Serious incidents at hospital investigated

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Richard Bunton
Richard Bunton
Two serious incidents at Dunedin Hospital are under investigation and one of them involves the death of a patient.

Southern District Health Board chief medical officer Richard Bunton (Otago) said he was not prepared to give details as a variety of investigations involving several agencies were under way.

Such investigations were standard practice with any unexpected hospital death.

Serious and sentinel events are reported annually in November, once investigations are completed. In those reports the incidents are explained without identifying the patients involved and any improvements made to services as a result of the investigation outlined.

The hospital investigations were designed to establish whether there was any kind of "systems failure which led to the patient's demise".

All incidents in hospitals were classified according to the four-part national severity assessment code (SAC).

The current investigations were either one or two on the scale, Mr Bunton said.

A one is described as an extreme risk with immediate action required. A root cause analysis investigation must be completed within 70 days.

A two rating - high risk - required senior management attention, and a detailed investigation completed within 70 days.

The Ministry of Health has to be notified in both one and two rated instances.

Those on the lowest two ratings may also need to be reported to the ministry if the incident is considered by the hospital to represent a potential risk of serious harm that should be widely known.

Sometimes, after investigation, the rating attached to an incident was downgraded.

In his recent report to the board, Mr Bunton said the hospital's complaints review committee had decided investigations into serious complaints made against a staff member should continue even if the staff member resigned during the investigation process.

If the complaint was found to be justified, the matter should be reported to the appropriate authority by the board, such as the health and disability commissioner, the privacy commissioner and the regulatory body of the staff member if they were a health professional.

That decision followed advice from the Health and Disability commissioner about a case from some years ago when a staff member had resigned after concerns about their practice.

The commissioner made the point that there was an obligation to undertake a full and thorough investigation of systems despite the resignation of the person.

elspeth.mclean@odt.co.nz

 

 

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