WDHB found to be in breach of Code of Health and Disability Services Consumers Rights
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25 August 2014
 
The Whanganui District Health Board (WDHB) has been found to be in breach of the Code of Health and Disability Services Consumers’ Rights (1994).
 
WDHB acting chief executive Brian Walden says a report released today sets out clearly that the WDHB was wanting in its care of a dental patient treated five years ago.
 
Before her dental surgery, the patient was seen by an anaesthetist.  A chest x-ray was taken, the radiologist reported a change in the left lung and recommended a follow-up investigation. The follow-up investigation did not take place. Twelve months later when the patient had chest pain, she was referred to Wanganui Hospital’s Emergency Department. Further investigation confirmed she had lung cancer which had spread and, sadly, she died seven months later.
 
Health and Disability Commissioner Anthony Hill states in his report the failure to follow up on the x-ray occurred in the context of a number of serious organisational and systemic failures on the part of the WDHB.
 
“The WDHB met with the patient and apologised as soon as the error was discovered,” Mr Walden says. “Multiple processes and systems failures as well as some human factors, led to the delay in diagnosis of the patient’s condition, and ultimately, her likely premature death.
 
“As a result of the error and subsequent investigation, the WDHB has put in place a number of systems and safety measures which reinforce accountability for test follow up.”
 
All doctors, including the anaesthetist at preadmission clinic, are now accountable for reviewing tests that they order and ensuring that information is conveyed to the treating team. The doctors sign off electronically to say they have reviewed those tests. On discharge from hospital, the treating team are expected to document on the discharge summary relevant information regarding results for the GP.
 
All radiology reports, including those of dental patients, are now sent automatically to GPs electronically, although several continue to receive them by fax or email. This keeps GPs up to date with clinical findings affecting their patients.
 
As an extra safety net, hospital dentists have implemented a process to note all their patients’ results and discuss them with the anaesthetist if required.
 
The radiology service delivered has also changed significantly since 2009. The template used to report the findings has changed in format and now radiologists must conclude their report with a statement that clearly identifies any suspicious, unexpected findings and suggested follow up.
 
The ‘red flag’ radiology system, which is dependent on the radiologist triggering the warning, is now supported by a checking system to ensure that these ‘red flag’ results have been reviewed by the accountable person. Audits are conducted to check whether radiologists are indeed using the ‘red flag’ warning and these expectations are made explicit in policy.
 
The anaesthetists who order many tests preoperatively, in recognising their accountability to review them, have set up a system within their department for ensuring that no results are missed.
“We sincerely regret that our systems failed a patient in our care and we are deeply sorry for the suffering and distress that accompanied this failure,” Mr Walden says.
 
“The WDHB remains truly sorry for its failings. We have worked hard to ensure a similar event does not happen again.”