Misplaced swab and deaths mar record

20:14, Nov 21 2013

A surgical swab left inside a patient and two deaths are among the most serious adverse events reported by the Nelson Marlborough District Health Board over the past financial year.

The Health Quality & Safety Commission issued its annual report into serious adverse events, formerly known as serious and sentinel events, yesterday.

The board was responsible for nine of the 489 general events reported nationally by the 20 health boards and other health providers.

A board spokesperson said she was unable to specify which of the general events occurred at Wairau Hospital rather than Nelson as the reporting exercise focused on the actions of district health boards, not individual hospitals.

One of the two deaths resulted from cardiac complications.

The report stated the patient had been given medical treatment for a heart attack in the intensive care unit, but within 24 hours of being transferred to the mental health unit, they died.


A review found that an abnormal blood test result had not been reviewed before the patient was discharged from medical supervision.

In response to the incident, the board has recommended that cardiac patients only be discharged when the results of all their investigations have been checked.

Another patient died from complications that resulted from a brain haemorrhage and a cerebral aneurysm.

The board refused to release any information clarifying its role in this death, but an external review of the assessment and treatment it provided had been held.

The review was completed but its findings and recommendations are yet to be finalised.

Changes to the way hospital theatres count their surgical swabs have been recommended after a swab was left inside a patient.

The Express reported in August that a female patient at Blenheim's Wairau Hospital had to be taken back to surgery in July after a swab was left inside her.

The Express understood the swab was discovered three or four days after the first operation, and the board quotes "delayed removal" in its report to the Commission.

Board chief medical officer Heather McPherson said the board had apologised to the patient for the pain and suffering caused by the incident, saying a "robust internal investigation" was being conducted to find out how the swab had been left inside the woman. The report mentioned a review of board theatres' swab counting procedure.

In six of Nelson Marlborough's nine events, a patient fell over and fractured a bone.

The commission decided to separate mental health and addiction services' serious adverse events from the main report in 2011.

The board's mental health and addiction services wing reported five events for this financial year, although it did not specify what the events were. Fairfax NZ

The Marlborough Express