An 81-year-old woman died following several failures by multiple staff employed by the Waikato District Health Board, an investigation by the Health and Disability Commission has today revealed.
Deputy Health and Disability Commissioner Rose Wall found the DHB in breach of consumer rights for poor co-ordination of care and communication.
The woman - who cannot be named for privacy reasons - was rushed to the emergency department with a fractured right leg. She was given a brace that was fitted to her leg and placed on bed rest for 12 weeks.
The doctor instructed that the leg needed to be monitored for pressure sores and asked for a referral to a pain specialist.
However, none of this was recorded in her medical notes and no referral was made.
Subsequently, after she was discharged from hospital to a rest home, she developed a urinary tract infection and symptoms that included severe pain and delirium.
She was then rushed back to hospital where a wound on her leg was discovered. The doctor instructed that the brace be removed and the wound reviewed daily but, again, this was not recorded.
It wasn't until two weeks later that staff at the rest home removed the brace and she was rushed back to hospital. She died the following day.
The woman's daughter, who made the complaint, said her mum's pain was "indescribable" and she suffered distress in the lead-up to her death.
Waikato DHB has admitted to the failings, saying it is committed to improving this area of care for all patients.
"We recognise that we failed in our duty of care to ensure directives were actioned during the care of the patient, and inadequate information was provided to a rest home upon the patient's discharge for ongoing care," acting chief operations officer Claire Tahu of Waikato District Health Board told the Herald today.
The deputy commissioner ordered the DHB to conduct an audit of staff compliance with the discharge policy and keep HDC updated with its progress. It also asked the DHB to review its process of referral to the pain clinic and to make a formal apology to the woman's family.
Tahu said as a result of the complaint improvements to the way they worked had been made and they had reviewed handover procedures to ensure patients received smooth transitions between facilities, including clearly documented care instructions.
"We are very sorry that the patient had this experience at Waikato and acknowledge how distressing it would have been alongside extended stays in hospital.
"We are working to implement the Health and Disability Commissioner's recommendations," Tahu said.