An under-fire hospital has been castigated by a health watchdog after a patient died following minor, routine surgery.
The Listener exposed the circumstances surrounding the death of Brian Davies last September and in a decision released today, the HDC has found the Counties Manukau District Health Board twice breached Davies’ rights as a patient, saying he did not receive quality and continuity of services.
Davies (78), died from a pulmonary embolism in April 2017 after what should have been routine surgery to debride an infected wound on his calf, sustained when he fell from a ladder at his home three weeks earlier. Despite his wound being assessed as requiring surgery within 24 hours of admission, Davies waited almost a week for the operation on his right calf after communication broke down between the hospital’s orthopaedic and plastics teams over who should operate on him. His family says team members had heated arguments in front of him.
The delay, during which he was largely immobilised in a leg brace with his anti-clotting medicine withheld because of the pending surgery, put him at high risk of venous thromboembolism (VTE), but he was given no documented clot assessment and no preventive therapy, until two days before his operation, when it’s likely the embolus had already formed in his leg before travelling through his body.
The hospital confirmed to the family that his surgery was not delayed by pressure on theatres from more acute cases and acknowledged a “temporary miscommunication”, saying “there were a number of areas during Mr Davies’ care where communication and documentation could be improved.” Discussions staff said they had with Davies about clot prevention and medication weren’t recorded.
“Mr Davies did not receive quality and continuity of services because of the failures in communication and lack of clear planning between the orthopaedics and plastic surgery teams,” the HDC found. Middlemore’s chief medical officer Dr Gloria Johnston has apologised unreservedly to the family, but Davies’ daughter Kim Davies-Haycock, who laid the complaint more than two years ago, says the HDC findings and recommendations, and the hospital’s apology feels too little, too late.
The HDC recommended the Counties Manukau DHB update its policy on clinical documentation and consider implementing policies outlining when patients should be dealt with by the plastic surgery team and when they should be transferred between teams and consultants. It recommended the DHB reiterate to its plastic and orthopaedics staff the need to document “communication pathways” accurately, update its VTE prevention plans and apologise to Davies’ family. The report says the DHB accepted the opinion and would comply with the recommendations.
Middlemore has been at the centre of a number of controversies in recent times, including resourcing issues blamed for a cluster of baby deaths, and infrastructure problems which have included rundown buildings with mould, asbestos and raw sewage issues. Last year, it was described as “the emblem of what is wrong with New Zealand’s health care system”.
Davies-Haycock says she wouldn’t be surprised if lack of resources contributed to the apparent unwillingness of either specialist team to operate on her father, “because neither of them wanted the cost to come out of their budget”.
She says the complaints process was arduous and challenging and took perseverance and resilience to navigate. The recommendations were “too late, too granular”, and unlikely to make any substantial change because they would be so narrowly applied in only one DHB. “It took more than two years to investigate something that is going to create one or two policy changes in one ward of one hospital.”
Davies-Haycock has spent hundreds of hours researching quality improvement systems worldwide and says New Zealand’s system, in which hospitals and DHBs are responsible for developing and monitoring their own health policies is inefficient, expensive, confusing to staff and potentially detrimental to patient safety. “The average New Zealand hospital with an intensive care unit has 1500-2000 control documents or policies – Middlemore, for example has 1756.” Policy documents were generally centrally-held, not readily accessible or transportable, and could be complex and difficult to follow. Each hospital having its own policies is akin to each town having its own traffic laws, she says. “Imagine if each town could decide its own speed limits and which side of the road you drove on. It would be chaos and our safety on roads would be hugely compromised. When each hospital gets to choose its own policies, each patient is at high risk of chaotic practices.”
In submissions to Heather Simpson, who’s chairing a wide-ranging government review into health and disability services, Davies-Haycock recommended New Zealand investigates replicating Scotland’s 10-year-old patient safety programme which has achieved significant health care improvements, and to roll out nationally the US-developed online programme Lippincott Solutions – evidence-based guides to performing 1700 clinical procedures – which is already used in 16 of our 20 DHBs.
Davies-Haycock says people with a loved one in hospital have to be strong patient advocates. “It would have made a difference if I had voiced my concerns very strongly and asked for more information about the risks of his drug being removed. My father was a very compliant, uncomplaining patient. He didn’t say ‘Why is my surgery not happening? I’ve been here 3, 5, 7 days … why am I not getting the care I should? If he’d been an advocate as well as someone in the family, it wouldn’t have happened. Don’t be a patient patient; be impatient. This situation could happen to anybody – all of us need to ask for the changes that keep us and our families safe.”