A patient who didn't get follow up treatment after a scan found lung nodules died of cancer two years later.
The incident is one of 23 adverse events reported by the Waikato District Health Board between 1 July 2011 and 30 June 2012 to the Health Quality & Safety Commission which released its annual Serious and Sentinal Events report today.
Other events include a patient who required a second surgery after a medical device was left behind following a surgical procedure, and a baby who was discharged a day after presenting with diarrhoea and vomiting but died later that same day.
In one maternity case a woman experienced delays in getting to theatre for a caesarean section after she was diagnosed with fetal distress upon admission. Her baby died two days later.
Of the 23 reported events by the DHB nine involved falls, eight were clinical management problems, two were medication errors and they had one each of inpatient suicide, retained instruments or swabs, absent without leave patient and 'other' which involved an acutely unwell patient assaulting a staff member.
It's the lowest number of adverse events reported by the DHB since publication of events started in 2007. Since then the DHB has reported 24, 36, 60, 52 and 51 events showing a dramatic drop in adverse events to just 23 events this year.
Lakes DHB reported seven serious events to the Commission including one incorrect surgery site, four falls, one joint infection following surgery and one ''absconded patient'' who was due to be admitted as an inpatient but left the facility and allegedly assaulted a family member.
Nationally it seems that delayed medical treatment in New Zealand hospitals was an "increasing trend" and resulted in people needing more treatment, losing function and sometimes death.
While the number of falls in New Zealand hospitals had decreased, clinical management events, delayed treatment and in-patient suicides had increased.
The report included events the country's district health boards considered to be serious in that they led to additional treatment or loss of function, or sentinel events which were life-threatening and/or led to an unexpected death.
Not all 360 events in the year to June 30 were preventable, but "many involved errors that should not have happened," the commission's chair, Professor Alan Merry, said.
"In some tragic cases errors resulted in serious injury or death. Each event has a name, a face and a family, and we should view these incidents through their eyes."
Nationally there were 111 clinical management events, up from 105 the previous year, and 17 cases of delayed treatment, which the report stated was an "increasing trend".
There were 18 medication errors, down from 25 the previous year, and 17 suspected in-patient suicides, up from the three the previous year.
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- © Fairfax NZ News
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