Hawke's Bay DHB under fire after report on patient's death

The Hawke's Bay District Health Board has apologised to the family of a woman who died in Hawke's Bay Hospital. Photo / File

The Hawke's Bay District Health Board has had to apologise to family of a woman who died two years ago after a "number of failings", including inadequate staffing levels, in her treatment at Hawke's Bay Hospital.

Chief Medical and Dental Officer Robin Whyman said in a statement after the release of a Health and Disability Commissioner's report on the care of the 68-year-old in 2017 that the DHB had apologised and also reviewed and changed a number of its systems including ensuring junior clinicians seek support and advice from the consultant on call, immediately, if they become concerned about a patient in their care.

As part of the review of the circumstances the DHB had also worked with the Health Quality and Safety Commission to implement a training programme for clinical staff focused on early recognition of warning signs and responding to clinical deterioration, he said.

It includes establishment of a Patient at Risk team, and Dr Whyman said: "This team includes a senior intensive care nurse, to support the ward areas with the management of acutely unwell people".

Health and Disability Commissioner Anthony Hill found DHB in breach of the Code of Health and Disability Services Consumers' Rights, for failing to provide services with reasonable care and skill.

After seeing two GPs about abdominal pain, the woman was assessed at the Emergency Department and admitted.

She had surgery for a perforated bowel the following day, but did not recover, and the commission found there was a pattern of poor care, including poor staffing levels and lapses in communication between services.

The commissioner also found handover policy was not followed, meaning staff were not aware of the patient's potential to deteriorate rapidly, and that an early-warning score chart used to alert staff when patients were deteriorating was not filled in.

"Observations did not trigger the escalation in care that should have occurred," the commissioner reported, adding documentation was poor.

"These factors hindered the co-ordination and delivery of care," Hill said. "While individual staff held some responsibility for their failings, overall the deficiencies indicated a pattern of poor care across services."

He considered that DHBs are responsible for the operation of the clinical services they provide and can be held responsible for any service failures, that "they have a responsibility for the actions of their staff and an organisational duty to facilitate continuity of care.

"This includes providing adequate support to its staff in respect of the application of relevant policies, and ensuring that staff work together and communicate effectively."

He recommended the apology and an audit of services to ensure the standard clinical tool was used to transfer consumer information between the Emergency Department and the Acute Admissions Unit.

He also recommended the DHB audit its compliance with the Early Warning System Policy in both the Emergency Department and the Acute Admissions Unit, and asked the DHB to provide evidence that better education would be provided for junior doctors about how and when to contact an on-call consultant, and that a dedicated surgical registrar would be available at night time.