding; there was no repeat investigation or referral to outpatient services following tests at the woman’s first visit, and the results were not recorded accurately. The woman’s family history of bowel cancer was not explored by any of the clinicians.

"I consider the cumulative effect of these factors and missed opportunities demonstrates a clear pattern of poor care, attributable to SDHB as the overall service provider," said Ms McDowell.

"I conclude there were numerous missed opportunities by a number of SDHB clinicians across several presentations to assess the woman’s presentation critically and coordinate the appropriate investigations, which had they been performed, would more likely than not have identified her rectal cancer," said Ms McDowell.

The SDHB has advised that as a result of the woman’s concerns around processes for referrals, the DHB is undertaking a full review of its processes to ensure referrals are handled in a more timely and transparent manner.

Notes

The full report of this case can be viewed on HDC’s website . Names have been removed from the report to protect privacy of the individual involved in this case.

We anticipate that the Commissioner will name DHBs and public hospitals found in breach of the Code unless it would not be in the public interest or would unfairly compromise the privacy interests of an individual provider or a consumer. HDC’s naming policy can be found on our website here.

HDC promotes and protects the rights of people using health and disability services as set out in the Code of Health and Disability Services Consumers' Rights (the Code).

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