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A ruling has identified a series of failures in care by the Hutt Valley District Board of Health.
“A series of failures” led to a woman being found in “excruciating pain” while unsupervised and deteriorating during a six-hour delay for facial surgery.
A report released today by the Office of the Health and Disabilities Commissioner found that the Hutt Valley District Board of Health failed to identify the woman’s impairment and opened a second operating room to ensure that she underwent timely surgery.
In May 2015, the woman, in her 40s at the time, underwent plastic surgery to reconstruct her upper jaw area after surgery to remove a tumor years earlier.
Four days after surgery, the woman experienced pain and swelling in the upper jaw area and was awaiting surgery to wash the wound.
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When the woman was taken to the operating room for surgery, instructions on checking her facial flap, transplanted tissue and bone were not given to the operating room staff, as it was anticipated that the woman would be the first to undergo surgery. .
Two urgent cases delayed her surgery and transferred her to the post-anesthetic care unit to wait.
“There was confusion among staff about who was responsible for monitoring it. The woman was left unattended and her condition worsened. Approximately six hours later, a second operating room was opened and the woman was operated on. During the surgery, the woman’s condition deteriorated and she was transferred to the ICU postoperatively ”, the report concludes.
At one point, a doctor found the woman in “excruciating pain” while waiting for surgery.
Former Commissioner Anthony Hill identified a number of failures in the services provided by DHB, including inadequate communication and handover among nursing staff; inadequate monitoring of the woman while waiting for the operating room; and inappropriate policies and procedures related to acute surgery after hours and the transfer of care between ward and operating room staff.
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Health and Disabilities Commissioner Anthony Hill made the decision after a woman complained about her care while waiting for facial surgery, which resulted in an ICU stay.
“It is extremely worrying that despite the nature of [the woman’s] condition, which required regular monitoring, no staff member took steps to monitor [the woman], check to see if he needed pain relief or other needs, or follow up with his surgical team, “Hill said.
Hill also stated that he had an expectation that when staff transfer care from one patient to another physician, a complete handoff would occur, particularly when regular monitoring of a patient was so important.
The report recommended DHB audit patient wait times for acute surgery over the weekend and follow-up of patients while they await surgery.
It also recommended that DHB provide an update regarding its revision of surgical policies and provide a written apology to the woman.
