Wanganui Hospital's number of serious adverse events has leaped from three last year and the year before to 12 for 2013/14, but the increase is down to a change in what incidents are reported, says hospital management.
Whanganui District Health Board (WDHB) chief executive Julie Patterson said the jump was caused by the decision to report all fractures that result from a fall while a patient is in hospital. "This is not the approach all DHBs are taking, so it does affect our numbers relative to other DHBs," Ms Patterson said in a report to the board on Friday.
Of the board's 12 serious adverse events, three were unexpected deaths and nine were falls in the hospital.
Of the deaths, one was an unforeseen allergic reaction to the anaesthetic during a dental surgery.
The unexpected death of a 68-year-old woman came about after hospital staff failed to adequately monitor her bowel function, although she came in for a knee replacement surgery.
The woman came in for her surgery and returned home four days later after making a good recovery, a summary of the serious adverse events said.
She went to a GP clinic three days later feeling unwell with signs and symptoms of abdominal problems. She received treatment and was sent home.
Her family brought her to the hospital's emergency department the next day and she was given emergency surgery, and was later transferred to a tertiary hospital where she died in the intensive care unit.
An internal team review and two external expert views found that the antibiotics the woman was taking before attending hospital affected her bowel function and caused sepsis, which led to her death.
"The hospital acknowledged that during her time in hospital staff did not adequately monitor her bowel function and at the time of her discharge the patient and family were not given sufficient advice regarding bowel function and when to seek medical help, particularly if her bowel function did not return to normal," the summary said.
"The GP clinic recognised that they did not pick up that the patient was as unwell as she was."
The woman's death drove a "significant" change to clinical practice, and there is now a discharge project underway to improve how people are given well-informed advice before leaving hospital.
Doctors have updated the way they do their rounds, to include the latest information on the patient, and the GP clinic has reviewed the way they assess patients who have the same abdominal symptoms as the woman following an operation of the type she received.
WDHB's director of nursing Sandy Blake said the case was "rare", which was why they needed two experts to review it.
"You keep on asking the question, why, why, why, until you get as good an answer as you can possibly get?" Mrs Blake said. "We will never be able to understand the contributing factors if we don't really understand them."
The third unexpected death happened when a 48-year-old woman came in for a gall bladder removal and developed a small tear under the operation site, which sealed over and wasn't noticed by theatre staff.
"When the patient collapsed, the tear had re-opened suddenly and the patient had a massive bleed that caused her death," the event summary said.
Patients who were not recovering at the expected rate needed vigilance in their monitoring, it said, and the woman's monitoring was not well documented.
Since the woman's death a system has been implemented for patients who are not recovering at the expected rate to ensure they are more closely monitored.
Mrs Blake said more DHBs were increasingly deciding to report all fractures from falls in the hospital, and said it was about transparency.
"We report everything that we can report," she said.
"The most important thing is out of respect for the person that has suffered the harm. We do something about it."
The hospital had an obligation to look "deeply" into these cases, Mrs Blake said. "We owe it to our community to learn. They have got to know that we're trying."