Health New Zealand Waitematā’s Care Falls Short Of Expected Standards 21HDC00557

A man’s rights under the Code of Health and Disability Services Consumers’ Rights were breached by Waitematā District Health Board (now Health New Zealand|Te Whatu Ora Waitematā) said the Deputy Health and Disability Commissioner Carolyn Cooper, in a decision released today.

Ms Cooper’s decision centred on the care the man received while at hospital for treatment of serious health conditions, including ischemic heart disease, pulmonary hypertension and chronic obstructive pulmonary disease (COPD).

The investigation revealed significant issues in discharge planning; in particular, the assessment of his need for home oxygen therapy.

The man was admitted to North Shore Hospital with symptoms of light-headedness, chest pain, and shortness of breath. He remained in hospital for ten days and was discharged without home oxygen. He returned to hospital the day after, as he became increasingly short of breath overnight and, sadly, died the following day.

Carolyn Cooper said the investigation identified four key areas where the care provided fell short of the expected standards.

First, there was no formal assessment of the man’s need for home oxygen prior to discharge, due to a misunderstanding about his oxygen availability at home.

Second, Ms Cooper found the combination of medications he was prescribed, including propranolol and losartan, was not adequately reviewed, despite their adverse effects on his condition.

Third, the decision to discharge the man was based on incorrect assumptions about his home oxygen use and did not consider his ongoing physiological instability.

Finally, she noted there was a lack of clear discharge advice, as the discharge summary did not provide specific recommendations for general practice review, or detailed advice on oxygen use at home.

"Mr A was a much-loved husband and father, and his passing has had a profound impact on his family. Our investigation highlights the need for thorough discharge planning and clear communication to ensure patients receive the care they need," said Ms Cooper.

HDC has made several recommendations to Health New Zealand Waitematā, including putting in place a formal assessment process for home oxygen needs prior to discharge, reviewing and updating discharge policies to ensure comprehensive planning and clear communication, and providing education and training for staff on the importance of critical thinking during discharge planning.

Notes:

The full report of this case can be viewed on HDC’s website - see HDC's ' Latest Decisions'.

Names have been removed from the report to protect privacy of the individuals involved in this case.

The Commissioner will usually name providers and public hospitals found in breach of the Code unless it would not be in the public interest or would unfairly compromise the privacy interests of an individual provider or a consumer. More information for the media, including HDC’s naming policy and why we don't comment on complaints, can be found on our website here.

HDC promotes and protects the rights of people using health and disability services as set out in the Code of Health and Disability Services Consumers' Rights (the Code).

In 2022/23 HDC made 592 quality improvement recommendations to individual complaints and we have a high compliance rate of around 96%.

Read our latest Annual Report 2023

Health and disability service users can now access an animated video to help them understand their health and disability service rights under the Code.

Learn more: Education Publications

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