North Shore Hospital report - New Zealand Doctor

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Health and Disability CommissionerAPPENDIX 4 — EXPERT ADVICE — MEDICAL CARE, DR JOHN HENLEYI have been asked to give an Independent Advisor‘s Report. I have read the guidelines andagree to follow these.My name is John Wilton Henley. I am a qualified specialist General Physician (MBChB,FRACP) and have worked in the General Medicine Department since 1977, for 12 years as itsClinical Director. Much of my work involves the care of acute elderly patients, initially viathe Admission & Planning Unit (of which I [was at the time of preparing this report] ClinicalDirector) and afterwards in the inpatient wards.The overall terms of reference for the report to the HDC are:1. The appropriateness of the services (medical) provided by the Waitemata District HealthBoard (WDHB) at North Shore Hospital between 1 July and 31 October 2007 to patientsattending the Emergency Care Centre (ECC) or in wards 10 and 11.2. The adequacy of the information (medical) provided by the Waitemata District HealthBoard at North Shore Hospital between 1 July and 31 October 2007 to patients attendingthe Emergency Care Centre or in wards 10 or 11.a) [Ms A] from 31 March to 2 April 2007b) [Mrs B] from 6 July to 14 July 2007c) [Mrs C] from 25 to 27 September 2007d) [Mr D] from 20 September to 18 Octobere) [Mrs E] from 17 to 19 October 2007Information for the basis of this report has been supplied to me by the Health & DisabilityCommissioner. This includes summaries of complaints, interviews with staff, full copies of allcase records and hospital protocols. A full record of all recorded information can be obtainedfrom the Commissioner.For the purpose of the report, comments regarding each patient will be made separately,preceded by a summary of the initial complaint.[Ms A] (dec)Executive Summary:[Ms A] was transferred from Waitakere Hospital to North Shore Hospital for investigationand treatment of probable haematemesis. Following her discharge from hospital on return toher rest home she was found to have a fractured hip and returned to North Shore Hospital.Specific Complaint:Discharged from hospital with a fractured hip.Expert Advice Required:Please comment on the standard of care provided to [Ms A] by medical staff in ECC. Pleaseexplain what standards apply and whether they were complied with. Please include commenton:a) The appropriateness of [Ms A‘s] discharge.[Ms A] was admitted to Waitakere Hospital on 31 March 2007 because of possiblehaematemesis. After full medical assessment, including neurological examination which132April 2009
Opinion 07HDC21742showed ―power N‖, she was transferred to NSH. No mention was made of any pain in thehips at that time.She was admitted to the ECC and NSH in the early hours of 1 April 2007. She was admitted,treated conservatively as far as her possible gastric bleeding was concerned, and eventuallydischarged on 2 April 2007.Careful perusal of both medical and surgical notes give no evidence at all of possible fallresulting in a fractured neck of femur. Noted to ―be comfortable‖ and to have ―no complaints‖recognising there was some mild confusion documented.She was reviewed at 11.30am on 2 April 2007 and discharged back to her rest home.Following discharge, she was placed in a private car, with the help of two ambulance officers.On arrival at the rest home [Ms A‘s] partner attempted to get her out of the car. He wasstopped by the nursing staff and she was placed in a wheelchair, following which shecomplained of pain and was unable to mobilise. X-ray confirmed a fracture. The rest homefilled out an incident form relating to these events.I disagree completely with the comment by [the General Manager for Adult Services] in aletter sent to the HDC on 17 September 2007. She said ―the possibility she did fall and the fallwas not witnessed however, cannot be discounted.‖ If [Ms A] had fallen and fractured her hip,she would not have been able to get up, and would have been found on the floor.I find there is absolutely no evidence that a fracture occurred in North Shore Hospital. Thetiming of such a fracture is conjecture and will not be further discussed.Summary:There is no evidence at all that a fracture occurred while [Ms A] was in the care of staff in theECC. Medical and nursing care was entirely appropriate.Perhaps attention should be given to providing more support for elderly patients going homewith their own transport.[Mrs B] (dec)Executive Summary:[Mrs B] was transferred to North Shore Hospital ECC on 6 July 2007, after suffering from asevere stroke while on holiday [overseas] in June 2007. She remained generally unresponsiveand died on 14 July. Her family have complained that while in ECC there was a lack ofcommunication and handover between staff. Changes in personnel required a reiteration ofpatient history on the family‘s part. [Mrs B] had an episode of breathlessness but was leftsupine by nursing staff. Once admitted to ward 11 later on 6 July, nursing staff appeared―stretched and stressed‖ which led to delays in nursing cares. There was also lack ofcontinuity of care with no particular staff taking ownership of [Mrs B‘s] care. On 14 July,[Mrs B] went into respiratory distress, and there was delay in her being seen by the on-callmedical staff. Her family believe that nursing staff failed to recognise the extent of herrespiratory distress.Specific Complaints from family were:1. Lack of communication and handover between staff.2. Reiteration of patient‘s history because of change-over of staff.3. Left lying supine despite breathlessness.4. Delays in nursing care as nurses ―stretched and stressed‖.5. Lack of continuity of care with no one taking ownership.April 2009 133
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