Annual Report for the year ended 30 June 2009 - Health and ...

COMMISSIONER’S REPORT
Introduction
Key features of 2008/09 were:
• No backlog of files
• 98.5% compliance with HDC recommendations
• North Shore Hospital inquiry
• Continued spotlight on patient safety
• 3rd Review of the HDC Act and Code
In the face of a 5% increase in complaints to HDC, we increased our
productivity (complaints resolved) by 6.5%. We ended the year with
the tally of open files at an all-time low of 274, with 87% of complaints
resolved within six months. We maintained our focus on early resolution,
with only 112 complaints leading to a formal investigation. We achieved
98.5% compliance with our recommendations of changes in a provider’s
practice; 39% of group providers reported significant systems changes
made as a result of HDC recommendations.
Ron Paterson
Commissioner
E.17
Advocacy and Proceedings
Advocacy continues to be a highly effective means of resolution, with 91% of complaints
received by the Advocacy Service partly or fully resolved with advocacy support. At the other
end of the complaints spectrum, the Director of Proceedings received 22 referrals during the
year (in relation to 15 providers) because of major shortcomings in care or unethical practice. In
2008/09 the Director was successful in 9 of 12 substantive hearings.
North Shore Hospital Inquiry
This inquiry, ably led by Deputy Commissioner Rae Lamb, focused on the plight of five sick,
elderly patients in the emergency department and on medical wards at North Shore Hospital
in mid-2007. Waitemata DHB was found to have breached the Code by failing to treat patients
with respect, lapses in nursing care, and poor communication. The report highlighted the need
for concerted action nationally to tackle the widespread problem of hospital overcrowding,
staff shortages and overwhelmed acute care services. The report held the DHB board and
senior management accountable for the failings in care, but noted the need for support from
central government for district health boards facing intractable pressures.
Patient Safety in Public Hospitals
The risk of patients being lost in hospital referral systems, with dire consequences, was
vividly illustrated in three HDC investigation reports released in October 2008 (07HDC20199,
08HDC06165, 07HDC19869). Four reports released in December 2008 emphasised the need for
robust systems in overcrowded emergency departments, effective supervision of junior staff, and
electronic, integrated patient records (07HDC17769, 07HDC14539, 07HDC10767, 08HDC00248).
Patient safety featured in several other HDC reports, highlighting the need to credential
surgeons and ensure good support services in provincial hospitals (07HDC17438), and the
importance of public hospital on-call arrangements not being compromised by consultants’
private work (07HDC15291). DHBs have been reminded of their statutory responsibility to
monitor the quality of care delivered by contracted providers in rural hospitals (07HDC11548).
Aged Care
Aged care has been in the public eye this year, with a notable increase in complaints to HDC.
Poor documentation, issues related to falls and the use of hoists to move residents, and
inadequate care were common themes. Wound care was a particular issue (see 07HDC17744
and 07HDC12520) and a number of cases examined the responsibilities of nurse managers
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