Hospital death prompts upgrade

Bed-booking systems and medical equipment have been upgraded at Rotorua Hospital following the death of an obese patient.

The Ministry of Health's chief medical adviser will visit the hospital in two weeks to check that nursing and medical staff have improved various processes to reduce the chance of similar deaths.

This month's audit by Dr David Galler follows sharp criticism of Rotorua Hospital and its care of the 55-year-old woman who died in 2005 after surgery to have a breast tumour removed.

Expected changes include improvements to communication between staff and patients' family members, the upgrade of medical equipment and systems to ensure staff are aware when patients need intensive care unit beds.

Health and Disability Commissioner Ron Paterson ruled that the 55-year-old woman, who has not been identified, did not receive post-operative care of an appropriate standard.

Her surgeon had decided to do the operation in a public hospital rather than a private one so the patient could be cared for in the HDU (high dependency unit) afterwards. The hospital failed to place her in a high dependency unit due to a mix-up with the bed-booking system. In the orthopaedic ward where she was placed, medical equipment used to monitor her was either not working correctly or was unavailable. She received less nursing support than required and her bed was too small and she was at risk of falling out. Her family was also upset to find dead insects on her sheets after she had died.

The health board has apologised to the patient's widower and reviewed its patient care systems following an internal review in 2005.

In February this year, an early warning system was introduced at Rotorua and Taupo hospitals to help nurses identify patients who are deteriorating, before they become too sick. The system, developed over six months, is in its early stages but Lakes District Health Board's quality and risk manager Lesley Yule said audit work so far indicated the new system was useful.

"Health professionals are always responsive to a Health and Disability Commission decision and are conscious of complying ... Any cases brought to their attention are closely looked at for improvements."

Other changes included a system for staff to "flag" the need for intensive care unit beds and better communication between staff and the family of a patient who has died.

A new policy was adopted late last year which has identified key hospital staff who are responsible for meeting family members after a death.

Rosters now name a co-ordinator for every shift in the orthopaedic ward and medical equipment has also been upgraded. To prevent insects getting inside hospital rooms, buildings are chemically washed to reduce insect build-up and window screens will be installed in the orthopaedic unit.

The death was one of five patient deaths at Rotorua Hospital linked to staff mismanagement in a report released by the Ministry of Health's Quality Improvement Committee in February.