Sentinel 11 Apparent intentional Review found that the action Review did not make any Referred to Coroner at time of removal of vascular by the patient could not have recommendations event. Coroner decision not to catheter by patient. been predicted and that staff open an inquiry. Despite emergency had acted appropriately when response the patient the incident occurred. died. Serious 4B Patient admitted due to Review found that while a Review recommended that a formal A process has been developed a complication one day delay had occurred in process for the introduction of new and implemented for the after having had removing the PEG, the equipment to the service be developed introduction of new equipment to insertion of a tube into patient’s care was appropriate and implemented and that a check be the service. A patient education the stomach and there were no significant completed to ensure all necessary brochure has been developed at (Percutaneous clinical concerns about the equipment is stocked. the request of the patient’s family Endoscopic PEG remaining in place until and is available. Gastrostomy tube the equipment was available. – Closed. PEG). The tube was The review team did not removed four days later consider that the delay (delayed removal). The contributed to the outcome. patient died later that Review identified that the day. delay occurred because the type of PEG tube had not previously been used in the department and specialist equipment for removal was not immediately accessible. The primary provider was informed Serious 4B Patient presented with Review identified that the Review recommended informing the bronchial carcinoma. It radiology report was primary provider of the event and and subsequently confirmed that was identified that a communicated to the patient’s outcome of DHB review, ensuring the the patient had been informed. chest X-ray taken two GP and that a clearer process patient had been informed, and Work is in progress to strengthen years previous showed for direct communication of development of a more robust system the system for communication and an opacity and such results should be for communication and follow-up of follow up of reports of unexpected recommended further developed as there was a lack reports. investigation. of clarity as to who was findings on chest x-ray. following up the result.
Sentinel 11 Apparent intentional removal of vascular catheter by patient. Despite emergency response the patient died. Review found that the action by the patient could not have been predicted and that staff had acted appropriately when the incident occurred. Review did not make any recommendations Referred to Coroner at time of event. Coroner decision not to open an inquiry. Serious 4B Patient admitted due to a complication one day after having had insertion of a tube into the stomach (Percutaneous Endoscopic Gastrostomy tube – PEG). The tube was removed four days later (delayed removal). The patient died later that day. Review found that while a delay had occurred in removing the PEG, the patient’s care was appropriate and there were no significant clinical concerns about the PEG remaining in place until the equipment was available. The review team did not consider that the delay contributed to the outcome. Review identified that the delay occurred because the type of PEG tube had not previously been used in the department and specialist equipment for removal was not immediately accessible. Review recommended that a formal process for the introduction of new equipment to the service be developed and implemented and that a check be completed to ensure all necessary equipment is stocked. A process has been developed and implemented for the introduction of new equipment to the service. A patient education brochure has been developed at the request of the patient’s family and is available. Closed. Serious 4B Patient presented with bronchial carcinoma. It was identified that a chest X-ray taken two years previous showed an opacity and recommended further investigation. Review identified that the radiology report was communicated to the patient’s GP and that a clearer process for direct communication of such results should be developed as there was a lack of clarity as to who was following up the result. Review recommended informing the primary provider of the event and outcome of DHB review, ensuring the patient had been informed, and development of a more robust system for communication and follow-up of reports. The primary provider was informed and subsequently confirmed that the patient had been informed. Work is in progress to strengthen the system for communication and follow up of reports of unexpected findings on chest x-ray.
SSE_cases_2010_11_FINALv1.docx