Care provided following major surgery in non-tertiary level hospital

Executive summary

1. This report concerns the care provided by Waikato District Health Board (DHB) to a man following elective major surgery at a hospital to remove a polyp. The man deteriorated postoperatively and was transferred to the Emergency Department (ED), but he later suffered acute cardiac failure and died. The Commissioner considered that the decision to perform the surgery at the non-tertiary level hospital, with the known risks and lack of staff, was misjudged, and should have been carried out at a more suitably equipped hospital.
2. Signs of infection, tachycardia, hyponatraemia, and fluid deficit were not responded to adequately. On a number of occasions, staff did not document Adult Deterioration Detection System (ADDS) scores satisfactorily, and senior staff were not contacted for advice when indicated and around the time of the man’s transfer to ED. In relation to the care in ED, communication between the ED consultant and on-call cardiologist was poor, and further investigations should have been undertaken before myocardial infarction (MI) was ruled out. The man was returned to the surgical ward from ED inappropriately, and was not monitored for two hours. In addition, staff did not take steps to follow up with his surgeon regarding pain medication, and concerns about his return to the ward were not documented by staff.

Findings

3. The Commissioner found that Waikato DHB breached Right 4(1) of the Code. He considered that on a number of occasions during the postoperative period, the staff responsible for the man’s care did not respond appropriately to concerning clinical signs, and that this illustrated a pattern of poor care for which Waikato DHB is responsible.

Recommendations

4. The Commissioner recommended that Waikato DHB apologise to the family and provide evidence of the implementation of a number of recommendations, including: (a) the policies and procedures in place, to ensure that complex and major surgery will not be undertaken at the hospital; (b) the criteria in place for the admission of acute and surgical patients to the hospital; and (c) the outcome of changing weekend rostering and staff handover processes since the events in this report.
5. The Commissioner also asked Waikato DHB to consider: (a) staff education and audits of MI diagnosis and treatment at the hospital; (b) how it could better share clinicians’ workload outside of daytime work hours; (c) the institution of a step-down unit with higher nursing staff levels; and (d) whether an explicit follow-up plan is required for patients who are transported from ED back to the ward.

Complaint and investigation

6. The Health and Disability Commissioner (HDC) received a complaint from Mrs A about the services provided by Waikato District Health Board (DHB) to Mr B. The following issues were identified for investigation:

• Whether Dr C provided Mr B with an appropriate standard of care between Days 1–5
• Whether RN D provided Mr B with an appropriate standard of care on Day 5 2016.
• Whether Waikato District Health Board provided Mr B with an appropriate standard of care between Days 1–5 2016.

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