Two dead after hospital errors

Two patients died, one lost some vision and another attempted suicide because of errors by Nelson Marlborough District Health Board staff in the past financial year, the health board's Quality Improvement Council report released this morning shows.

The summary, voluntarily released as part of a national process, shows that during the 2008-09 year there were six "serious and sentinel events" across the district from 27,480 admissions to hospitals.

A sentinel event is a death or major loss of function where a significant failure of the hospital's care is possible.

One patient, already suffering multiple myeloma or cancer of the white blood cells, died when septic shock and low blood pressure went undiagnosed after he was admitted for hip pain as well as low blood pressure.

It was found that staff did not read the pink card which the patient's wife showed them, which clearly stated the patient may need immediate treatment with antibiotics.

Another patient died when a CAT scan of their abdomen was delayed and an abscess related to a ruptured gallbladder was only found days after admission. The report said there was misunderstanding in paperwork between the consultant, house surgeon, surgical and medical teams and the family.

A third patient lost some vision when a detached retina went undiagnosed.

A fourth patient had the wrong vertebra fused because of poor imaging quality. The patient underwent a second operation without problems.

A fifth patient was on 10-minute observations but escaped from the mental health unit. He went to another part of the hospital, smashed a window with a fire extinguisher, and jumped from the sixth floor in a suicide attempt.

Nelson Marlborough District Health Board chief medical adviser Andre Nel said he could not give any more detail on individual cases and could not say in which hospital the errors occurred, citing patient confidentiality. He said the deaths and injuries were "a tragedy".

Dr Nel said clinicians reviewed mistakes and worked on improving. Families were also consulted and the process and outcome of any review was discussed with them. He said staff were aware that any serious events had to be reported.

"Our staff are very caring, competent people and we believe we have a good notification process," he said.

The Nelson Marlborough District Health Board hospitals had 16 serious and sentinel events in the five years to June 2007.