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Wednesday, April 25, 2018

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A failure in ‘end-of-life’ care

Posted at 7:56am Wednesday 29 Mar, 2017


Deputy Health and Disability Commissioner Rose Wall has found a private hospital and two registered nurses in breach of the Code of Health and Disability Services Consumers’ Rights for the treatment provided to a man receiving palliative care.

A 74-year-old man with terminal prostate cancer and bowel cancer was admitted to a private hospital for pain management and palliative care.

He remained there for 23 days.

His medications at admission included the controlled drugs OxyContin, methadone and haloperidol.

During the man’s admission there were a number of errors made regarding his medication, including a failure to administer methadone for six days in accordance with his prescription, and the administration of oral haloperidol for five days despite the prescription having been discontinued.

On multiple occasions staff also failed to record the administration of his medications correctly.

The man was not informed about the medication errors, and there was a 10-day delay in notifying his family of the haloperidol errors. In addition, there were numerous delays in the man being provided with appropriate pain medication.

Rose considers this to be an example of poor end-of-life care and believes the hospital failed woefully in its duty of care to the man and his family at a critical time in his life.

She says consumers in such circumstances require holistic care, including, but not confined to, the provision of adequate pain relief. Furthermore, staff need to be trained appropriately in palliative care, and to be alert to the changing requirements of consumers.

She found staff consistently failed to adhere to relevant policies, and to manage the man’s pain and medication adequately. As a result, staff made multiple errors in relation to the ordering, storage and administration of the man’s medication.

Despite the man experiencing high levels of pain, there were multiple occasions on which his pain assessment and management were suboptimal.

Furthermore, once the medication errors were identified, staff failed to respond appropriately in documenting and notifying the man of the errors.

Rose also found the clinical manager (also a registered nurse) failed to ensure staff complied with relevant policies and procedures, particularly regarding pain and medication management.

The clinical manager did not act promptly when administering pain relief to the man. In addition, the clinical manager did not follow up to ensure that corrective actions had been carried out following identification of the medication errors and failed to inform the man’s family of the errors in a timely manner.

The commissioner recommended the hospital management provide ongoing training to all registered nurses with regard to its policies and procedures, communication with residents and their families, medication management, and professional standards regarding documentation; conduct an audit with regard to the corrective action plan; and disseminate the learnings from this case to all its facilities nationwide.

The hospital has provided a written apology to the man’s family.


Name, shame and avoid

Posted on 29-03-2017 16:56 | By jaydeegee

Why the name suppression of the private ’hospital’? It is the interests of the public to publish the names of organizations which contravene the law and are negligent in their duty of care. The public has a right to know which hospitals etc. not to avoid. What are the penalties for deliberate abuse (i.e. not having proper systems in place) of patients as in this case?
My End of Life Choices

Posted on 29-03-2017 14:40 | By nerak

is a booklet which can be picked up from Tauranga Hospital reception, and filled in by anyone wanting to give directive when that time comes. All adults should have one, it will hopefully go some way to addressing various issues when perhaps an individual is no longer capable of doing so themselves. Sadly, the above story is all too common, and only scratches the surface of the appalling care of our elderly in so called ’care’ facilities. It’s all about the $$$
Euthanasia part 2

Posted on 29-03-2017 13:55 | By Peaches

Them, keeping them alive and suffering is only a huge callous money making plan, as we can all see by the many volume of resthomes and hospitals popping up in every corner of our country.I so wish by the time I reach my end that I have loving people around who will say enough is enough and give me a needle in my arm so I am at peace with the world.

Posted on 29-03-2017 13:46 | By Peaches

I know there area lot of people against it but you have to wonder how many have experience resthomes and palliative care and if they have seen and helped look after their loved ones dying for Cancer and Demetria, do they have a change of heart??I have had my Mum die, I looked after her for 19 years but in the end as much as it broke my heart I had to put her into care in a resthome and I have worked in a couple and seen such sadness, I had to give up.Would Euthanasia not be a better option, and I am only talking of the ones that have no quality of live due to terminally ill patients or ones with very bad Demetria, I have seen patients who can’t move or very little who can’t talk or no nothing of what is happening around..
Require more information to judge...

Posted on 29-03-2017 13:36 | By jed

My partner worked as a nurse in a rest home once... worse job shes ever had. The management allow no time for anything other than a smooth shift. This is worse at night, because if one patient has issues then care of other residents must be reduced below requirements. Then, at the end of the night one nurse having to write out notes for 40 people is just nuts (more normal would be 6 people). She quit, because the management had set the working conditions such that it was impossible to do her job properly. Some nurses may just put up with it, and the review will blame the nurse while the management can just do what they like.
@ Tish

Posted on 29-03-2017 12:27 | By Roadkill

A slow death is in the facilities best interest, as the Government pays huge money while they remain alive no matter how thin the thread is.
Having watched an elderly person die slowly

Posted on 29-03-2017 10:39 | By tish

in a local, supposedly "high end" retirement village hospital ward, this article echoes just some of what we witnessed on a daily basis for 3 weeks. I’d rather they took me out and shot me than consigned me to end of life "no-care" in such a place. Their fees are huge, the care sub-standard.
No Surpise

Posted on 29-03-2017 10:39 | By Peaches

I bet you it wasn’t even the registered nurses giving out the tablets, as I know my very young niece was ask to in a dementia care unit, she had no medical training, she said NO and then left the unit, she said there was no way she would have blood on her hands.

Posted on 29-03-2017 10:35 | By MaureenR

An apology letter just dosnt cut it as far as I am concerned, I do Palliative care ...Rose should have named and shamed this facility for sure, the punishment dosnt go far enough.
Name and Shame

Posted on 29-03-2017 08:21 | By Darth Vader NZ

Why isn’t the name and location of the private hospital named in this article ? without the naming and location of it puts other private hospitals under the spotlight of suspicion of being the culprit and for the private hospital to only write an apology letter is beyond belief the family should have the right to sue the private hospital as this was no accident and as such they would be liable for an array of charges i.m.o far to many people, companies get away with a "sorry" now days

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