Gisborne Hospital Report - Health and Disability Commissioner

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(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
pathologist, staff shortages and professional isolation, and have resulted in de-registration by International Accreditation New Zealand (IANZ) in 1992, 1998 and July 2000, after the PSA problem was discovered. 7.2 The PSA testing errors, which affected 500 test results and 117 patients, were due to failures of quality control and human error. 7.3 The head of the biochemistry section of the laboratory, Mr John Rutledge, made serious errors of judgment. He failed to comply with relevant standards and breached Right 4(2) of the Code. 7.4 THL failed to address the systems problems that IANZ had highlighted, and bears organisational responsibility for the lapses that occurred. THL’s failure to exercise due care was a breach of Right 4(1) of the Code. 7.5 Fortunately, none of the 117 affected patients suffered any harm apart from the distress of being notified of the error and the need for re-assessment. 8. PATIENT CARE IN ICU AND SURGERY, APRIL – MAY 2000 8.1 The NZNO letter to the Minister of Health called for an independent audit of standards of care in the Intensive Care Unit (ICU) and surgery in April and May 2000. The attached anonymous letter from a senior ICU nurse described five patient care situations as examples of safety concerns. 8.2 THL commissioned a confidential independent review of the files of 10 patients admitted to ICU in April and May 2000, which concluded that overall the standard of care was impressive. 8.3 Recommendations by external reviewers of ICU and the incident reporting system at Gisborne Hospital have been, or are being, implemented. This follow-up, and Tairawhiti District Health’s positive response to the recommendations in my report, reassure me that the public can have confidence in the standard of patient care in ICU and Surgery at Gisborne Hospital. 8.4 The five cases referred to in the anonymous letter are not dealt with in my report. They are being dealt with under the Health and Disability Commissioner’s standard investigation processes and will be reported on separately. Those investigations will be confidential to the persons involved. v
Page 1 and 2: GISBORNE HOSPITAL 1999 - 2000 A rep
Page 3 and 4: Table of Contents Page Executive Su
Page 5 and 6: 1. BACKGROUND EXECUTIVE SUMMARY 1.1
Page 7: 3. THE ENVIRONMENT 3.1 My investiga
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Page 29 and 30: Chapter 2 Quality Assurance Systems
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RECOMMENDATIONS Quality Assurance S
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Gisborne Hospital 1999 - 2000 Recom
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APPENDIX NZNO LETTER TO MINISTER OF
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11. The anaesthetist had a practice
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THE ANONYMOUS LETTER The anonymous
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GLOSSARY ABBREVIATIONS A&E A,T&R AQ
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Gisborne Hospital Report - Health and Disability Commissioner

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