Aged Care Commissioner Carolyn Cooper found short staffing contributed to substandard care of the man by Te Whatu Ora. Photo: RNZ / Samuel Rillstone
A junior doctor was the only one on duty for "more than 50" patients in Gisborne Hospital the night an elderly man died, in a case criticised by the Health and Disability Commission.
In a report released today, the Aged Care Commissioner Carolyn Cooper found short staffing contributed to substandard care of the man by Te Whatu Ora Health NZ.
The patient was in intensive care after surgery when his blood pressure changed over time, indicating a heart problem, and he went into cardiac arrest and died.
A nurse was criticised for not giving adequate information about the man's deteriorating condition to a junior doctor when she called him for advice, very early in the morning.
The doctor should also have come to review the patient in person but there were "numerous mitigating factors", Cooper said.
The doctor told the commission that when he was paged, he was in the emergency department (ED) talking to a large family of a dying patient.
"In addition I had four other patients waiting to be seen on four different wards, as well as four others waiting to be admitted in the ED," he told the commission.
He was the only doctor rostered on for the wards overnight and estimated there were more that 50 patients. There was a senior doctor on for ED.
"I do know I was frantically busy all night," the doctor told the commission.
Unmanageably busy night shifts had been discussed with management and were not unusual.
"Almost invariably whenever I was on night duty, I found myself virtually running from patient to patient all night long. I felt that the workload was unsafe," he said.
In releasing the findings, Cooper said she was aware of the pressure hospitals were under nationally.
But, "healthcare consumers had the right to expect hospitals to be sufficiently resourced with the appropriate mix of skilled and experienced staff to provide safe and competent care," she said.
At the time of the incident, Gisborne Hospital was still part of Tairāwhiti DHB but that had been merged into Te Whatu Ora.
The hospital had since added another junior doctor to the overnight shift.
Cooper expressed her sincere condolences to the man's family and recommended Te Whatu Ora apologise for the deficiencies in his care.
She also recommended the situation be written into an anonymous case study for education purposes.
Among her other recommendations were that all staff be trained about deteriorating patients and verbal prescriptions in critical care and that Te Whatu Ora review how its extra staffing was working.
