Auckland District Health Board Taikura Trust Aranui Home and ...

Health and Disability Commissioner
115. It was also stated that ADHB could ―… not comment on Ms A’s impression that she
was discharged to Oak Park Private Hospital under a court order as upon Ms A’s
discharge it would have been clear to ADHB staff that there was no order in place as
Ms A had not been served with an order and there was no court documentation to
support such an order under the PPPR Act‖.
116. However, ADHB subsequently acknowledged that it appeared that discharge
proceedings had progressed in the belief that the PPPR Act application had been filed.
It apologises to Ms A for the breakdown in this process and the fact that she was not
advised that the application had not been lodged. 23
117. ADHB noted in response to my provisional opinion that it is important to distinguish
between discharge and discharge planning, in relation to consent. While preparation
for discharge, and subsequent care in a rest home, are provision of services requiring
the consent of the patient or his or her representative, the decision to discharge a
patient is made by the hospital, and consent is not required.
118. ADHB has noted the learning that has resulted from these events:
There need to be checks to ensure important documentation such as PPPR Act
applications meet their destination.
That placement arrangements need to be carefully documented in discharge
arrangements.
That the PPPR Act application process can be a lengthy affair which may not
be completed before a patient is discharged. As such, ADHB’s responsibilities
for co-ordination may not stop when a patient leaves hospital.
119. ADHB also advised that further training for social workers by legal services had been
initiated, and provided HDC with a protocol developed to guide staff with court
orders under the PPPR Act.
120. ADHB undertook its own adverse event investigation, issuing its final report in
November 2009. The purpose of the investigation was to identify factors that led to
the failure to ensure appropriate legal authority was obtained to transfer Ms A to a
[residential facility]. ADHB identified the primary cause as:
121. ―The lack of an individual or a multidisciplinary team to coordinate and be
accountable for:
Identifying appropriate legal authority to treat and transfer [Ms A]
The lodgement of the PPPR Act application for [Ms A].‖
122. A number of contributory factors were outlined. Several recommendations were made
for the development of processes for PPPR Act applications. The person or team
responsible, and the timeframes were not specified.
23 This apology was contained in correspondence submitted to HDC before Ms A died.
20 3 November 2010
Names have been removed (except Auckland DHB, Taikura Trust, Aranui Home and Hospital/Oak
Park Dementia Unit and the expert who advised on this case) to protect privacy. Identifying letters are
assigned in alphabetical order and bear no relationship to the person’s actual name.