A man in his 80s died from choking on his food at an Auckland hospital after staff failed to follow a dietary plan that required puréed food, a new report has revealed.
Deputy Health and Disability Commissioner Rose Wall found the Waitematā District Health Board breached the disabled man's rights and referred the agency, now under Te Whatu Ora, to the commission's director of proceedings for consideration.
In 2021, the man was admitted to Waitakere Hospital in West Auckland with a chest and urine infection, according to the commissioner.
He was an elderly man with intellectual disabilities and limited communicative capacity, who resided in residential care for most of his life and required support with daily living.
The man's caregivers provided information to hospital staff about the man's needs for supervision and that his food needed to be puréed due to the risk he would choke.
But Wall's report read: "While an inpatient, the man was given non-puréed food, contrary to his dietary plan with the care facility.
"Shortly afterwards, the man appeared to be choking. He then became pale and unresponsive and subsequently suffered a respiratory arrest and died."
The investigation found the man's dietary requirements and the level of care he required were not handed over adequately between staff, or documented clearly, after he was transferred from the ED to the assessment and diagnostic unit (ADU), and during two subsequent ward transfers.
During the man's time in the ADU, some entries in clinical notes were made by a nursing student and were not countersigned by a registered nurse, Te Whatu Ora told the HDC.
Meanwhile, due to the Covid-19 restrictions for visitors that were in place at the time of events, the man also did not have his usual caregivers on site.
Wall said: "Effective handover is vital to achieve high-quality communication of clinical information and transfer of care, and to protect patient safety.
"I agree that quality handover practices between departments/wards is key, with the ramifications of inadequate communication tragically playing out on this occasion.
"Hospital staff did not give sufficient attention to a significantly disabled patient who was unwell in an unfamiliar environment, isolated from his usual caregivers and his familiar day-to-day routine.
"He was unable to communicate his needs to the various staff caring for him.
"All these considerations required staff to adjust their usual practice to accommodate the unique situation they were faced with.
"This case reinforces the significance of clear communication. It is the cornerstone of providing safe and effective care to patients, even more so when the patient is particularly vulnerable and reliant on others to keep them safe."
A number of changes have been made since the events, including a review of handover documentation, which now includes a field to record dietary needs, Wall noted.
"The wards that were involved in the man's care have been asked to ensure that dietary requirements are part of the shift handover, and the wards must ensure that the patient information board correctly reflects both the patient's individual dietary needs and any assistance they may require," she said.
The deputy commissioner made several recommendations, which included that the DHB provide training to all relevant staff on the handover processes and the handover expectations, and on the importance of the dietary requirements of patients, so that they are aware of the risks in failing to adhere to any dietary plans and/or restrictions.
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