Gisborne Hospital Report - Health and Disability Commissioner

Gisborne Hospital 1999 – 2000
Incident Reporting and Complaints Procedure
4.10 Further examples of Tairawhiti Healthcare’s failure to identify the root cause
of incidents are reflected in the response to incidents relating to Dr Lucas. The
focus of management actions was on proximal events and there was no
tracking back to root causes. For example, there was no initiation of a multidisciplinary
forum for discussing proposed changes to practice prior to the
introduction of restraints (straps), or resolution of communication difficulties
between Dr Lucas and theatre staff.
4.11 Another issue discussed by some interviewees was the responsibility and
accountability for following up incident reports. One senior clinician noted
that there is a gap between the general management reporting pathway and the
Clinical Director pathway when there are recommendations for action on an
incident. He commented that “the gap appears when it comes to identifying
who ultimately takes responsibility for those recommendations”. He observed
that “there are often debates at Senior Management Group meetings over who
should bear responsibility for dealing with incidents”. The Human Resources
Manager illustrated the dilemma. He asked rhetorically, in relation to the
alleged needle throwing incident, “who is responsible for handling the
incident, the Clinical Director as a professional issue or the Group Manager as
a disciplinary matter?”
Feedback to staff following incident reporting
4.12 The investigation team consistently received strong comment from staff that
they expected, but had not received, feedback on the incident forms they
submitted. The persistent lack of feedback has severely damaged the
credibility of the incident reporting system in the eyes of many staff. The New
Zealand Nursing Organisation stated in its submission: “NZNO members have
a strong view that completing incident forms was a waste of time because
feedback was rare and frequently negative .… Professional responsibility and
an awareness of the importance of documentation led staff to continue filling
in forms, rather than the belief that the situation would be addressed.”
4.13 One senior doctor stated that “to fill in an incident form and get no feedback is
like hitting your head against a brick wall. The perception is that the incident
form goes into a big dark hole so there is no point in filling them in.”
4.14 One of the strongest advocates that feedback should occur was Dr Lucas (see
also para 4.40). His suggestion to that effect was passed on to the Senior
Management Group by a Clinical Director.
4.15 In contrast to the staff experience of receiving no feedback, the Human
Resources Manager, who oversees the system, expected “the person who
completes the incident form will be spoken to. The process is that the incident
form is completed, the manager investigates and provides feedback to that
person.”
4.16 THL stated that:
“The system is only as good as the people who use it. The staff need to
fill in incident reports and there is no excuse for not completing them.
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