Gisborne Hospital Report - Health and Disability Commissioner

(situations where harm does occur, due to a health care intervention). It fails
to capture “near misses” as a category of incidents.
5.2 The current policy has also proved problematic in practice. There are no
guidelines for completion of incident reports, no mechanism to track filed
reports, and inconsistency about which incidents are drawn to the attention of
the Senior Management Group.
5.3 Where incidents were reported in the period under review, THL paid
lipservice to the concept of root cause analysis, but staff personally involved
in the incidents experienced criticism and blame. Incident reporters often
received no feedback.
5.4 Quality and continuity of care for patients at Gisborne Hospital was
potentially compromised by the failure to have an effective incident reporting
system, and THL therefore breached Right 4(5) of the Code.
5.5 Complaints were also not well handled by THL. The complaints database was
incomplete and the response to complainants was variable. The policy does
not ensure that consumers are informed of any relevant internal and external
complaint procedures, and THL therefore breached Right 10(6)(b) of the
Code.
6. OPERATING THEATRE PROTOCOLS, OCTOBER 1999 –JUNE 2000
6.1 A raft of allegations of inappropriate conduct in operating theatre by
Canadian anaesthetist, Dr Brian Lucas, was central to staff concerns at
Gisborne Hospital, the NZNO decision to intervene, and my investigation.
6.2 I found that Dr Lucas was a skilled and competent anaesthetist, who complied
with professional standards, but who got offside with nurse and anaesthetist
technician colleagues. The majority of the allegations against him were
unsubstantiated.
6.3 Dr Lucas’ admitted re-use of syringes did, however, expose patients to a tiny
but avoidable risk of infection, which necessitated a “look back” programme
for affected patients. No evidence of disease transmission was found. By
failing to provide services in a manner that minimised harm to patients, Dr
Lucas breached Right 4(4) of the Code.
6.4 On some occasions Dr Lucas failed to dispose of sharp instruments in theatre
in an approved manner, in breach of a Gisborne Hospital protocol and
therefore in breach of Right 4(2) of the Code. No actual harm to any patient
resulted.
6.5 On two separate occasions Dr Lucas failed to comply with the legal
requirements of informed consent, and breached Right 6(1)(b) and Right 7(7)
of the Code respectively.
7. PSA TESTING PROCEDURES, APRIL 1998 – JUNE 2000
7.1 The biochemistry section of the Gisborne Hospital Laboratory has had a
troubled history. Problems have included periodic lack of a resident
iv