Gisborne Hospital Report - Health and Disability Commissioner

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Chapter 1 Introduction and Environment 1. INTRODUCTION Concerns about patient safety at Gisborne Hospital 1.1 On 13 June 2000 Brenda Wilson, Chief Executive of the New Zealand Nurses Organisation (NZNO), visited Gisborne Hospital and met with nursing staff. Ms Wilson also met briefly with the Chief Executive and advised in general terms that, on the basis of her discussions with nursing staff and local NZNO representatives, she had a number of serious concerns about patient safety at Gisborne Hospital. Specifics were not discussed. 1.2 On 14 June NZNO wrote to the Minister of Health expressing concern about standards of care at Gisborne Hospital, seeking an independent review and noting that NZNO would not have confidence in a review undertaken by the Ministry of Health. This letter attached two documents: the first, a memorandum dated 1 June 2000 from a regional NZNO representative to NZNO head office outlining a number of issues of concern in relation to Dr Lucas – including re-use of anaesthetic syringes and Gisborne Hospital’s response to this issue; the second, an anonymous letter from a nurse at Gisborne Hospital which expressed concerns about “increasingly poor levels of medical, surgical and management practices and accountability”. The writer described five recent cases of alleged inadequate patient care. These documents are set out in the Appendix. 1.3 Tairawhiti Healthcare Ltd (THL) learnt of NZNO’s complaint to the Minister of Health and its concerns about patient safety from a Radio New Zealand news story the following day, 15 June. In a discussion with NZNO representatives on 20 June, the Chief Executive requested that NZNO provide Tairawhiti Healthcare with the names of patients cited in the anonymous letter, so that it could investigate. NZNO refused to provide the names of the patients and instead responded by advising that it wanted an independent retrospective audit of ICU and surgical cases over the last three months. The reason NZNO gave THL for refusing to provide the names of the patients was that the nurse who had provided the information requested anonymity. 1.4 In a Radio New Zealand interview on 16 June, NZNO called for an investigation by the Health and Disability Commissioner. This call was repeated in the media over the following days. However, at no stage did NZNO approach the Commissioner and exercise the right that any person has under section 31 of the Health and Disability Commissioner Act 1994 to make a complaint to the Commissioner. 1.5 By a letter to NZNO dated 23 June, the Chief Executive again requested the names of the patients and stated that “it is simply not acceptable (legally or ethically) for registered health professionals to refuse to disclose to the HHS [public hospital] relevant information, while complaining to other authorities
Gisborne Hospital 1999 – 2000 Introduction and Environment about lapse of care in relation to specific patient .… It is essential that I have this information to investigate the concerns.” 1.6 By a letter to the Chief Executive dated 28 June, NZNO stated that it was “absolutely aware of nurses’ obligations to report adverse incidents [and] also aware of how risky this proves to be for individual nurses”, and that it held no further information, “apart from that which may identify the nurse making the complaint”. NZNO stated that “we should be ashamed that the element of fear which permeated the New Zealand Health Service under the previous administration has resulted in nurses’ inability to raise concerns with their own management”. The letter was copied by NZNO to the Minister of Health. 1.7 The Minister of Health and THL both signalled their intention to inquire into the quality of care at Gisborne Hospital in response to the NZNO allegations, which had been extensively covered in the media. 1.8 In these circumstances, as Health and Disability Commissioner I considered the allegations and the mounting public concern, and decided to commence an independent investigation into patient care and quality assurance systems at Gisborne Hospital. The first four terms of reference were announced on 30 June 2000. 1.9 THL then became the subject of further allegations, this time involving the Gisborne Hospital laboratory and allegations of inaccurate PSA testing (used as an indicator of prostate cancer). On 12 July 2000 the terms of reference of my investigation were extended to cover the laboratory issue. Terms of Reference 1.10 On 30 June 2000 I announced the following terms of reference for an inquiry into patient care and quality assurance at Gisborne Hospital: “THE HEALTH AND DISABILITY COMMISSIONER’S OWN INITIATIVE INQUIRY INTO PATIENT CARE AND QUALITY ASSURANCE SYSTEMS AT GISBORNE HOSPITAL As a result of allegations concerning standards of patient care and quality assurance systems at Gisborne Hospital, the Health and Disability Commissioner, Ron Paterson, is to commence an independent inquiry under section 35(2) of the Health and Disability Commissioner Act 1994. The following matters will be investigated to determine whether any action by Tairawhiti Healthcare Limited or any individual health care providers at Gisborne Hospital has breached patients’ rights under the Code of Health and Disability Services Consumers’ Rights: • Operating theatre protocols and compliance with such protocols between October 1999 and June 2000; 2
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RECOMMENDATIONS Quality Assurance S
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APPENDIX NZNO LETTER TO MINISTER OF
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11. The anaesthetist had a practice
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THE ANONYMOUS LETTER The anonymous
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GLOSSARY ABBREVIATIONS A&E A,T&R AQ
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Gisborne Hospital Report - Health and Disability Commissioner

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