The Capital and Coast District Health Board (CCDHB) has apologised to the family of a woman who died after a fall and admitted staff failed the woman.
Deputy Health and Disability Commissioner Rose Wall today released a report finding CCDHB in breach of the Code of Health and Disability Services Consumers' Rights.
The report detailed how a woman was admitted to a public hospital in 2016 for the ongoing treatment and management of lymphoma.
Numerous staff provided care for the woman, including specialists and nurses, however, the report said they failed to complete and then update a care plan for the woman, which meant she was not provided with adequate care to meet her changing health needs.
"A care plan was not fully completed on her admission to hospital, which meant there was no baseline of information to monitor whether her condition was deteriorating.
"There was also no risk assessment for falls or delirium, which meant staff were not able to provide all the care required," the report stated.
Several days after the woman's admission, she fell and hit her head at 6.20am.
No injuries were visible apart from redness on the back of her neck. She was reviewed by a doctor at 7.40am but did not receive a full assessment until 9.40am.
During this assessment the haematology registrar noted a small skin laceration and bruising, and ordered a CT scan.
At 12pm a physiotherapist recorded that the woman was displaying some confusion and that her neurological condition was worsening.
The house officer agreed that there were new symptoms. A CT scan was performed at 1pm, and at 1.30pm the woman was examined by a consultant haematologist.
At this stage, the woman's fall and her condition were discussed with her family for the first time since the fall. The family were advised that it was likely that the woman had central nervous system lymphoma and that her prognosis was poor.
The woman's neurological status continued to deteriorate, and at 2pm she was recorded as "virtually unresponsive".
Apart from a brief entry by the nurse who took the woman for the CT scan, there were no nursing entries in the progress notes until 4.05pm. The woman received ongoing care, and died two days later.
"After the woman had a fall while in hospital, the results of assessments were inadequately recorded in her care plan and some assessments were not completed or updated," the report stated.
"Her changing condition was not monitored accurately, and there was an unacceptable delay in communicating with the family regarding the fall.
"Accordingly, the DHB failed to provide services to the woman with reasonable care and skill."
Commissioner Wall said accurate health assessments were the foundation of good nursing practice and clinical decision-making.
"The district health board is responsible for ensuring that its staff provide appropriate health assessments and care.
"By failing to complete a care plan when this woman was admitted to hospital and to update it accurately on the days following, CCDHB did not undertake a full assessment of her condition or monitor her changing condition accurately," she said.
In response to the deputy Commissioner's draft report CCDHB said it would provide a letter of apology for the consumer's family.
It also noted that it had made changes to its practice. CCDHB carried out audits of staff compliance with care plan documentation and noted that compliance increased from 30 per cent at the time of the events, to 95 per cent in December 2018.
CCDHB also made changes to staff training, by appointing a dedicated nurse educator, and a range of related education, to help staff complete these care plans.
CCDHB indicated it will review its care plans. Wall recommended that CCDHB provide her with an outcome of its review of the use of care plans.
The DHB's chief nursing officer Emma Hickson told the Herald: "We wish to express our sincerest condolences and deepest regret to the family of this patient. We agree with the Health and Disability Commissioner's findings, and agree that we failed the patient and her family.
"As a DHB we are continually looking at how we can improve the way we support patients who are at risk of falling. There has been a significant focus on recognising the risk of falling, and developing individual care plans. This continues to be a work in progress, and the organisation has learned from this sad event.
"We have written to the patient's family to apologise for their sad loss, and to advise that we are committed to implementing all the Commissioner's recommendations.""