The Northland District Health Board admits the care of an
elderly man who died following knee surgery at Whangarei Hospital was
inadequate, following the release of a report slamming his treatment.
The Health and Disability Commissioner pointed a finger at
both the nursing team and orthopedic specialists, following the investigation
into the death of the 75-year-old, who died in 2009.
The man had been admitted to hospital for total knee joint
replacement, an operation that was carried out successfully, leaving him in
good health.
However, in the days afterwards the man's blood pressure
dropped, and he failed to pass urine, a strong indicator of a problem.
Nursing staff recognized the issue but failed to pass on the
information to the orthopedic team or other staff who cared for the man in the
following days.
Orthopedic staff also failed to inform nurses of other
conditions the man suffered that made his case high-risk.
The miscommunication was released four days after the
Operation, but only shortly before the man died from cardiac and respiratory
Arrest.
In a decision published on Monday, commissioner Anthony Hill
Blamed staff for "poor communication, inadequate documentation, and the
Widespread failure of the nursing team to consistently comply with relevant
Procedures, which compromised the man's right to continuity of care."
Northland DHB said it "profoundly regrets" the
incident and accepts that the care was "not to a high enough
standard".
The DHB has apologized to the man's family.
Mr Hill made several recommendations in the report aimed at
improving the level of care, all of which the DHB says have already been
introduced.
"This sad case has led to many changes within the
hospital," chief medical officer Dr Mike Roberts said.
"Standards of quality and safety within the organization
are much higher now."
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