As NDIS care providers on the Gold Coast, we are very aware of the vital importance of staff handover. Whether a patient is transferring from one setting to another or simply changing staff at the end of the shift, the importance can never be overlooked. Sadly, this report highlights the tragic consequences if things go wrong.
A tragic incident at Waitākere Hospital resulted in the choking death of a disabled man, as revealed by a recent report. The man, who was at high risk of choking and required a pureed food diet, died after being provided with regular food due to mishandled communication of his dietary needs during transitions between hospital units.
The individual, who needed supervision while eating and was limited to pureed foods, was left unattended to consume a full meal while in the hospital. Less than an hour later, he tragically lost his life.
The Hearing Highlights
Health and disability commissioner Rose Wall’s investigation, unveiled on Monday, unveiled a concerning trend of inadequate care provided to the man by the hospital. This care deficit led to a violation of the Code of Health and Disability Service Consumers’ Rights.
According to Wall, hospital staff neglected their duty to adequately care for a significantly disabled patient in an unfamiliar setting. This lack of attention resulted in the oversight of his specific dietary requirements, ultimately leading to his demise. Following the transfer of the patient to the Waitākere Hospital emergency department, the caregiver submitted the patient’s comprehensive medical records, including dietary plans.
The patient, an individual in his 80s with dementia and limited language capabilities, was moved between four different units during his brief hospital stay. The initial transfer omitted the patient’s dietary plan from the handover. During the second move, his dietary information was inaccurately recorded, indicating a need for a soft mechanical meal instead of pureed foods.
Upon transfer to the final ward, there was no documentation provided during the handover. This communication lapse resulted in the incorrect meal being served to the patient and vital information regarding his choking risk and required supervision not being conveyed.
A healthcare assistant served the patient a soft mechanical meal and left him unattended to serve other patients. Shortly after, the patient began choking, turned pale, and lost consciousness, leading to respiratory arrest and his subsequent passing.
The Coroner Attributed the Man’s Death to an Aspiration Event
An examination by Te Whatu Ora highlighted the absence of clear handover documentation related to the patient’s dietary needs and a lack of adequate supervision and assistance. The hospital acknowledged the insufficient communication of the man’s information between different teams.
In light of these findings, Commissioner Rose Wall proposed several recommendations. These include comprehensive training for all relevant staff regarding handover procedures and the importance of adhering to patients’ dietary requirements. Wall also advised Te Whatu Ora to conduct a comprehensive review of clinical documentation practices to ensure accurate recording of patient needs.
Te Whatu Ora has revamped its handover documentation to include specific fields for recording patient dietary requirements.