Serious 10 Delay in treatment Review under way. [HQSC comment subsequently advised by DHB – due to transport after SSE report went to printing that case not an problems SSE] transporting patient from regional hospital. Patient died. Serious 4G Patient died on Review way. ward shortly after admission from ED. Serious 4A in diagnosis Review under way. of cancer due to failure to follow up results. Patient has subsequently died. Serious 4D Patient suffered Review under way. complications during surgery and required further surgery. Serious 4B Communication Department staff unaware of the Department will contact requesting clinician breakdown requirement to contact the requesting directly to advise of significant change. between services clinician if a significant change to a Develop a process for recording this communication resulted in result or diagnosis is made. in the clinical record. delayed treatment Department staff currently have no for patient. Patient Department to adjust format of report sent so that if process of recording these notifications/ has since had further work is being done to confirm diagnosis this conversations in the patient’s clinical appropriate will be clearly documented in report. record. management and treatment.
Serious 10 Delay in treatment due to transport problems transporting patient from regional hospital. Patient died. Review under way. [HQSC comment – subsequently advised by DHB after SSE report went to printing that case not an SSE] Serious 4G Patient died on ward shortly after admission from ED. Review way. Serious 4A in diagnosis of cancer due to failure to follow up results. Patient has subsequently died. Review under way. Serious 4D Patient suffered complications during surgery and required further surgery. Review under way. Serious 4B Communication breakdown between services resulted in delayed treatment for patient. Patient has since had appropriate management and treatment. Department staff unaware of the requirement to contact the requesting clinician if a significant change to a result or diagnosis is made. Department staff currently have no process of recording these notifications/ conversations in the patient’s clinical record. Department will contact requesting clinician directly to advise of significant change. Develop a process for recording this communication in the clinical record. Department to adjust format of report sent so that if further work is being done to confirm diagnosis this will be clearly documented in report.
SSE_cases_2010_11_FINALv1.docx