Better communication and clarity of responsibilities required in care of man

With a fever and high temperatures, blood cultures, blood tests and chest and back x-rays were taken, and the man was admitted to the Orthopaedic Department, however, due to a lack of beds in the ward, the man remained in ED overnight. The man received care from both the ED and the Orthopaedic Department while he was "boarding" in the ED.

The man, in his seventies, tested positive for a bacterial infection and his condition deteriorated during his night in ED. He had low blood pressure that remained untreated, his urine was not tested and staff had difficulty finding the man’s observation chart.

Ms James considered that the collaboration and escalation of care between the ED staff and the Orthopaedic Department was inadequate and "there was confusion between the ED and the Orthopaedic Department as to who was responsible for the man’s care."

"When a patient is being seen by different teams during the course of a hospital admission, it is essential clear and effective communication occurs between all teams involved, and SDHB should have in place formal policies and processes to optimise care.

"It is SDHB’s responsibility to provide clear guidelines to its staff and ensure they understand the areas of clinical presentation for which they are responsible for," says Ms James.

In her decision, Ms James acknowledged the challenging environment and overloaded hospital system at the time of events and considered the delays in treating the man’s low blood pressure were likely the result of a "dysfunctional/overloaded" hospital system, and therefore was a systemic rather than an individual issue.

In Ms James’ opinion, the care failures can be attributed to the man’s prolonged stay in the ED. This amounts to a service delivery failure for which SDHB is responsible.

Ms James also made adverse comment about one of the orthopaedic doctors who cared for the man.

"The doctor’s failure to note the man’s vital signs was a missed opportunity to recognise his persistently low blood pressure and to treat it. The doctor should have taken further action to locate the man’s observation chart and assess his vital signs," says Ms James.

Following its own review of this case, SDHB introduced a new national observations chart as part of the Health Quality & Safety Commission’s deteriorating patient programme, a patient flow taskforce has been established to implement safer principles across inpatient wards, to strengthen and refine current reporting metrics, and support services to find ways patient flow can be improved. SDHB also plans to establish a working group to implement an escalation plan for the public hospital. Approval has also been given to increase nursing staff.

Ms James recommended SDHB provide an apology to the family for the services provided to the man, and provide HDC with an update on the development, implementation and effectiveness of the escalation plan for the public hospital, and develop a formal policy and procedures to define responsibilities between different teams and manage risks.

She also recommended SDHB review its current system for storing observation charts in ED, and provide training to staff on the importance of assessing a patient’s vital signs, recognition of critical illness and symptoms of septic shock, and the escalation of care and coordination between departments.