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Failure to recognise deterioration in elderly patient (11HDC01101)
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(11HDC01101, 19 May
District health board ~ Older person's health service ~
Rehabilitation ward ~ Vertebral trauma ~ Deterioration ~ Falls
management ~ Medical review ~ Handover ~ Communication ~ Continuity
of care ~ Rights 4(1), 4(5)
An elderly woman in her 90's was referred to a DHB's older
person's health service. She had presented to her family doctor a
few weeks earlier with low back pain and restricted mobility. She
was subsequently admitted to a rehabilitation ward at a public
hospital; a rest home; a medical ward at a second public hospital;
and again to the rehabilitation ward at the first public
On the first admission to the rehabilitation ward the woman had
a spinal X-ray showing a compression deformity at the T12 vertebra.
She was assessed as a high falls risk. Morphine was charted as
required. Her mood was very low.
Initially the woman was considered as being suited for discharge
to hospital level care. However, after a family meeting it was
planned that she be discharged to a local rest home for rest home
level care. The discharge was to happen the day after a long
During her admission to the rehabilitation ward, the woman had
seven reviews documented by doctors over the first 16 days. No
medical review was documented in the final 11 days of her
admission, despite her deterioration, which included increased
levels of pain and a fall. Over the long weekend there were no
routine ward rounds or multidisciplinary team meetings, and no
doctors were asked to see the woman.
The rest home was not contacted by DHB staff the day before or
the day of discharge, and was therefore not ready to accept the
woman when she arrived. The woman stayed at the rest home for three
days, before being acutely admitted with abdominal pain to the
medical ward of the second public hospital.
On admission to the medical ward the woman had investigations
relating to her abdominal pain. She had an unwitnessed fall and the
sensor clip she was wearing was found not to have batteries in it.
The woman had MRI tests and was placed on antibiotics for presumed
infections. Test results led to an incidental finding of a T12
fracture and spinal canal narrowing.
The woman was transferred back to the rehabilitation ward at the
first public hospital. A spinal MRI was ordered. Initially no
sensor mats were available on the ward to assist with falls
management. Despite changes to falls strategies, the woman had two
further falls. The MRI showed a new T11 fracture and further
compression of T12 causing spinal stenosis.
After discussions with family and neurosurgeons, a conservative
approach to care was taken. A placement for private hospital level
care was arranged and the woman was transferred. The woman died a
few weeks later.
The DHB team caring for the woman failed to interpret and
recognise the signs of a declining patient who was in pain,
particularly in the 11 days leading up to her discharge from the
rehabilitation ward. This failure was a significant contributing
factor to her not undergoing medical review during that time.
Consequently, the level of assessment of the degree of vertebral
trauma in this period was affected. There were nursing deficiencies
in falls management, and a lack of clarity and rigor in the
assessment of the woman's suitability for discharge to rest home
care. The DHB's care and management of the woman was below
standard. Accordingly, the DHB breached Right 4(1).
Rehabilitation ward staff did not communicate appropriately with
the rest home about the arrangements for the woman's discharge.
This included both a failure to confirm transfer arrangements, and
a failure to conduct any clinical handover. These failures had
significant consequences for the woman's quality and continuity of
care and, accordingly, the DHB breached Right 4(5).