Northland health staff have been criticised after a 75-year-old man had a knee replacement and died five days later in their care.
Health and Disability Commissioner Anthony Hill found the failures of orthopaedic and nursing teams were directly attributable to the Northland District Health Board.
The decision, released today, highlights a failure of staff to exhibit reasonable care and skill, poor communication and inadequate documentation.
Hill also said there was “widespread failure by the nursing team to consistently comply with relevant procedures, which compromised the man’s right to continuity of care”.
The 75-year-old patient underwent elective surgery to replace his right knee joint and the surgery was initially deemed successful.
However, two days later, the man’s urine output and blood pressure began to decrease.
While the nursing team noted concerns about the man’s condition, those concerns were not passed on to the orthopaedic team.
The failure was compounded on the morning of the third day after the operation when a nurse incorrectly recorded the total of urine that the man had passed.
By day four it was noted that the man had not passed urine since the removal of his catheter the previous morning and attempts were made to treat his deteriorating condition.
The man died the following day after a cardiac and respiratory arrest.
If the man had been referred for specialist medical review when his urine output decreased and blood pressure dropped as it should have, the death may have been avoided.
“A combination of poor documentation and poor communication led to the failure by both the orthopaedic team and the nursing team to fully recognise the man’s deteriorating condition,” Hill said.
“In addition, critical information about the man that was available to both teams was not adequately accessed and used.”
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