'Pattern of poor care' by Southern DHB with patient who died

Source: 1News

The Southern District Health Board has been found by the Health and Disability Commissioner to have "a pattern of poor care" for a patient that later died.

An emergency department at a hospital (file image).

A woman in her 60s presented to the emergency department for a possible pulmonary embolism, or a blockage in one or more of the arteries in the lungs, which was quickly confirmed by a CT scan.

Despite the embolism being described as massive, with significant effect on the cardiovascular system, the SDHB staff adopted a "wait and see" approach while they considered treating her with thrombolysis - a treatment used to dissolve blood clots, Health and Disability Commissioner Morag McDowell said.

Although the woman was critically unwell, junior staff did not escalate her care to a senior medical officer, and she was not treated with anything other than fluids.

The woman died 17 hours after she was admitted to hospital.

McDowell considered that the SDHB staff failed to exercise sound clinical judgement and assess the woman’s condition critically. In addition, they failed to escalate the woman’s care to the responsible senior medical officer and initiate treatment (thrombolysis) when it was clinically indicated, and to communicate with each other effectively.

McDowell considered that these failures indicated a pattern of poor care across the woman’s patient journey, as well as a culture of non-compliance with SDHB’s policies and procedures.

"There were repeat failures involving numerous individuals across the emergency department and the respiratory team, and I consider this to be a service delivery failure for which, ultimately, SDHB is responsible." McDowell said.

The commissioner recommended SDHB review its medical staffing levels overnight to ensure there was an adequate mix of skills and capacity to meet demand, and create its own guideline with regard to looking after patients in emergency departments waiting inpatient beds.

Several other recommendations were also made.

In addition, the Commissioner referred SDHB to the Director of Proceedings.

The full report for the case is available on the Health and Disability Commissioner website.