Gisborne Hospital Report - Health and Disability Commissioner

Gisborne Hospital 1999 – 2000
PSA Testing Procedures
7.38 THL responded that senior management had relied on management within the
laboratory. THL also pointed out a range of staffing issues, including the
number of part time staff who demonstrated a reluctance to increase hours or
assist in times of peak workload. THL continued:
“Everyone must take responsibility for delivering quality services. We
believe that the problems with the laboratory are not all associated with
management, leadership and a lack of vision. These matters relate also
to the openness, conflict resolution, clinical practice and the behaviour
of staff of all professions. The decisions and behaviour of nurses, both
junior and senior medical staff, contribute to and impact on patient
services.”
7.39 It is abundantly clear that the troubles at the biochemistry section of the
laboratory at Gisborne Hospital existed well before the period covered by this
term of reference, and that they continued to dog the section until mid-2000.
The biochemistry section was, as several people observed, a disaster waiting to
happen.
7.40 Given the record of the biochemistry section of the laboratory in the
independent assessments made by IANZ, it is hard to understand why no
concerted effort was made to investigate why this core diagnostic service
failed to meet minimum standards on two previous occasions, to such a serious
degree that it was de-registered a third time. A failure of this degree clearly
warranted special attention from senior management, and significant changes
or additional resources to support the technical staff and enable them to rectify
the problems permanently. THL does not appear to have adopted a long-term
risk management approach to the identified quality issues in the biochemistry
section of the laboratory.
7.41 THL must accept some responsibility for the situation that developed in the
biochemistry section of the laboratory at Gisborne Hospital, and for the
evident failure to respond adequately to the specific problems identified in the
assessment by IANZ in 1998, that led to de-registration.
7.42 In my opinion, THL did not ensure that consumers received clinical
biochemistry services of an appropriate standard from the Gisborne Hospital
laboratory. Biochemistry services were not provided with reasonable care and
skill and, as a direct consequence, in June 2000 many consumers who had
undergone PSA tests faced the stress and uncertainty of re-testing and review.
7.43 These failings by Tairawhiti Healthcare Ltd amounted to a breach of Right
4(1) of the Code.
IANZ
7.44 Given its limited regulatory role, it is not possible for IANZ assessors to carry
out a full audit of every method, instrument, and quality system that should be
in place in the time they spend on site. IANZ can sample only a number of
facets, and relies to a large extent on laboratory staff to bring potential
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