Waitākere Hospital. Photo: RNZ / Dan Cook
Waitematā District Health Board (now Te Whatu Ora Waitematā) has been found in breach of the Code of Health and Disability Services Consumers' Rights for failing to follow a disabled man's dietary plan.
The patient, an elderly man with intellectual disabilities, was admitted to Waitākere Hospital with a chest and urine infection.
He lived in residential care for most of his life and required support with all aspects of daily living.
The man's caregivers provided information outlining that he needed to be supervised and his food pureed due to his risk of choking.
Following the man's transfer from the emergency department, his dietary requirements and the level of care he required were not handed over adequately between staff, or documented clearly.
His dietary plan was not adhered to, and he choked and died.
Deputy Health and Disability Commissioner Rose Wall found Waitematā DHB breached Right 4(1) of the code, which gives consumers the right to services provided with reasonable care and skill.
She also found the DHB failed to provide services in a manner consistent with his or her needs.
"Effective handover is vital to achieve high-quality communication of clinical information and transfer of care, and to protect patient safety. I agree that quality handover practices between departments/wards is key, with the ramifications of inadequate communication tragically playing out on this occasion," Wall said.
Rose Wall. Photo: Supplied / HDC
"Hospital staff did not give sufficient attention to a significantly disabled patient who was unwell in an unfamiliar environment, isolated from his usual caregivers and his familiar day-to-day routine. He was unable to communicate his needs to the various staff caring for him.
"All these considerations required staff to adjust their usual practice to accommodate the unique situation they were faced with. This case reinforces the significance of clear communication. It is the cornerstone of providing safe and effective care to patients, even more so when the patient is particularly vulnerable and reliant on others to keep them safe."
A number of changes have been made since the events, including a review of handover documentation, which now includes a field to record patients' dietary needs.
Wall made several recommendations, which included that the DHB provide training to all relevant staff on the handover processes and the handover practice expectations, and on the importance of the dietary requirements of patients, so that they are aware of the risks in failing to adhere to any dietary plans and/or restrictions.
Waitematā DHB will also be referred to the Director of Proceedings.