Coordination of care at public hospital

Health and Disability Commissioner Anthony Hill today released a report finding Counties Manukau District Health Board in breach of the Code of Health and Disability Services Consumers’ Rights for its care of a man who had sustained injuries from a fall.

The man, in his late 70s, had initially undergone surgery for his injuries and been discharged home. He was readmitted 10 days later because one of his wounds had become infected. It was decided that he needed further surgery, but it was six days after his admission before the surgery occurred. During the surgery, he became unresponsive. He had a large stroke and later died.

Mr Hill found that there had been poor communication and a lack of clear planning between the Orthopaedics and Plastic Surgery teams at the hospital, which had led to a delay in undertaking the man’s necessary surgery. Despite identifying the need for surgery, there was no clearly documented plan setting out which team would be carrying out the procedures.

"Although I acknowledge that in public hospitals delays in performing surgery do occur based on the acuity of other patients, in my view the delays in this case were a result of poor communication between the Orthopaedics and Plastic Surgery teams."
Mr Hill was also critical that the Orthopaedics team had not initiated anticoagulant treatment for the man earlier.

Mr Hill recommended that Counties Manukau DHB provide a written apology to the man’s family, update its policy on clinical documentation, consider implementing policies outlining when a patient should become a Plastic Surgery patient and when to transfer patients between teams, and reiterate to all Plastic Surgery and Orthopaedics staff the need to establish and accurately document communication pathways.

The report for case 17HDC00893 is available on the HDC website.