Cancer patient who died after falling in hospital had inadequate care plan – review –


A woman with cancer died after falling while on her way to the bathroom. There were numerous signs prior to the incident that she was at risk of falling, however her care plan was never fully completed by DHB staff. (File photo)

A woman with cancer in the care of Capital & Coast District Health Board fell and later died after no staffers completed a proper care plan for her, an independent review has found.

Deputy Health and Disability Commissioner Rose Wall released a report on Monday, which found the DHB breached the Code of Health and Disability Services Consumers’ Rights, for failing to complete and update a patient care plan for the woman. It meant she wasn’t provided adequate care.

The DHB acknowledged it failed the woman and her family, and apologised to them.

The patient was transferred into the DHB’s care in 2016. She required ongoing treatment for lymphoma, a type of cancer.

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However, a patient care plan – an individualised plan to guide care – wasn’t completed on the day of her admission. Plans are supposed to be completed within eight hours.

The woman deteriorated after four days in the DHB’s care. There were several indicators she was at risk of collapsing, including references to fatigue, breathlessness, disorientation, and a need for assistance.

While this information was recorded in “various documents”, the care plan still wasn’t completed regularly, despite the woman being cared for by 14 different nursing staff during her first nine days.

Rose Wall, Deputy Health and Disability Commissioner, released her findings into the patient's care on Monday. (File photo)


Rose Wall, Deputy Health and Disability Commissioner, released her findings into the patient’s care on Monday. (File photo)

On the morning of the ninth day the woman fell and hit her head while going to the bathroom.

She was found by a nurse, and soon after was reviewed by a doctor. However, she didn’t have a full assessment until more than three hours after the incident.

A physiotherapist later recorded she was displaying confusion and her neurological condition was worsening.

After a CT scan, and an examination by a haematologist, her fall and condition were finally discussed with her family – more than seven hours after the incident. They were told her prognosis was “poor”.

The commissioner found that delay was “unacceptable”.

Within 30 minutes of the haematologist’s examination, the woman was recorded as “virtually unresponsive”.

More observations and reviews were undertaken by several staff, however apart from one “brief” entry by a nurse, there were no entries in her progress notes until almost 10 hours after the fall.

She remained unresponsive, and died three days later.

The woman’s daughter later made a complaint about her mother’s care to the commissioner.

The woman's daughter made a complaint to the Health and Disability Commissioner about her mother's treatment by hospital staff. (File photo)


The woman’s daughter made a complaint to the Health and Disability Commissioner about her mother’s treatment by hospital staff. (File photo)

Wall said accurate assessments were the foundation of good nursing practice.

“By failing to complete a care plan when this woman was admitted to hospital and to update it accurately on the days following, [the DHB] did not undertake a full assessment of her condition or monitor her changing condition accurately.”

The DHB apologised to the patient’s family, and said it had made changes to its practice following the woman’s death.

An internal audit found compliance levels for patient care plan documentation were at just 30 per cent at the time of the incident.

However, the DHB said the compliance level was, as at December, 95 per cent.

The DHB had appointed a “nurse educator” and had made changes to training to help staff complete care plans. It planned to review the way it used its care plan system.

In a statement, DHB chief nursing officer Emma Hickson said the DHB “failed” the patient and her family.

“We are continually looking at how we can improve the way we support patients who are at risk of falling.

“There has been a significant focus on recognising the risk of falling, and developing individual care plans. This continues to be a work in progress, and the organisation has learned from this sad event.”

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