Te Whatu Ora Taranaki breached code with ‘unsafe discharge’ from Taranaki Base Hospital

An elderly man died shortly after he was discharged from Taranaki Base Hospital with no proper care plan in place. Photo / Tara Shaskey

An elderly man with a lung condition was discharged from a hospital while still struggling to breathe and with no proper plan for his care in place. About 40 minutes later, he was dead.

The man, in his 80s, had been discharged into the care of his elderly wife, who had to ask for the public’s help to move him from his wheelchair to the car as they left the New Plymouth hospital.

Then the pair struggled up three flights of stairs into their home where he died five minutes after arriving.

Now Aged Care Commissioner Carolyn Cooper has labelled the man’s discharge unsafe and slammed Te Whatu Ora Taranaki for its lack of critical thinking and communication.

According to findings released by Cooper today, the man, who is not named, was admitted to Taranaki Base Hospital for treatment of worsening chronic obstructive pulmonary disease (COPD) and abdominal pain in 2021.

He was in hospital for five days and treated with antibiotics and steroids before being discharged into the care of his elderly wife.

When discharged, he was short of breath, could not walk unassisted, and needed help with daily activities.

He was given prednisone and prescriptions for antibiotics and told to visit his GP or the emergency department if he had worsening shortness of breath.

After his death, his daughter complained to the office of the Health and Disability Commissioner that he did not receive any physiotherapy or occupational therapy services while admitted as a patient and that there was minimal consideration of how he would manage at home on discharge.

According to his daughter, the man and his wife needed help from the public to get him from his wheelchair to their car and then struggled up three flights of stairs into their home.

Cooper found Te Whatu Ora Taranaki had breached the Code of Health and Disability Services Consumers’ Rights during its care of the man by not providing services of an appropriate standard.

“The nursing assessment and care planner was only partially completed … The information about recent weight loss was incomplete. The discharge planning section (which starts at admission) was also largely incomplete, noting only that [the man] lived with his wife,” Cooper said in her findings.

“The discharge checklist includes important information such as whether the patient is likely to have any difficulties with self-care on discharge … whether they are concerned about returning home, the level of support services they currently receive, and their arrangements for transport on discharge. None of this information was included.”

The man's daughter raised concerns with the office of the Health and Disability Commissioner after his death about his care. Photo / Tara Shaskey

She further noted there was no evidence of physiotherapy or occupational therapy during his stay and no referral was made for either of these supports in his discharge plans.

Cooper said the man was discharged in an unsafe manner.

“I am concerned that a lack of critical thinking and communication resulted in an unsafe discharge. I am also concerned about the lack of documentation of a formal assessment of [the man’s] functional ability and any safety-netting advice provided and that no consideration was given to the age and health status of [his wife] and her ability to assist [him] at his discharge.”

According to the findings, Te Whatu Ora Taranaki acknowledged it had let the man down.

“His admission documentation was incomplete and a baseline assessment pertaining to his activities of daily life (ADLs) and home situation was not assessed. This is a nursing responsibility,” it stated.

A complex discharge coordinator, who assists complex patients and their families in the discharge process and ensures a seamless transition from inpatient care to the primary place of residence, was on annual leave when the man was discharged, and the position was not covered.

Cooper made several recommendations, including that Te Whatu Ora Taranaki formally apologise to the man’s family.

She also recommended that it conduct an audit of the completion of admission documentation for the past six months, survey nursing staff on their understanding of fall risk, update training on discharge planning and review and update its discharge planning procedure.

Evidence of all recommendations must be supplied to the Health and Disability Commissioner.

The findings stated that since the man’s death, Te Whatu Ora Taranaki has trained a senior ward registered nurse to undertake the role of complex discharge coordinator during times of leave.

In a statement to NZME, Te Whatu Ora Taranaki acknowledged the findings and accepted the recommendations.

Katy Sheffield, acting group director of operations for Taranaki, said the recommendations have been complied with.

“We have extended our sincere condolences to the patient and their whānau for this failing,” she said.

“Patient safety and quality of care are our utmost priorities and we have worked with the team involved to review the inadequacies identified and implement the HDC’s recommendations by the November 2024 deadline.”

Tara Shaskey joined NZME in 2022 as a news director and Open Justice reporter. She has been a reporter since 2014 and previously worked at Stuff covering crime and justice, arts and entertainment, and Māori issues.