DHB and nurse failed dementia patient after nasty fall, commissioner finds

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An 87-year-old Auckland dementia patient's flight from a locked hospital ward has earned a nurse and the Waitemata District Health Board a rebuke from the country's leading health watchdog.

The man, who had been living alone in his home, was admitted to hospital in 2012 for urinary troubles and on his second day there he slipped and fell.

Neurological observations were done that day then stopped, against the DHB policy. The man's mental state worsened and he was placed on 15-minute checks because of his disruptive behaviour and wandering.

On day four he left, unnoticed, with departing visitors when the 15-minute checks were omitted because his nurse was busy with other work.

The DHB later said the nurse "should not have been trying to do so many things" and should have sought a one-to-one "watch" for the patient, according to a report by Deputy Health and Disability Commissioner Theo Baker.

CCTV footage showed the patient at 5.41pm "striding out the door like a man on a mission", according to a security officer's version of events reported by the man's son.

At 7.51pm, ambulance officers tended to him at a bus stop and took him back to hospital. They had been called by a member of the public who had found him sitting there, speaking incomprehensible words.

On readmission to hospital the man, who has not been named, had a CT scan which showed a large subdural haematoma - bleeding between the brain and its tissue covering. He died several days later.

A pathologist's report indicated the haematoma might have started with the hospital fall and that there might have been later falls when he left the hospital that contributed to it.

Ms Baker said the nurse and DHB breached the code of patients' rights. The nurse did not make all required 15-minute checks and failed to hand over the patient's care adequately before leaving on a meal break.

The DHB failed to ensure its staff made all the required neurological observations and failed to act when his condition deteriorated. Ms Baker criticised the DHB's lack of any formal process for meal-break handover of patients by nurses; that "visual handover" was not required; and that there was no structure to ensure appropriate staff were present during breaks.

The DHB told investigators the newly graduated nurse to whom the patient's care was passed had later reported she was overwhelmed by being responsible for 11 patients during her colleague's meal break. She was not told she needed to check the patient every 15 minutes, nor when he had last been checked.

The DHB said yesterday that it accepted Ms Baker's findings and had apologised to the man's family.

"We have learned from the unfortunate chain of events outlined in the HDC report and made some systemic changes as a result," said chief medical officer Dr Andrew Brant.

Alzheimers New Zealand executive director Catherine Hall said: "Our hearts go out to the family in this tragic matter.

"We need to lift the quality of care and support for people living with dementia so they ... are delivered collaboratively, have the necessary resources, and are focused on the person with dementia and their family/whanau."