The number of patients facing serious delays in hospital
treatment is increasing, with a health watchdog blaming
failings in hospital systems.
The trend has been highlighted in the Health Quality and
Safety Commission's latest report on serious and sentinel
events - failings that lead to significant additional
treatment, threaten patients' lives or result in death.
The report said there were 360 serious or sentinel events
across all the district health boards (DHBs) in the last
year, down 3 per cent on the previous year.
About a third were clinical management failings - including
17 serious delays in treatment, up on 13 the previous year
and eight the year before that.
The commission said it was probable the number of reported
delays represented just a small fraction of all cases because
many fell below the reporting threshold.
The cases not only illustrated weaknesses in patient
management and communications systems, but also failings in
the amount of say that patients have over their own care.
The commission's reportable events clinical head, Dr David
Sage, said the cases emphasised how important it was for
clinicians to follow up when tests were ordered, referrals
were made, or further treatment was recommended.
He said the commission was looking at measures which could
reduce the likelihood of delays.
"For example, making sure patients are full partners in the
management of their care - so they too are aware if there
needs to be a further test, result from a specimen, or
referral to another specialist."
Commission chairman Professor Alan Merry said not all the
serious events described in the report were preventable, but
many involved errors that should not have happened.
"In some tragic cases errors resulted in serious injury or
death. Each event has a name, a face and a family, and we
should view these incidents through their eyes."
He said the overall decrease in serious events showed DHBs
had put in a lot of hard work to both report and prevent
"At the same time, however, we have seen an increase in the
number of cases of delayed treatment and suspected inpatient
There were 17 suspected inpatient suicides in the last year,
up from three the previous year, but Dr Merry said they did
not appear to be part of an increasing trend.
"The commission has looked at the reviews into these very sad
events and there appear to be no common factors. There is
also no evidence of a trend of increasing inpatient
Most of the cases involved mental health patients, although
at least two were patients who had been on general wards.
The commission was working with the mental health sector to
identify the best approach to reviewing and reporting on
suicides involving mental health service users, and in future
will issue a separate report on those events.
The latest report also highlighted a decrease in the number
of falls, which make up almost half of all serious events
reported by DHBs.
There were 170 serious falls in the last year, a 13 per cent
decrease from the 195 falls the previous year.
Associate Health Minister Jo Goodhew said cases of delayed
treatment were not a result of administration staffing
The Government has invested heavily in bolstering the number
of frontline hospital staff and and streamlining back-office
functions within the public health sector.
"They relate to hospitals having good checks and processes in
place and, as Dr Sage of the Health Quality and Safety
Commission has said, clinicians following up when tests are
"Keeping patients informed and involving them more in the
management of their care will also help."