Gisborne Hospital Report - Health and Disability Commissioner

Gisborne Hospital 1999 – 2000
Introduction and Environment
• Quality assurance systems at Gisborne Hospital including incident
reporting protocols and systems;
• The handling of incidents reported by staff between October 1999
and June 2000, including the issue of re-use of anaesthetic
syringes;
• Allegations of inadequate standards of patient care in surgical and
intensive care services in April and May 2000.”
The terms of reference were extended on 12 July 2000 by the addition of the
following term of reference:
• “PSA testing procedures from April 1998 to June 2000.”
1.11 During the course of the inquiry, the Minister of Health dismissed the Board of
THL on 12 July 2000 and appointed Mr Wayne Brown as the interim
Chairperson. The Chief Executive of THL, Ms Sheryl Smail, resigned at the
end of October 2000, and was replaced by Mr Jim Green, formerly of
Northland Health, on 4 December 2000.
The Investigation Team
1.12 The investigation team included two clinical advisors and a project manager:
Dr Sharon Kletchko BMSc, MD, FRCPC, Cert Neph, FRACP, FACEM
Mrs Debbie Penlington RGON, BA (Nursing), M Ed
Mrs Alyson Howell M Phil, BA.
Additional clinical expertise was obtained from:
Dr A N Barker BSc, MBChB, MSc, MAACB, FRCPA
Dr Malcolm Futter BSc, MBBS, FRCA, FANZCA.
How the investigation was conducted
1.13 I visited Gisborne Hospital with my investigation team for the first time on 17
July 2000. Open meetings were held with staff and management to brief them
on the process of the investigation. Posters were placed around the hospital to
ensure that all staff knew about the process. Advertisements were placed in
the local newspaper. The Health and Disability Commissioner’s 0800 number
was advertised to ensure staff could make confidential contact with the
investigation team. THL staff co-operated fully with the investigation team to
ensure that staff knew about the investigation.
1.14 Some staff were approached by the investigation team and invited to take part
in the interview process. Other staff came forward of their own volition.
Seventy-eight people were interviewed (and six people were re-interviewed).
The majority of interviews occurred in Gisborne. Five hui were held in
Gisborne, Te Karaka, Tolaga Bay, Te Puia and Ruatoria. Current and former
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