NDHB failed to prevent death

By Mike Dinsdale

1 comment

The daughter of an elderly man who died in Whangarei Hospital five days after a knee replacement says discrepancies in her dad's death certificate and what doctors had told her sparked her determination to find out what really happened.

Northland District Health Board (NDHB) was this week criticised by Health and Disability Commissioner Anthony Hill over the death, who found that the 75-year-old Whangarei man died after hospital staff failed to exhibit reasonable care and skill, poor communication and inadequate documentation.

"The orthopaedic team's failure to communicate to the nursing team that particular attention needed to be given to [the man] in the post-operative period given his co-morbidities, resulted in a lost opportunity to ensure that [he] was monitored closely, and increased the risk of harm."

NDHB Chief Medical Officer Mike Roberts said the health body profoundly regrets what happened and accepts that the care the man received was not of a high enough standard. Dr Roberts said NDHB has expressed profound apologies to the man's family.

He acknowledged that following internal enquiries NDHB quickly implemented corrective actions and has already complied with the recommendations made in his report.

"This sad case has led to many changes within the hospital. Standards of quality and safety within the organisation are much higher now."

But the man's daughter said she only got an inkling that something may be wrong when she saw her father's death certificate. "The death certificate said dad died from renal failure, but the doctors told us that he died of a cardiac arrest. That's what made me realise something may have been wrong and request his (hospital) notes. When I saw that I had to find out what really happened and I'm not sure we would have got to this stage if I hadn't noticed the discrepancy."

She said it was important the NDHB made sure the same trauma did not happen to another family. "It was really, really basic stuff. It wasn't major technical issues or medication or equipment, it was basic lack of communication and basic care, not taking careful observation and not letting everybody who needed to know what was happening."

Mr Hill found the failures of orthopaedic and nursing teams were directly attributable to NDHB. He also said there was "widespread failure by the nursing team to consistently comply with relevant procedures, which compromised the man's right to continuity of care".

The man had a total knee joint replacement at Whangarei on February 15, 2010.

He was advised beforehand of the risk that he would not survive surgery, but was determined to have it. The operation went without incident, but he died five days later.

"In essence, there was a pattern of suboptimal behaviour in the care [of the man].

"NDHB breached [the Code] for failing to provide [the man] with services with reasonable care and skill ..." Mr Hill said.

- Northern Advocate

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