Deputy Health and Disability Commissioner Rose Wall today
released a report finding a district health board (DHB) and
a rest home provider in breach of the Code of Health and
Disability Services Consumers’ Rights (the Code) for
failures in the care of an elderly man following a
stroke.
The man, aged in his eighties at the time of
events, was admitted to the DHB with slurred speech and a
left facial droop. He was transferred from the DHB to the
rest home, and required hospital-level care.
At the
rest home, his agitation and pain were not assessed and
managed adequately, Te Ara Whakapiri end-of-life planning
was not initiated, and hospice or other services were not
contacted for guidance. Sadly, he passed away three months
after being transferred to the home.
Deputy
Commissioner Rose Wall found that the DHB’s review of the
man’s deteriorating condition was inadequate. There was a
lack of consideration for thrombolysis treatment and
escalation to a senior doctor, a lack of documentation, and
the DHB’s policies and systems to support staff to provide
adequate after-hours care and treatment were
inadequate.
Ms Wall was critical of the rest home’s
overall assessment of the man’s agitation and the
management of his pain, and the lack of discussion with his
family and his GP. She was also critical of the rest
home’s documentation and follow-up of UTIs, and that Te
Ara Whakapiri end-of-life planning was not initiated nor the
hospice consulted when the man’s condition
deteriorated.
“I strongly emphasise to health
providers the importance of initiating end-of-life
conversations and instigating end-of-life protocols once a
patient has been assessed for palliative care and prior to a
patient’s deterioration, to enable the person to have a
voice (if able) along with their family,” said Ms
Wall.
Ms Wall recommended that the DHB use an
anonymised version of HDC’s report as a case study;
consider updating its stroke thrombolysis protocols and
reviewing its stroke management pathway; evaluate its
mechanisms to identify and manage spikes in workload
after-hours; and provide a written apology to the
family.
She recommended that the rest home develop a
guideline for the timing of end-of-life conversations and
protocols; review its current process for end-of-life care;
provide training on end-of-life care; and provide a written
apology to the family. She also recommended that the rest
home provide its registered nurses with education on the
assessment of patients following a stroke; document a plan
for regular reassessment of patients who require increased
surveillance; and consider training staff on the correct
documentation and communication regarding specimens sent for
analysis.
To read the full report on case 18HDC02364,
visit the HDC
website.
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