A Hawke's Bay District Health Board (HBDHB) patient died after a potential delay in recognising a partial lung collapse, the annual Serious Adverse Events report to June 30 reveals.

A serious adverse event represents life-changing harm or death during health care.

A review of the death found a delay in alerting clinicians to an x-ray finding and the matter was referred to the coroner, who declined to make a ruling.

"If the coroner had thought the collapsed lung had been significant to the death he would have taken jurisdiction," Hawke's Bay District Health Board chief medical officer John Gommans said.


The number of events was the same as last year's report.

"It is reassuring that the number of deaths and the number of serious treatment injuries are less - there are fewer broken hips than previously - serious consequences are not as prominent," he said.

The report also listed seven falls, two collapses and one self harm attempt. Injuries included broken ankles, hips, wrist, ribs and a lung injury.

He said 11 events was a small number compared with the 34,000 patients admitted to hospital.

"For each of those 11 it can be a devastating event for them and their families but the bulk of our patients can be assured, for the vast majority of the time, we do things well."

The HBDHB scored one of the lowest ratios of adverse events to 100,000 bed days at 9.77. West Coast DHB scored the highest at 46.75 and Bay of Plenty DHB the lowest at 6.45.

Dr Gommans said fall prevention remained a focus. Chief nursing officer Chris McKenna chaired a falls minimisation committee which recommended strategies for system improvement in hospital and community.

More than $70,000 had been spent on measures to reduce harm from hospital falls including systematic assessment of risk of the elderly within 24 hours of admission, a visual signalling system at the bedside of patients that alerted staff and visitors of a patients risk, alert monitors and specialised beds.


A Vitamin D prescribing programme was in place for the aged care sector, with 80 per cent of clients prescribed Vitamin D to help make bones stronger.

The Health Quality and Safety Commission's sixth annual report features Hawke's Bay DHB's Early Warning System implemented in August last year.

The system identifies early patients whose condition has seriously deteriorating and may need urgent intervention.

Dr Gommans said no system was perfect and patients who experienced harm during health care should expect their case reviewed by an experienced team to find out what happened and measures put in place to prevent it happening again.

Nationally, there was a 4 per cent increase in events, 454 compared with 437 in 2012/13.

Commission chair Professor Alan Merry said the increase likely reflected the health sector's improved reporting.

New Zealand Nursing Organisation professional nursing adviser, Kate Weston, said events reported nationally had doubled since the first report in 2007 and she was unconvinced better reporting was the sole reason for the increase.

"The research demonstrates that there are some patient indicators that are particularly sensitive to nursing numbers and skill mix.

"These include patient falls, infections and pressure areas. There is an urgent need to address nursing resourcing in hospitals and communities to reduce these adverse events."

Hawke's Bay's numbers of adverse events in the first report were 12, one more than this year.

A HBDHB spokesperson said there were 1402 nurses in September this year, compared with 1310 in September 2010.