Death one of six in SDHB hospitals

18:22, Nov 21 2012

Southland Hospital staff did not perform CPR on a patient who had collapsed and later died because it was wrongly assumed the patient had a "do not resuscitate" order, a report released by Southern District Health Board says.

The death was one of six in Southland and Otago that was included in a Health Quality and Safety Commission serious and sentinel adverse events report for the 2011-12 year. It was the only death reported at the hospital.

Medical director of patient services Richard Bunton said it was unclear why staff had assumed the patient had a "do not resuscitate" order.

The report had identified there was no defined "not for resuscitation" process in the ward. There was also no identified senior registered nurse on shift.

Training had since been held to prevent a recurrence, and a handover sheet for each patient had been put in place.

The other five deaths in Southern District Health Board hospitals are understood to have been at Dunedin Hospital.


Other errors that led to patient deaths were missed or delayed diagnosis of cancer and unnecessary surgery because of a biopsy error.

Two of the six deaths reported were in-patient suicides.

In total, 30 serious and sentinel events happened in Southern District Health Board hospitals from July 1, 2011, to June 30, 2012, with 11 of those at Southland Hospital.

This was an improvement on the previous year when 40 events were reported - 14 of those cases resulted in death, with one of the deaths being reported at Southland Hospital.

Several of the cases in the latest report are still under review or investigation. Other cases have led to changes being introduced, the report says.

In the report, errors in diagnosis and treatment account for 12 of the incidents for the Southern district; patient falls accounted for 11; three incidents were reported for wrong medication, or an incorrect dosage.

New systems being put in place was one of the positives things to come out of the report, Mr Bunton said.

One of the medication errors had led to the purchase of three trolleys to display observation charts, keeping them separate from notes.

In one incident a tumour was identified on a scan and not followed up, leading to a review of how outpatient clinic appointments were made. The same incident had also led to a recommendation that the process of reviewing follow-up imaging results be reviewed.

Nationally, incidents reported for all 20 health boards in New Zealand dropped from 370 reported for 2010-11, to 360 this year, the report says.

The report notes there is an increasing trend of clinical management errors across New Zealand - including cases of delayed treatment because of failures in the hospital system.

Health Quality and Safety Commission chairman Professor Alan Merry said not all the events described in the report were preventable, but many involved errors that should not have happened.

The Southland Times