The Waitematā District Health Board (DHB) has breached the Health and Disability Services Consumer's Rights code after an elderly patient's dietary plan wasn't followed and he later died.
The patient, who was in his 80s, was admitted to Waitākere Hospital with a chest and urine infection. He was born with intellectual disabilities owing to brain damage caused at childbirth. He also had dementia with behavioural and psychological symptoms of dementia, as well as severe language impairment and minimal communicative capacity.
As a result, he'd lived in residential care for most of his life and required support with all aspects of daily living.
The patient had a comprehensive dietary plan that said he could only have pureed or liquid foods, and he needed to be supervised at all times while eating.
His usual caregivers gave the hospital information about his dietary plan. But Deputy Health and Disability Commissioner Rose Wall found that after the man was transferred from the emergency department to the assessment and diagnostic unit, and two subsequent ward transfers, his dietary requirements and the level of care he required were not handed over adequately between staff or documented clearly.
According to the Health and Disability Commission report, at dinner time on day five in hospital, a healthcare assistant gave the patient his food and sat him in an upright position to eat it. They then left to hand out dinners to other patients. The healthcare assistant said they were unaware of the man's dietary requirements.
Soon after, a nurse came to give the man medication and noticed he was distressed and it looked like he was trying to cough. She said she used a spoon to remove chicken and cauliflower from his mouth. A doctor arrived and applied back blows, and more chicken came from his mouth.
Although the man's oxygen levels returned to 97 percent, he soon became pale and unresponsive. The medical emergency team administered more back blows, but this had no effect. His oxygen levels began dropping again, his pupils dilated, and no heart rate or breathing sounds could be heard.
He was announced dead shortly after.
According to the report, a police constable tasked with investigating the patient's death said: "During this investigation it was found the deceased was served solid food when he should have been served pureed or liquid food. This may have contributed towards his death."
Wall said the Waitematā DHB - now named Te Whatu Ora Waitematā - breached Right 4(1) of the Code which gives consumers the right to services provided with reasonable care and skill. She also found the DHB breached Right 4(3), which gives consumers the right to services provided in a manner consistent with his or her needs.
"Effective handover is vital to achieve high-quality communication of clinical information and transfer of care, and to protect patient safety. I agree that quality handover practices between departments/wards is key, with the ramifications of inadequate communication tragically playing out on this occasion," Wall said.
"Hospital staff did not give sufficient attention to a significantly disabled patient who was unwell in an unfamiliar environment, isolated from his usual caregivers and his familiar day-to-day routine. He was unable to communicate his needs to the various staff caring for him."
This case reinforces the significance of clear communication, Wall said, and all the considerations for this patient meant staff needed to adjust their usual practice to accommodate the unique situation.
The patient's nephew told the Health and Disability Commission that staff at the man's care facility had given him "intensely personal" services over a number of years and his death has caused them "significant distress".
The care facility didn't comment and Te Whatu Ora said it had no comments to make. Although Te Whatu Ora offered its condolences to the patient's family.
The Health and Disability Commission report said a number of changes have been made since this man's death including a review of handover documentation, which now includes a field to record patients' dietary needs.
The wards that were involved in the man's care have been asked to ensure that dietary requirements are part of the shift handover, and the wards must make sure the patient information board correctly reflects both the patient's individual dietary needs and any assistance they may require.
Wall recommended Te Whatu Ora Waitematā provide training to all relevant staff on the handover processes and the handover practice expectations, and on the importance of the dietary requirements of patients.
Te Whatu Ora Waitematā will also be referred to the Director of Proceedings for the purpose of deciding whether any proceedings should be taken.
