Health NZ Southern breaches Code for poor record keeping and administration of steroids without patient’s consent - 20HDC01118

Southern DHB (now Health New Zealand | Te Whatu Ora Southern) breached the Code of Health and Disability Services Consumers’ Rights (the Code) in respect to aspects of care provided to a woman who required spinal surgeries.

In a report released today, the Deputy Health and Disability Commissioner said Health NZ Southern breached the Code by not giving the woman full information, and not upholding her rights to give informed consent when it administered steroids without discussing their use.

Dr Vanessa Caldwell said "…people have the right to receive the information that any reasonable person would expect, in the same circumstances, in order to make an informed choice or give informed consent. In my view, the necessary information was not provided to this woman and, this is an error for which Health NZ must take responsibility."

She was also critical of its poor record keeping, noting, "Good documentation is essential to maintain continuity of care."

The case involved the complex management of the woman’s neurological symptoms and spinal surgeries which had to be rescheduled several times. The woman was prescribed a steroid for pain relief but there were no records of this being discussed with her. She complained to Health NZ Southern but was very critical of its management of her complaint.

Dr Caldwell acknowledged the woman’s distress. "Ms A had a difficult patient journey. It is understandable that she feels let down by the public hospital. I am concerned about three key aspects of the care provided to Ms A, namely around informed consent, record keeping and Health NZ’s response to her complaint."

Dr Caldwell made an adverse comment on the surgeon’s failure to introduce himself and advise the woman that he was replacing the original surgeon in performing surgery. She recommended that he undertake HDC’s elearning module on informed consent.

She has also recommended Health NZ Southern apologise to the woman and review neurosurgery service staff training on informed consent and audit its standard of record keeping.