Death Inquiry slams NZ Health Board

New Zealand’s Hutt Valley District Health Board (HVDHB) has been severely criticised for inadequate processes to manage information that led to the death of a man being treated for an injury while on holiday.

A report from NZ Deputy Health and Disability Commissioner Dr Vanessa Caldwell found the Board in breach of the Code of Health and Disability Services Consumers’ Rights.

Despite the fact that the HVDHB learning that the man had a possible allergy to flucloxacillin, this information was not recorded in any database. “… and the level of detail provided to the man about his new possible allergy is unclear” the report found.

The man had self-administered some flucloxacillin at home after experiencing a sore toe and asking his partner of they had any antibiotics.  He subsequently experienced itchy skin and shortness of breath, and collapsed.

An ambulance took him to the local Emergency Department, where his condition improved. A doctor advised him of possible allergy to flucloxacillin but this was not added to the national Medical Warning System, or HVDHB’s own drug alert system.

Three weeks later, the man was on holiday when he presented to a different DHB with a sore toe. He was asked whether he had any allergies, and he advised staff that he did not. He was administered intravenous flucloxacillin as treatment for his sore toe, and, died of anaphylactic shock shortly afterwards.

“While acknowledging the weaknesses that exist in the current national Medical Warning System and with information sharing between DHBs, the Deputy Commissioner found HVDHB in breach of Right 4(5) of the Code for having an inadequate system for ensuring that allergies were recorded and flagged, and for its inadequate communication with the man’s usual general practice. The Deputy Commissioner also reminded the DHB of the importance of ensuring that all communication with patients, particularly in relation to advice as vital as allergy information, is fulsome and documented, and that patients have a good understanding of the implications.

“Adverse comment was made about the Emergency Department registrar at HVDHB, for her documentation and communication in this case.

“The Deputy Commissioner also made adverse comment about the man’s usual general practice, as it was provided with notes from the man’s presentation to HVDHB, but the man’s new allergy information was not added to the Practice Management System, and was instead filed without action.”

HVDHB told the Health and Disability Commissioner that “all doctors …  are able to add a drug alert onto “Concerto” (the DHB’s electronic patient management system), with a tick box option to make the alert a “National Alert” via the Medical Warning System. However, no guidelines or policies were in place at the DHB on when and how to enter a drug alert to a patient record directly.”

Dr Caldwell said, "This case is an example of the weaknesses that exist within the current system. Without doubt issues with the national system contributed to these events, I nonetheless consider it vital for individual medical centres and DHBs to have their own adequate systems and processes in place for drug and medication allergies, to ensure that staff are supported adequately in their decision-making and reporting requirements.”

She recommended the Hutt Valley DHB provide the man’s family with a written apology.

Practical recommendations included the development of an “end-to-end” process for the ED and general hospital for when patients experience new actual or suspected medication allergies, a new discharge form, better education for staff around allergy reporting, and intermittent audits of whether policies relating to allergy reporting are being observed and are adequate.

The full report is available HERE