Names have been removed to protect privacy. Identifying letters are assigned in alphabetical order and bear no relationship to the person's actual name.
Dear Mr A and Ms B
Complaint
Following an investigation I have now formed my final opinion on the complaint made by Mr A and Ms B which I summarised as follows:
"At some time during her admission to [the Rest Home and Hospital] between 18 November 1999 and 12 September 2001, Mrs C dislocated her left prosthetic hip. Staff at the [Rest Home and Hospital] failed to diagnose the dislocation, investigate the source of pain experienced by Mrs C or provide adequate treatment for this pain."
Information
During this investigation I have carefully reviewed information from the complainants, the Rest Home and Hospital, the public hospital, Dr D, and Dr E.
Medical
Mrs C's medical condition is described in her records as:
- Chronic Obstructive Pulmonary Disease
- Congestive heart failure
- Atrial fibrillation
- Chronic renal impairment
- Cognitive impairment
- Gout
- Hypertension
- Osteoarthritis
Independent expert advice
I have also received independent expert nursing advice from Ms Jan Featherston and enclose a copy of her advice.
Ms Featherston advised me that, although the notes did not indicate any particular date when the dislocation occurred, it would have been detected if there had been regular reviews or assessments of Mrs C's physical and cognitive function. She said that Mrs C did show signs of pain that was demonstrated by her increasing anxiety when she was moved or transferred and increasing confusion. This should have led nursing staff to assess her for pain. Ms Featherston advised that such reviews are common practice and noted that a full pain assessment on Mrs C was never undertaken.
Ms Featherston also informed me that much of the nursing literature identified how patients with dementia are not adequately assessed for pain and that patients (such as Mrs C) who are confused express pain in different ways. Ms Featherston said that it appears staff considered this but thought Mrs C's expression of pain was due to her confusion. My expert advisor also said Mrs C's medication indicated that she was treated for anxiety and confusion rather than pain.
Decision
In my opinion the Rest Home and Hospital breached Right 4(3) of the Code, which states that every consumer has the right to have services provided in a manner consistent with his or her needs.
My decision is made on the following grounds:
- I accept the advice of my expert advisor, Ms Featherston, that the Rest Home and Hospital did not regularly review Mrs C's physical and cognitive condition and, if they had, staff would probably have detected the dislocation in her left hip. This view is supported by the fact that, although Mrs C was admitted to the Public Hospital on 12 September 2001 with increasing confusion, calling out and deteriorating ability to swallow, it was noticed on admission that she had pain in her left leg on movement and she was referred for an x-ray, which revealed the dislocation. During this admission, staff considered that Mrs C had been increasingly agitated because of her progressive cognitive impairment and pain from her dislocated hip. It was also recorded that she was prescribed morphine PRN (as required) and received two small doses when staff considered that she was in pain from her dislocation.
- I also accept the advice of Ms Featherston that the staff at the Hospital treated Mrs C's expressions of pain as confusion. This view is also supported by Mr C, who told me that staff had said that his mother's screaming when being moved was "anxiety". Ms B also said to me that her mother had mentioned pain in her leg a few times; however, when she asked staff about it they said her mother was "disturbed". This is also supported by Mrs C's medication, which my expert advisor said indicated that she was treated for anxiety and confusion rather than pain.
- Although I accept that it is not possible to determine the date when Mrs C's hip became dislocated, an x-ray taken on 13 September 2001 during her admission to the Hospital was reported as indicating upward dislocation of the femoral component and bone arching over the head of the femoral component. The report stated that this suggests the dislocation had been present for some time and a false joint was forming. The orthopaedic registrar also concluded on the basis of the x-ray that Mrs C's hip had been dislocated for "a long time".
- Mrs C was admitted to the Rest Home and Hospital in November 1999 from the Public Hospital where she had received treatment for an acute dislocation of her left prosthetic hip. Her medical records indicate that she had had two previous hip replacements. In view of this medical history I consider that staff at the Rest Home and Hospital should have been more vigilant concerning Mrs C's physical condition.
Response to provisional opinion
In its response to my provisional opinion the Rest Home and Hospital accepted that it knew about Mrs C's previous hip problems and that the dislocation of her hip had been present for a considerable period of time.
However, the Rest Home and Hospital also stated that Mrs C was capable of expressing pain but did not do so in relation to the movement of her hip. It said that, although she expressed anxiety or confusion, this related to her fear of falling when being moved or transferred by staff, but it was not associated with pain. Therefore it was reasonable that staff did not detect Mrs C's dislocation.
I consider it probable that Mrs C was in pain because of the dislocation of her hip and that she was not able to clearly express this in view of her confusion and anxiety. It is likely that her expression of pain was subtle and not easily detectable. The Hospital should have had a system, as part of Mrs C's care, to ensure that regular physical and mental reviews of her condition and a pain assessment were conducted. As noted above, staff at the Public Hospital detected that Mrs C's hip was dislocated very soon after her admission there in September 2001, yet staff at the Rest Home and Hospital, who had been caring for Mrs C on a 24 hour basis, had not detected her dislocated hip.
It was essential that the care received by Mrs C at the Rest Home and Hospital was of an appropriate standard, particularly since she was unable to clearly and consistently express her pain owing to her anxiety and confusion. Mrs C was in a very vulnerable situation and she relied on health care providers to meet her needs. In failing to adequately meet those needs, the Rest Home and Hospital breached Right 4(3) of the Code.
Notwithstanding my decision that the Rest Home and Hospital breached Right 4(3) of the Code, I agree with my expert advisor that the Hospital carried out a thorough investigation of the complaint.
In its response to my provisional opinion, the Hospital said that it was following my recommendation and was establishing three-monthly multi-disciplinary reviews, which will include the resident and the family. These will be undertaken in conjunction with a full medical check. The Hospital also advised that it had followed the other recommendation in my provisional opinion and now required staff who make entries in the progress notes to record their designation.
I also acknowledge that the Rest Home and Hospital was very cooperative during my investigation.
Actions
- A copy of my final opinion will be sent to the Ministry of Health Licensing Section and the Private Hospitals Association New Zealand.
- A copy of my final opinion, with identifying features removed, will be sent to Age Concern New Zealand Incorporated and Alzheimers Society NZ.
Yours sincerely
Ron Paterson
Health and Disability Commissioner