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Transfer of trauma patient (13HDC00046)
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District health board ~ Rehabilitation provider ~ Trauma ~
Enoxaparin ~ Transfer ~ Communication ~ Documentation ~ Rights
A 58-year-old man was involved in an accident. He sustained
multiple injuries and was taken to hospital in a critical
condition, and underwent multiple surgeries. He spent time in the
Intensive Care Unit (ICU) and was placed under the care of a DHB
Trauma Service. Treatment included deep vein thrombosis (DVT)
prophylaxis. He was transferred to the High Dependency Unit, and
later to a surgical ward and encouraged to mobilise. His
medications on discharge from ICU included 40mg enoxaparin
(Clexane) prophylaxis, once a day.
The man made good progress. Hospital staff considered a transfer
to a rehabilitation provider for further rehabilitation closer to
the man's home.
DHB policy stated that discharge from the public hospital to
another facility would occur only when discharging medical staff
gained verbal acceptance from an admitting medical team. There were
two co-existing rehabilitation provider admission documents in
place, neither acknowledging the existence of the other, and each
document providing a different process regarding medical review:
the policy stating that a doctor should review the patient within
24 hours of admission, and the procedure making no reference to a
timeframe for medical review after admission.
The DHB said that it was advised by the rehabilitation provider
that a doctor would admit the man on arrival. The rehabilitation
provider said that at no stage did it indicate that the man would
be admitted by a doctor. No medical staff were contracted to work
at the rehabilitation provider at the time of the man's
The final arrangements for discharge and transfer were made late
on a Friday. Public hospital staff met with the man and his wife
prior to discharge. Three syringes of enoxaparin and a prescription
for analgesia were given to the man's wife to take with them. DHB
staff also met with the transfer flight nurse. The meeting details
were not documented by DHB staff. The flight nurse's transport
record does not refer to being advised of the thromboprophylaxis
The public hospital discharge summary did not refer to discharge
medications or thromboprophylaxis, and nor did it refer to
supplementary documentation which outlined discharge medications.
At 8.15pm, the man arrived at the rehabilitation provider. He was
not reviewed or admitted by a doctor on arrival. He was mobilising
appropriately. On Saturday morning, the man's wife took the
hospital prescriptions for analgesia to a pharmacy to be
The enoxaparin was not on the discharge summary, and was not
given by the staff at the rehabilitation provider. The man and his
wife enquired why the man had not yet been given enoxaparin. A
rehabilitation nurse telephoned the public hospital for
clarification. The nurse was given erroneous advice that enoxaparin
was no longer needed.
For two days the man was given inadequate pain relief. Confusion
had arisen for rehabilitation nursing staff in the absence of
information on the public hospital discharge documentation
regarding the man's ongoing medications. The man developed chest
pain and suddenly collapsed. Sadly, he could not be revived.
It was held that the man's co-ordination and continuity of care
was compromised for the following key reasons:
- The transfer by the DHB without obtaining verbal acceptance by
a doctor from the rehabilitation provider was not in accordance
with DHB policy.
- Transfer documentation did not contain all the relevant and
important clinical information.
- DHB staff did not ensure that there were clear written
instructions passed on about the man's enoxaparin regimen.
- The man was transferred late on a Friday.
The DHB did not ensure adequate quality and continuity of
services for the man and, accordingly, breached Right 4(5).
It was also held that it was the responsibility of the
rehabilitation provider to have adequate oversight and systems in
place to support its staff and ensure its policies were clear and
understood by all staff. Having two documents (one a policy and one
a procedure) regarding admission, and ineffectively communicating
that information to staff resulted in very unclear direction to its
staff about the requirements for admission and the timing of
medical review. Accordingly, the rehabilitation provider failed to
provide services to the man with reasonable care and skill and
breached Right 4(1).
Adverse comment was also made that the man had less analgesia
than he needed for a period of approximately 48 hours.