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DHB found in breach of health code after failures relating to cardiac issues

Fuseworks Media
Fuseworks Media

Health and Disability Commissioner Anthony Hill today released a report finding a district health board in breach of the Code of Health and Disability Services Consumers’ Rights (the Code) for failures relating to the care of a woman with cardiac issues.

A woman in her forties presented to the emergency department (ED) of a public hospital with shortness of breath and atrial fibrillation. An ED consultant performed a point-of-care echocardiographic examination, which he interpreted as showing impaired cardiac function. Later that night, the woman was admitted to the high dependency ward.

The following morning, the woman was discharged home with a prescription for anticoagulant medication. No future hospital appointments were made for either an echocardiograph or cardiology follow-up.

Mr Hill was critical that there was no record of a full cardiac history and examination having been undertaken while the woman was in the high dependency ward, nor was a follow-up echocardiogram arranged, and those responsible did not pick up on the ED doctor’s earlier assessment of the woman’s cardiac function.

Six weeks later, the woman was admitted to the ED via ambulance. A junior doctor reviewed her and spoke to the on-call consultant physician and cardiologist, and the woman was administered flecainide. However, the woman suffered a flecainide-induced cardiac arrest. Following a successful resuscitation procedure, she was transferred to another hospital.

Mr Hill was critical that key information in the woman’s past ED discharge summary was not received by the on call consultant physician and cardiologist, and so was not considered by her when flecainide was prescribed, which was contraindicated in the woman’s situation.

Mr Hill recommended the DHB implement recommendations arising from an internal review of the events and provide evidence of steps taken to improve the DHB’s record system.

The full report for case 16HDC00984 is available on the HDC website.

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