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In three recent reports, the Health and Disability Commissioner (HDC) has highlighted concerns about poor management and communication by practitioners across three different medical disciplines.

Report one – a DHB

The first report concerned a 77 year old woman, Ms A, who was frail and underweight. Ms A was admitted to a public hospital run by the Waikato District Health Board (Waikato DHB) for a right hemicolectomy (removal of the right side of her colon). Following the surgery, the on-call house doctor charted regular paracetamol for Ms A. Following some abnormal liver function tests, nurses withheld further paracetamol from Ms A.

A few days later, a consultant gastroenterologist thought that no specific recent drugs explained the abnormal liver function tests but that it was likely drug-induced hepatitis. Ms A continued to receive paracetamol regularly for another week until another gastroenterologist noted that she had post-surgery acute liver derangement and ascites. The consultant enquired whether Ms A’s deranged liver function tests were caused by a drug such as paracetamol, and instructed that no more paracetamol be given to Ms A. A few days later, Ms A died.

The HDC found that the paracetamol dose prescribed to Ms A was too high for a frail, underweight patient with liver failure and that Waikato DHB ‘did not think critically’ and failed to adjust Ms A’s paracetamol dosage to respond to her circumstances. However, nurses at the hospital ‘did well’ to respond to Ms A’s deteriorating liver function by withholding the paracetamol administered to her.

The HDC also found there was inadequate communication between nursing and medical staff regarding the response to Ms A’s deranged liver function tests and to ensure ‘quality and continuity of services’ was provided to Ms A.

Report two – a doctor

The second report concerns a 52 year old man, Mr C, who went to see his general practitioner, Dr A, regarding significant changes in his bowel habits and rectal bleeding. Dr A’s differential diagnosis included ‘inflammatory bowel disease, infectious colitis, irritable bowel syndrome (IBS), and carcinoma’. Dr A referred Mr C to Gastroenterology Outpatients, but the referral was not received until several months later.
Mr C subsequently went to the emergency department with groin swelling. The emergency department considered Mr C had an inguinal hernia and referred him to the general surgical team at the Waitemata DHB. Dr A subsequently received a message from the general surgical team that a referral had been declined, because of wait list management. Dr A mistakenly believed that this message was in relation to his referral to Gastroenterology Outpatients.

Mr C returned to the emergency department a few months later where a specialist determined he had rectal cancer. Mr C later died in hospice care.

The HDC expressed concerns about Dr A’s care and management of Mr C, and his focus on a diagnosis of IBS, rather than ‘more sinister pathology’. The HDC was also concerned about Dr A’s insufficient follow up, and that he did not take steps to check on Mr C’s symptoms or advocate for Mr C with the DHB.

Finally the HDC expressed concern about Dr A’s incorrect interpretation and lack of follow up regarding the message from the DHB which declined the general surgical referral. This was a further lost opportunity for Dr A to have verified that happened to his original referral and why an investigation or specialist review had not gone ahead.

Report three – a midwife

The third report expresses concerns about the quality of services provided by a midwife to Mrs C. The midwife failed to establish Mrs C’s medical history, monitor Mrs C appropriately by urinalysis, and to elicit from Mrs C that she had oedema (fluid retention) and fetal movement had reduced. In addition, the midwife’s records were very limited and, in some instances, handwritten and electronic records did not match.

Mrs C was particularly concerned about the incident when her and her husband emailed the midwife to express their preference that a student midwife not be present at the birth. In her email response, the midwife said that the student was working with her, that she needed to show her experience, and that she thought ‘it is not a wise decision and her being there will be a tremendous support for the anxious husband.’

The HDC expressed concern about the respect shown to Mrs C. Mrs C had the right to decide to not have a student present at the delivery and the midwife’s email response was inappropriate and disrespectful. The HDC was also concerned about the records kept by the midwife. The midwife departed from accepted practice by failing to keep contemporaneously verifiable documentation throughout Mrs C’s antenatal record. Indeed, the midwife accepted that the documentation she kept was ‘suboptimal’.

Lessons learned

In these three reports, the HDC expressed concerns about the management of cases, not merely with the quality of healthcare. Communication by clinicians was criticised in all three reports, either between practitioners or communication between practitioners and patients. These reports show the importance of record keeping and communication across all areas of medical practice.



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