50-plus adverse events

Nigel Millar
Nigel Millar
The death of a newborn baby is one of more than 50 adverse events reported by the Southern District Health Board in the past year.

The SDHB’s serious adverse events report, released yesterday, found there was a delay in diagnosing an obstructed birth after it was incorrectly identified as foetal distress.

The report noted further harm was caused after the family was contacted by the anaesthetic services, which were not aware of the baby’s death, for feedback on its services.

The coroner will look into the death.

As a result, the SDHB has recommended it reviews the requirements for regular refresher education topics for all professional groups and document when they have occurred.

Initially, the death was not discussed with the coroner despite the baby being born in poor condition and after a drug error, the report found.

It was one of two deaths included in the serious adverse events report.

Another patient died after a delay in diagnosis. No future details were released on the case.The two deaths were among 52 adverse events recorded from July 2016 to June 2017.

Only ones higher were the Auckland (95) and Canterbury (73) District Health Boards.

An adverse event is any  which results in serious harm to patients which may have led to significant additional treatment, was life-threatening, led to a major loss of function or unexpected death.

About half of all the SDHB’s adverse events were caused by clinical processes, which included delays in assessment, diagnosis and treatment.Issues with the ophthalmology service continued. Seven patients suffered some form of  vision loss because of a delay in follow-up appointments.

An external review, carried out last year as a result of the  high number of adverse events due to delayed follow-up appointments in the 2015-16 recording period, led to the SDHB making changes to the service.

These included employing an additional ophthalmologist and making changes to the way  high-risk patients were identified, those whose follow-up could not be delayed.

SDHB chief medical officer Dr Nigel Millar said, despite the efforts  to improve the service, the delays were unacceptable and the health board apologised for its failure to deliver the care patients were entitled to.

Health Minister David Clark said yesterday he remained deeply concerned about the  ophthalmology situation at the SDHB. He had  asked health officials to keep him updated on  progress.

Other adverse events included delays in cancer follow-up appointments and diagnosis and an accidental overdose of morphine.

Nationally, 542 adverse events were reported by DHBs and 86 by other health providers, such as ambulance services.

Clinical management events,  which include delays in diagnosis and treatment, were the most reported events with 282 cases nationally.

Serious injuries from a fall were the second most reported events, with 210  last year, including 77 patients  suffering a fractured neck or femur. The figures were released as part of the Health Quality and Safety Commisson’s learning from adverse events report.

Commission chairman Prof Alan Merry said the report reflected a steady improvement in reporting culture and transparency.



"Serious injuries from a fall were the second most reported events, with 210 last year, including 77 patients suffering a fractured neck or femur." This is a terrible figure and points to insufficient staff available to be with patients at risk from a fall. I was recently requested to spend the night in a chair at a confused relative's bedside- in case he tried to get out of bed and had a fall. He was discharged home the next day- (still confused) into the care of a very sleep deprived person. This was at a private hospital in Dunedin.