Response to Health and Disability Commissioner's decision

Media Release 29 June 2019 | Counties Manukau District Health Board (CMDHB) accepts the Health and Disability Commisioner’s (HDC) findings, released today, into the death of a patient at Middlemore Hospital in April, 2017.

We have apologised to the family concerned for the way their loved one’s care was managed and we have extended our deepest condolences.   We sincerely regret that we did not provide the high level of care that we expect of ourselves.

 We have examined the way our systems worked in the care of this patient and sought expert opinion, resulting in major changes either being implemented or in the process of being implemented.  These changes will significantly reduce the likelihood of a similar incident happening again.  They include:

Extensive work completed to improve approach to Venous Thromboembolism (VTE) activity, including;

  • Counties Manukau Health organisational VTE committee that meets monthly to review tracked activity, including volumes, clinical treatment, guidelines and process across individual services
  • The development of detailed VTE guidelines to be included in patient’s documentation and also included in junior medical staff orientation documentation
  • A monthly review of VTE patient treatment plans and outcomes by a dedicated Senior Medical Officer with direct feedback to the responsible surgeon and on-going monitoring of patients with complications as per guidelines, as part of quality control process within the Orthopaedic service
  • VTE has been included in an organisational auditing process with on-going review of audit tools

Work to develop a policy outlining when a patient should become a Plastic Surgery patient with discussions underway on how best to approach patient transfer when there is uncertainty.

Reiterating to all Plastic Surgery and Orthopaedics medical staff that clear communication must be established and documented following a consultation and to escalate to acute team when relevant staff cannot be reached.

An update of the Registered Medical Officer handbook noting changes to the clinical documentation policy to ensure clear interactions between medical staff are documented and it is clearly noted in clinical records whether a request for another service team’s input clearly states a status of review or transfer of care. 

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