Gisborne Hospital Report - Health and Disability Commissioner

Gisborne Hospital 1999 – 2000
PSA Testing Procedures
work with Dr Gowland, Mr Ted Wesley, an executive member of the Prostate
Awareness and Support Society:
“As a lay person I was pleased with the professional attitude and the
trouble being taken to track down and organise clinic visits for ‘at risk’
men following errors in PSA reporting by the laboratory at Gisborne
Hospital. I am satisfied that everything possible is being done in the
follow-up of these men. It is pleasing that of the men seen so far, no
patient has been placed at further risk or clinically disadvantaged due to
mistake in the PSA results. This, in no small part, reflects the rigorous
follow-up and ongoing care they have received over the years despite the
errors in the PSA tests.”
4.13 Dr Gowland began the summary of this report by commenting that “the THL
laboratory appears to have been a disaster waiting to happen”. This is not just
a retrospective view, made with the benefit of hindsight. Much the same
language was used, and assessment made, by the Clinical Director (Surgery) in
a letter to the Group Manager (Community & Support Services) dated 28
September 1999. The Clinical Director (Surgery) complained of the regularity
with which “fundamental” mistakes were occurring in the laboratory and
insisted that they required correction urgently. “These [mistakes] simply
should not happen and need addressing with the utmost urgency before the
disaster that is waiting to happen does happen.” The Clinical Director was not
referring to mistakes in PSA testing, of course, but his assessment that the
biochemistry section of the laboratory was a disaster waiting to happen was
shared by others at the time, and confirmed by the events in 2000.
5. ORGANISATIONAL, MANAGEMENT AND INSTITUTIONAL
FACTORS
5.1 As will be clear already, the problem with PSA testing must be understood in
context. Several organisational, management and institutional factors clearly
contributed to the environment in which the mistakes occurred.
Lack of resident pathologist
5.2 Over the last ten years THL has had eight pathologists. There has been
difficulty in attracting and then providing sufficient work, and work of a
sufficiently varied and interesting nature, to keep an active pathologist fully
occupied. The last resident pathologist resigned in late 1999 and, despite
conscientious efforts, THL has been unable to appoint a successor.
5.3 Throughout all the changes of the last few years THL has been determined to
maintain an on-site pathologist, particularly in light of the needs of Maori.
THL’s proposal to contract laboratory services to an alternative on-site
provider (discussed later in this chapter) had at its core the requirement for an
on-site pathologist. At a hui attended by my investigation team, staff were
told of a perceived lack of cultural sensitivity by THL due to the lack of a
residential pathologist at Gisborne. Since there was no pathologist at
Gisborne, bodies were “stockpiled” before transportation to Tauranga for
157