Staff at two Christchurch hospitals failed to care for an elderly woman who was in constant pain and showing signs of deteriorating health.
A decision by the Health and Disability Commissioner Anthony Hill released today has found that a 92-year-old woman did not receive a medical review for 11 days before being discharged and transferred to a rest home, despite requiring further treatment.
Hill's report showed the Canterbury District Health Board (CDHB) committed a series of breaches, including lack of medical review, failure to recognise patient decline, and lack of falls management and assessment of suitability for rest home-level care.
The report also found that no routine ward rounds happened during Queen's Birthday weekend in 2011 and that the woman suffered numerous falls while in hospital.
Staff notes showed the woman complained of chronic back pain and at times struggled to sit upright. She was assessed as suffering from mild to moderate depression and often refused to eat or drink.
By the end of her hospital stay she required full assistance to shower and dress, was described as being in a ''very low mood'', and had lost more than 5 kilograms of weight.
The patient, known as Mrs A, was referred to the CDHB older person's health specialist service because of persistent back pain and restricted movement and was admitted to hospital on May 11, 2011. A spinal X-ray showed a compression fracture of a vertebra and was treated with morphine. Mrs A was also assessed as being a high falls risk.
After a family meeting, it was planned that the woman would be discharged to a rest home on June 7, the day after Queen's Birthday Weekend.
She was last reviewed by a doctor on May 27 and received no subsequent medical review leading up to her discharge from hospital, despite her deterioration, which included increased levels of pain and a fall on June 6.
Commissioner Hill also found that DHB staff did not contact the rest home before Mrs A's discharge from hospital and that the rest home was not ready to accept her when she arrived on June 7.
Mrs A stayed at the rest home for three days, before being acutely admitted to the medical ward of another public hospital with abdominal pain on June 10.
She had another fall the next day but because the sensor clip she was wearing did not have batteries in it, staff were not aware of the incident, the report says.
On June 15, test results found a vertebra fracture and spinal canal narrowing. Mrs A was transferred back to the first hospital and an MRI scan showed a new back fracture and further compression of vertebrae.
She had further falls on June 22 and 24 and was transferred to a private hospital on June 27.
She died a few weeks later.
The woman's daughter complained about the care her mother received and the Health and Disability Commission began investigating in August, 2012.
Hill found there had been several ''systemic shortcomings'' in Mrs A's care, meaning the severity of her back injuries was not picked up on quickly enough.
The DHB had since made several changes including:
- New staff orientation to the rehabilitation ward
- Falls strategies had been reviewed and each unit now had the use of sensor clips and sensor mats
- All patients on the ward are reviewed by a doctor on the day of their discharge
- Handover and transfer of care forms and processes have been upgraded
The commissioner also recommended several reviews to DHB procedure as well as a formal written apology to Mrs A's family.
- The Press
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