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Standard of care provided at an emergency department (11HDC01077)
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(11HDC01077, 31 March
Emergency department ~ Hospital ~ District health board ~
Fall ~ Chest and shoulder injuries ~ Competence ~ Assessment ~
Documentation ~ Discharge ~ Rights 4(1), 4(2), 4(5)
A woman complained about the standard of care provided to her
husband at the emergency department of a hospital.
At approximately 10.30pm one evening the man had fallen about
two metres onto concrete and had injured his left chest and
shoulder. The man was taken by ambulance to the emergency
department, where he was reviewed by a medical officer of a special
scale (MOSS). The MOSS noted that the man was alert but in pain,
his abdomen was tender on examination, and his lungs were clear.
Results from laboratory tests and an abdominal X-ray were
unremarkable, and a chest X-ray was interpreted as not showing any
rib fractures or pneumothorax, although the result was noted to be
suboptimal. The MOSS diagnosed the man with a left chest and
abdominal wall contusion and, having prescribed him pain relief
medication, cleared him for discharge at 1.50am. As the man was
unable to arrange transport at that time, he remained in the
emergency department, where nursing staff continued to monitor
At 6.30am nursing staff contacted the MOSS after it was noted
that the man was hypotensive and had an obvious step-off in his
left acromioclavicular joint. The MOSS charted further pain relief
medication and IV fluids, and advised the man that he should follow
up with his GP for his shoulder injury. At 8am a shift change took
place. At the request of the nursing staff, the oncoming senior
medical officer (SMO) prescribed the man with further pain relief
medication and IV fluids, on the understanding that the man would
again be reviewed by the MOSS. At handover, the MOSS advised the
SMO that the man was for discharge, which occurred at 9.50am.
Eight days later the man was diagnosed with left-sided rib
fractures with possible effusion at the left lung base, and
possible underlying lung consolidation.
It was held that the MOSS's clinical reviews of the man at
12.45am and 7am were poor, and did not fully take account of his
history and clinical presentation. In addition, the MOSS's handover
to the SMO was inadequate. The MOSS failed to provide services to
the man with reasonable care and skill, in breach of Right 4(1).
The MOSS's clinical documentation was also inadequate, in breach of
The SMO was not found in breach of the Code. However, it was
recommended that, when the SMO provides treatment to a patient
under another clinician's care, they should communicate that
treatment to the responsible clinician. It was also recommended
that the SMO reflect on the importance of ensuring the provision of
relevant patient information at handover.
The DHB is responsible for ensuring that patients receive care
that complies with the Code. The DHB failed to take adequate steps
to ensure that the MOSS was competent to perform the services for
which they were employed. Therefore, the DHB failed to ensure that
the man was provided with services with reasonable care and skill
and, accordingly, breached Right 4(1). In addition, the pattern of
suboptimal clinical documentation by multiple staff members
compromised the continuity of care provided to the man, in breach
of Right 4(5).