HDC is committed to promoting and protecting the rights of everyone using health and disability services in Aotearoa New Zealand, and in doing so honouring our Te Tiriti o Waitangi obligations.
‘It’s vital that people who experience poor outcomes in the health and disability system understand their consumer rights and their right to request feedback through HDC’s complaints process. We must close the gap in systemic disparities and inequity. We can only achieve this by working together,’ says our Kaitohu Matamua Māori/Director Māori, Ikimoke Tamaki-Takarei (Waikato, Tainui).
Whānau involvement is fundamental in the health and wellbeing of their whanaunga. He Korowai Oranga — Māori Health Strategy defines the importance of whānau to achieve Māori health and wellbeing, with the aspiration that ‘Māori families are supported to achieve the fullness of health and wellbeing within te ao Māori and New Zealand society as a whole’. [1]
Right 1(3) of the Code of Health and Disability Services Consumers’ Rights (the Code) states:
‘Every consumer has the right to be provided with services that take into account the needs, values, and beliefs of different cultural, religious, social, and ethnic groups, including the needs, values, and beliefs of Māori.’
The following recent HDC decisions reinforce the importance of culturally safe practice and the negative impacts on people where such consideration is lacking.
Assessment of needs and values vital to providing culturally appropriate care
The mental health services provided to a 34-year-old Cook Island Māori woman did not adequately take into account cultural considerations. The then DHB’s ‘Risk Assessment and Management in Mental Health’ policy stated that staff must consider any cultural factors when assessing risk, and that cultural support is part of how consumers are supported to participate in the assessment and implementation of strategies to manage risk. The policy further stated that risk assessment and management should occur at each and every intervention to minimise potential safety risks to service users and those around them. In addition, the Intake and Acute Assessment Pathway stated that during triage, staff were to ‘identify any cultural or specialist needs, consult/access services or support as indicated’, and the service’s ‘Client History Adult’ and care plan forms explicitly guided clinicians to consider cultural factors in the woman’s assessment and treatment plan.
Despite the many opportunities staff had to consider culturally appropriate care for the woman, there was no evidence in the clinical records or otherwise that her cultural needs were assessed or that options for culturally safe care specific to her needs were discussed. Her cultural needs were not assessed at the point of triage, and the option of follow-up from a cultural mental health team was not offered.
Deputy Commissioner Dr Vanessa Caldwell found that the woman was not informed about the cultural support options available to her, or offered any specific cultural support that met her needs. The DHB was found to have failed to provide the woman with services that took into account her cultural values and needs as a Cook Island Māori woman and was found to have breached Right 1(3) of the Code.
https://www.hdc.org.nz/decisions/search-decisions/2022/20hdc00354/
Culturally safe care needs to be respected in assessment pathways
A kaumātua’s cultural needs and beliefs were not upheld while he was an inpatient in a regional hospital. The case highlighted the importance of an appropriate assessment pathway to consider cultural needs or options for culturally safe care.
Following assessment and observation in the Emergency Department, the kaumātua was transferred to a ward, where he was an inpatient for approximately four weeks. During the admission process and while the kaumātua was an inpatient, his cultural needs and beliefs were not considered.
Aged Care Commissioner Carolyn Cooper concluded that consideration of cultural needs of the kaumātua and appropriate options should have been made available from the time of his admission to hospital, to enable the whānau to exercise control in caring for their koroua, in accordance with their tikanga and kaupapa — mana whakahaere.[2] Instead, the whānau were left to self-navigate the health services to determine the support available to their koroua.
Ms Cooper recommended that the hospital:
- Facilitate a whānau hui, to allow the kaumātua’s whānau (as part of their healing) to speak of the mamae they experienced while their koroua was a patient in hospital, and to allow the hospital to provide an apology;
- Reflect on the whānau experience, and consider how the navigation of separate health services for whānau can improve in the future, taking into consideration a whole-of-system approach;
- Review its protocols, outlining the cultural support pathway at the time of admission for all Māori patients, taking into consideration the whānau’s choice to engage in Māori services, and acknowledging that the option for cultural services should be provided in the first instance and not as an afterthought; and
- Outline in their kaupapa training framework how the practice of tikanga with patients and their whānau is developed with all hospital staff and provide comment on how this framework aligns with the aspirations of Te Aka Whai Ora, with consideration of the elements of Pae Ora.
https://www.hdc.org.nz/decisions/search-decisions/2022/20hdc02383/
Assessment and action taken by an Emergency Department
A Māori man in his thirties presented to hospital on five occasions over two months with a recurring middle ear infection. Deputy Commissioner Dr Vanessa Caldwell concluded that clinicians did not undertake adequate investigations to understand the extent of the disease, and the DHB breached Right 4(1) of the Code by failing to provide services with reasonable care and skill. Sadly, the man died as a result of a brain abscess — a rare but known complication of the ear infection. During the man’s presentations, clinicians also suspected him to have been intoxicated with drugs, but failed to assess him adequately to determine if this was the case. In this respect, Dr Caldwell emphasised the importance of ensuring that suspected drug use is ruled out so that the root cause of any symptoms (potentially assumed to be from drug use) can be explored fully. The failure to do so raised the issue of potential bias in relation to the man’s care. In addition, there was concern about the content and manner of a discussion with whānau. The Medical Council’s statement on cultural safety[3] was referenced — specifically, doctors should formulate treatment plans in partnership with patients that fit within their cultural contexts and are balanced by the need to follow the best clinical pathway and include the patient’s whānau in their healthcare when appropriate.
It is not sufficient for providers to have policies and protocols regarding cultural support pathways. What is needed is that these are put into practice in order to improve consumers’ experiences and outcomes within the health system. It also behoves providers to practise in a culturally safe manner, for example, by involving whānau in decision-making, and being mindful of personal and institutional biases when people present for care, and when they express their choices about the cultural support they require.
https://www.hdc.org.nz/decisions/search-decisions/2022/19hdc01783/
I wish to acknowledge Dr Cordelia Thomas for her assistance/contribution to the writing of this piece.
Morag McDowell
Health and Disability Commissioner
NZ Doctor, March 2023
[1] Ministry of Health. 2014. The Guide to He Korowai Oranga — Māori Health Strategy. Wellington: Ministry of Health.
[2] Ministry of Health. 2020. Whakamaua: Māori Health Action Plan 2020–2025. Wellington: Ministry of Health.
[3] https://www.mcnz.org.nz/our-standards/current-standards/cultural-safety/.