Names have been removed to protect privacy. Identifying letters are assigned in alphabetical order and bear no relationship to the person’s actual name.
Introduction
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This report discusses the care provided to Mrs A by Braemar Hospital Ltd. (referred to as Braemar Hospital).
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On 20 January 2024, the Health and Disability Commissioner (HDC) received a complaint from Mrs A, who raised concerns about the care she received from Braemar Hospital. She sought a thorough investigation and an appropriate apology from Braemar Hospital.
Background
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Mrs A underwent a mastectomy on 26 July 2023 at Braemar Hospital. During the surgery, she was positioned on a warming mattress. At the end of the surgery, Mrs A was transferred onto a ward bed and irritation was noted across her right hip, buttock and thigh. On further examination, it appeared to be a burn approximately 15 × 10cm. The anaesthetist immediately contacted a plastic surgeon, who agreed to review the injury. The plastic surgeon established that Mrs A had sustained a thermal burn, which would require a skin graft to heal. Mrs A underwent skin graft surgery on 10 August 2023 with a different provider.
Information from Braemar Hospital
The warming mattress
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Braemar Hospital advised HDC that the warming mattress is a pad placed between the patient and the operating table surface. It is designed to provide safe warming of the patient at a temperature of 35–39°C to maintain a person's normal core body temperature during surgery.
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The patient’s skin must be in direct contact with the mattress sensors. The control unit, which operates the mattress, has several alarms (both audible and visual) to indicate issues with the mattress and/or control unit. If an alarm is triggered, an error code appears on the screen and the heating function automatically turns off. According to Braemar Hospital’s standard processes, any triggering of the alarms must be investigated.
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When the mattress is set and/or reset, it starts a gradual ‘warming-up process’, during which it can ‘spike’ up to a temperature of 43°C before settling at 39°C.
The event
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Braemar Hospital told HDC that it was unable to determine the exact cause of Mrs A’s burn. However, their internal investigation found that the most likely reasons for the burn were:
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the placement of a saline bag under Mrs A’s armpit, which could have occluded or otherwise affected the heat regulation sensor on the mattress, causing it to alarm, which, when reset and reheating, caused a spike in temperature briefly to 43°C and/or;
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a combination of heat and pressure from Mrs A’s hip area, when positioned in the right lateral position for an extended period, which could have heated that area above the usual 39°C.
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It is relevant to note that the mattress was not malfunctioning, as evidenced by examination and testing of the specific mattress conducted by both the manufacturer and Braemar Hospital.
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Braemar Hospital noted that the mattress alarm was triggered twice during the surgery and that, instead of determining why the alarm had gone off, the staff overrode and reset the alarm and turned the mattress back on. Braemar Hospital advised that this was common practice and had previously not led to any problems. However, Braemar Hospital acknowledged this was concerning and that theatre staff did not follow standard process.
Resolution proposal
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On 18 September 2025, I notified Braemar Hospital of HDC’s investigation of this matter. I proposed that HDC find Braemar Hospital in breach of Right 4(1) of the Code of Health and Disability Services Consumers’ Rights (the Code)2 based on a review of the complaint, Braemar Hospital’s response, and in-house clinical advice from Dr Fiona Whitworth.
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On 30 September 2025, Braemar Hospital agreed to the proposed finding of a breach of the Code.
Responses to provisional decision
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Braemar Hospital was given an opportunity to respond to the provisional decision and confirmed that it does not have any further comments to make.
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Mrs A was given an opportunity to respond to relevant parts of the provisional decision. She reiterated her view that Braemar Hospital did not provide her with an appropriate standard of care and would like a further apology. I acknowledge Mrs A’s desire for a fresh and proper apology to be provided as part of her resolution needs.
Decision: Braemar Hospital Ltd – breach
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Braemar Hospital had a duty to provide an adequate standard of care to its patients while adhering to its internal processes and to the Code, which unfortunately did not occur and is discussed further below.
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I have obtained clinical advice from Dr Whitworth regarding the standard of care Braemar Hospital provided to Mrs A. The full advice is attached as Appendix A.
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Dr Whitworth advised:
It would appear that there was a possible culture of turning the equipment for which an alarm sounded on and off again to reset them. I would conclude that this is not acceptable practice – and hence it is likely that all precautions were not taken to prevent the burn.
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I accept Dr Whitworth’s advice, and I am critical that the mattress was reset twice after the alarm sounded during Mrs A’s surgery. It is concerning that the reason for the alarm sounding was not interrogated, particularly noting that the alarm system is designed to ensure patient safety, and that such interrogation may have identified an overheating problem. Braemar Hospital has acknowledged that there was a culture of resetting the warming mattress after the alarm had been triggered, without determining the cause of the alarm, which, in my view, demonstrates a lack of appreciation and/or understanding of the core safety function of such a system.
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I acknowledge that Braemar Hospital has been unable to determine the exact cause of the burn, and I agree with the plausibility of both possibilities identified in paragraph 7.
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In summary, I am not satisfied that all precautions were taken to prevent the burn, and it was not acceptable to have ignored the alarms and reset the warming mattress. This failure involved several people within the theatre team, and it is appropriate for Braemar Hospital to be held accountable for that failure. On this basis, I am satisfied that Braemar Hospital did not provide Mrs A with an adequate standard of care. Accordingly, I consider that Braemar Hospital breached Right 4(1) of the Code.
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I note that Braemar Hospital has accepted this finding.
Changes made as a result of this event
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Following this incident and an internal review, Braemar Hospital undertook and will undertake, the following:
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Provided an apology about the incident to Mrs A.
- Supported Mrs A to lodge a treatment injury claim with ACC.
- Disposed of the mattress in question after incident testing.
- Updated and communicated the Equipment Disposal Procedure to all managers.
- Attached a hard copy of the reference key related to the alarm codes to every mattress.
- Ensured that anaesthetists now keep records of all alarm codes.
- Provided refresher training related to the use of warming mattresses, including any risks associated with use and alarm code causes, to all theatre staff.
- Clinical managers will complete root cause analysis and actions training.
- All clinical equipment will be reviewed to ensure that appropriate key alarm codes and user information is available at each machine.
- Any normalising of machine alarms culture will be addressed.
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It was appropriate for Braemar Hospital to have considered how it could mitigate the risk of this type of adverse event occurring again, and I am satisfied that Braemar Hospital has taken and is taking steps to ensure that systems are in place to prevent an event like this reoccurring.
Recommendations
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I recommend that Braemar Hospital provide a written apology specifically related to the identified failings and the breach of the Code identified in this report. The apology should be provided to HDC, for forwarding to Mrs A, within three weeks of the date of this decision.
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In addition, I recommend that Braemar Hospital provide evidence to HDC within three months of the date of this report, to confirm that actions (h) – (j) (inclusive) from the list above in paragraph 21 have been completed. I note in particular that I would like to be assured that staff have been trained on the appropriate management of machine alarms as well as the management of pressure relief for patients when positioned in a certain way for extended periods.
Follow-up actions
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A copy of this report with details identifying the parties removed, except Braemar Hospital Ltd and my clinical advisor, will be sent to HealthCERT and placed on the Health and Disability Commissioner website, www.hdc.org.nz, for educational purposes.
Morag McDowell
Health and Disability Commissioner