Eight deaths among DHB adverse events

Eight people's deaths while in the care of the Southern District Health Board are among 48 cases recorded in the organisation's latest adverse events report.

The deaths included two ascribed to medication error, one involving an unexpected deterioration in condition, one involving an emergency system issue and a death possibly due to the failure of a medical device.

SDHB chief medical officer Nigel Millar said the SDHB regularly benchmarked itself against New Zealand and Australian organisations, and its death rate during care was average.

"We do not stand out as having a significant problem with mortality, but it is something we watch very closely and monitor," he said.

"When someone enters hospital, particularly for a planned procedure, and ends up dying, that is terrible and an important issue for us to follow through on."

In six of the cases investigations are either being carried out or a draft report has been filed.

Three have had recommendations from reports carried out, while one case involving a death on Stewart Island is awaiting planning work for how to cope with medical emergencies on the island.

In one case where a patient unexpectedly died, the family felt news of the death was not given to them "in the most supportive way".

As a result, the SDHB updated its policy for how to break bad news to families, especially at night.

"We have been working on that, through our cultural transformation programme," Dr Millar said.

"We feel we are making progress on that ... We feel it is so important that we keep working on that."

The SDHB recorded 66 adverse events last year, but Dr Millar did not want to amplify the significance of the decrease

"It is good from a mathematical point of view, but these things are random ... I don't want to draw any trends from that.

"They are small numbers, but every adverse event is a person who has been affected by our treatment, and that is one too many."

The number of adverse events last year was partly driven by crises in the ophthalmology and urology services which resulted in soaring waiting lists and resulted in some patients receiving inadequate treatment.

While measures taken to address those issues might have contributed to the decline in adverse events, it was difficult to say so with certainty, Dr Millar said.

"Doing so would be fraught with difficulty because these are reported events and of course there may be events we haven't heard about.

"On the other hand, we are still learning from the events that we know about and that is the important thing, that we are taking them seriously and responding to them."

Falls, the cause of the second-highest number of adverse events, have been the subject of a national campaign co-ordinated by the Health Quality and Safety Commission, the national body which collates adverse event data.

While the ageing population meant more frail patients were being seen by clinicians, that was a risk hospitals needed to identify and address Dr Millar said.

"For some of these people these are really serious injuries. Breaking your hip, which happens to a lot of older people unfortunately when they fall, is a tragedy because we know it is very hard to get back to your previous abilities, and the mortality rate of people with a broken hip over the next six months to a year is quite high because of the debilitating effect.

"We have to continue to strive to find better ways to reduce and prevent falls ... We have a significant problem, but I hope we can do better."

Nationally, 916 adverse events were recorded, 566 of them being reported by DHBs and 232 from DHB mental health and addiction services.

Of the 566 DHB events, 278 were clinical management events, 255 were falls, 18 were healthcare-related infections and 11 were related to medication or IV fluid.

Two were consumer accidents, one was a nutrition error and another was a documentation error.


But don't worry, the SDHB are going to improve.....their apologies!