Major 11 2 Self-harm while on leave Intent for self harm Length of leave granted should reflect Ongoing. from inpatient service. Risk not fully individual’s needs with emphasis on shorter canvassed. periods in the first instance. Review individual risks and discuss with Implemented. relatives prior to leave. Ensure discussion is documented. MidCentral Serious Event code* SAC 1/SAC 2/ Description of event Review findings Recommendations/ actions Follow up or (see codes N/C (not sentinel below) classified) 4B 2 Patient not receiving Failure of referral mechanisms to Implementation of a system to ensure A system was tertiary intervention in an tertiary hospital. referrals are received and implemented to appropriate timeframe. actioned. ensure inter-DHB Referral not followed up on when referrals are tracked Patient outcome: stroke patient not reviewed within a and actioned. with significant reasonable timeframe. DHB in hemiparesis. breach of its obligations under the Health and Disability Code. 4B 2 A woman was transferred Inability to replace loss in transit All relevant teams and Ambulance Recommendations to secondary facility with and lack of clarity as to receiving service agree to appropriate are currently being complications following a service at secondary hospital in the communication and transfer implemented. normal delivery. acute situation. arrangements for women being transferred from a primary maternity Patient outcome: unit to the secondary services with emergency surgery and extreme complications. admission to ICU
Major 11 2 Self-harm while on leave from inpatient service. Intent for self harm Risk not fully canvassed. Length of leave granted should reflect individual’s needs with emphasis on shorter periods in the first instance. Ongoing. Review individual risks and discuss with relatives prior to leave. Ensure discussion is documented. Implemented. MidCentral Serious or sentinel Event code* (see codes below) SAC 1/SAC 2/ N/C (not classified) Description of event Review findings Recommendations/ actions Follow up 4B 2 Patient not receiving tertiary intervention in an appropriate timeframe. Patient outcome: stroke with significant hemiparesis. Failure of referral mechanisms to tertiary hospital. Referral not followed up on when patient not reviewed within a reasonable timeframe. DHB in breach of its obligations under the Health and Disability Code. Implementation of a system to ensure referrals are received and actioned. A system was implemented to ensure inter-DHB referrals are tracked and actioned. 4B 2 A woman was transferred to secondary facility with complications following a normal delivery. Patient outcome: emergency surgery and admission to ICU Inability to replace loss in transit and lack of clarity as to receiving service at secondary hospital in the acute situation. All relevant teams and Ambulance service agree to appropriate communication and transfer arrangements for women being transferred from a primary maternity unit to the secondary services with extreme complications. Recommendations are currently being implemented.