Gisborne Hospital Report - Health and Disability Commissioner

Gisborne Hospital 1999 – 2000
PSA Testing Procedures
programmes, which accept data directly from the analyser without the need for
transcription. This would have alerted the operator immediately if tests had
been out of control.
7.32 No external quality assurance programme was instituted for PSA testing. Such
a programme would have acted as a final safety net and shown THL’s results
to be erroneous when compared with peers performing the same test using the
same reagents and the same type of instrument. As noted earlier at paras 3.27
– 3.29, there is a difference of view as to whether THL denied access to
external quality control of PSA test results on financial grounds or whether Mr
Rutledge did this off his own bat. I cannot resolve this issue. If the former is
correct, I would simply say that saving costs by not using quality control
programmes is never the right decision. If the latter view is correct, surely
management should have been aware of the situation.
7.33 It is accepted that Mr Rutledge was doing his best to cope in an unsatisfactory
working environment. He was working in isolation from other senior
colleagues and with managers who appeared somewhat unsympathetic to the
problems faced by the biochemistry section of the laboratory. At the time the
PSA testing problem occurred Mr Rutledge was not receiving training, was
denied the opportunity to attend user group meetings, was under stress from
disciplinary action, allegedly had insufficient staff to enable him to do his job
properly, and was undoubtedly working in a tense environment.
7.34 In the light of the context within which the errors took place and especially the
history of the biochemistry section over the last eight years it may seem
invidious to apportion individual, rather than systemic, blame. However, some
individual failings transcended generic systems failure.
7.35 Taking full account of the difficult working environment Mr Rutledge found
himself in, and his efforts to ensure effective quality control of the PSA test
results provided in the biochemistry laboratory, it is clear that he made serious
errors of judgement and failed to comply with relevant standards.
Accordingly, in my opinion Mr Rutledge breached Right 4(2) of the Code.
Organisational responsibility
7.36 Management appears to have been less than sympathetic to the problems faced
by the biochemistry section of the laboratory over recent years. The air of
uncertainty, unexpected announcement of plans for the service with little
explanation given, and a general disregard or non-recognition of the
experience and concerns being expressed by technical staff have all
contributed to a difficult and tense environment, which increased the
likelihood that the system would fail.
7.37 Staff concerns at workload, expressed prior to and at the time of the PSA
discovery, were directly related to their concerns about potential risk to
patients. A colleague in Mr Rutledge’s department had commented to him
several times, in response to the fact that he was unable to review all the work
done by biochemistry laboratory staff: “We’re flying by the seat of our pants.
It [is] only a matter of time before we have a major.”
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