Babies among five deaths from 'serious adverse events'

The death of five people, including two babies, are among the 17 serious adverse events reported by the Lakes District Health Board last year.

They include two babies that died during or following childbirth and a death after a fall, one after a delay in diagnosis or treatment, and one where the person was discharged.

An incidental finding included another woman who died after using over the counter cough medicine that reacted with her other medicines.

There were also five falls that resulted in serious harm as well as a patient lighting a fire in the patient area.

The number of serious adverse events in the report released by the Health Quality and Safety Commission was seven higher than the previous year. Two were "near misses" which could have had a serious outcome but didn't.

Health board quality and risk manager Lesley Yule said the health board very much regretted the events and they should not have happened.

Ms Yule said a death during or as a result of childbirth was "very distressing". In the two cases last year both babies "succumbed to difficulties during the labour" and there were lessons to be learned about the observations and actions during the labour.

Since the deaths, a heart monitor was bought for the theatre, guidelines were established regarding the criteria for performing an emergency caesarean section and a change in protocol for managing a baby delivered unwell with the immediate involvement of a doctor.

Falls were identified as a major risk for patients when they were admitted to hospital, Ms Yule said.

An initiative in the orthopaedic unit had patients who were at an increased risk of falling being given special red socks to wear had seen the number of falls almost halve in the past two years.

The socks had extra grips, and were bright and noticeable so staff could quickly identify patients who needed help the most.

There were three major medication errors in the last year, including the case where a woman died because of inadequate monitoring of the side effects of a drug in the community after she took an over the counter cough mixture in addition to her "complex medication regime".

Delay in diagnosis or treatment resulted in three serious adverse events. Two prolonged the patients' treatment and delayed their recovery while the third had no serious harm, but was reported and investigated as another result from the delay could have caused harm.