An external review of Southland Hospital's treatment of a woman who critically injured a baby says the incident was a "landmine event" and staff could not have predicted it.
Sucharitta Milton was taken to Southland Hospital with self-inflicted wounds to her wrists on September 2. She had also critically injured a baby.
The baby was initially taken to Southland Hospital but later flown to Starship children's hospital in Auckland.
The report, which The Southland Times has seen, looks at Milton's treatment on September 2 and earlier visits.
Her husband, David Milton, was critical of her treatment, the report says.
However, the report has exonerated the hospital, labelling the incident as a "landmine event", "unavoidable and unpredictable".
"We have been unable to identify any clear warning signs [red flags] that clinical staff may have been able to detect to anticipate and prevent the traumatic events that took place."
The report says David Milton took his wife to the hospital on September 1 after she complained of abdominal and body pain.
She was seen by a doctor 40 minutes after arriving at the emergency department and tests showed no abnormalities, the report says.
Her condition began to improve and after consultation with other specialist clinical staff she was cleared to go home. She was discharged three hours after arriving. Twenty-four hours later she was taken back to hospital with the self-inflicted wounds.
She was later assessed by mental health services and transferred to Dunedin.
The report says several people involved in the care of Sucharitta Milton were interviewed during the review.
David Milton was also interviewed.
The review was carried out by two Christchurch-based medical staff and an emergency doctor employed by the Lakes District Health Board in the North Island.
The report says the senior medical officer who treated Sucharitta Milton had worked in the emergency department for more than six years and was well respected by his clinical colleagues.
"The review team has not identified any clinical competency issues," the report says.
The review team also examined how hospital staff had treated the injured baby.
It found no deficiencies in the care of Sucharitta Milton and labelled hospital care of the baby as "exemplary".
However, the report highlights "deficiencies" in the health board's communications team.
"An incident team was quickly established but this does not appear to have close communication with the ED [emergency department] . . . and media releases were apparently not discussed with ED senior leadership," the report says.
The review team recommended the health board review its communications processes, particularly for "serious sentinel events".
It also recommended clinical staff document thought processes to help formalise decision-making.
"While no specific evidence of poor note-keeping [was found] . . . patients identified with mental health issues require documented risk assessment to ensure safety on discharge."
- The Southland Times
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