Taranaki Base Hospital failed to do pre-discharge checks on man who died an hour later

A new report has highlighted failings at a New Plymouth hospital over the death of an elderly man who died less than an hour after being discharged in 2021.

Monday’s decision by the Aged Care Commissioner found Taranaki Base Hospital breached the Code of Health and Disability Services Consumers’ Rights.

The man in his 80s spent five days at hospital after being admitted for worsening chronic obstructive pulmonary disease and abdominal pain.

He was treated with antibiotics and steroids during his stay.

Chronic obstructive pulmonary disease is defined as an inflammatory lung disease that causes obstructed airflow from the lungs.

The man was discharged into the care of his elderly wife and supplied with prednisone and “back pocket” prescriptions for antibiotics and more prednisone should he experience further flare-ups of symptoms.

The report by commissioner Carolyn Cooper showed the man was struggling with shortness of breath and mobility upon being discharge.

The man and his wife required assistance from the public to get him from his wheelchair to their car.

His daughter told the Health and Disability Commission the pair struggled up three flights of stairs to get into their home.

The man died five minutes later.

The report highlighted a lack of discharge planning, required checks and communication resulted in the man being discharged in an unsafe manner.

Cooper highlighted several points of failure prior to the man’s discharge.

“The nursing assessment and care planner was only partially completed,” she said.

“The information about recent weight loss was incomplete.

“The discharge planning section (which starts at admission) was also largely incomplete, noting only that [the man] lived with his wife.

“The discharge checklist includes important information such as whether the patient is likely to have any difficulties with self-care on discharge, whether they are concerned about returning home, the level of support services they currently receive, and their arrangements for transport on discharge.

“None of this information was included.”

The commissioner added there was no evidence of physiotherapy or occupational therapy during the man’s stay and no referral was made for either of these supports in his discharge plans.

“I am concerned that a lack of critical thinking and communication resulted in an unsafe discharge.

“I am also concerned about the lack of documentation of a formal assessment of [the man’s] functional ability and any safety-netting advice provided and that no consideration was given to the age and health status of [his wife] and her ability to assist [the man] at his discharge.”

Several recommendations have been proposed from the report, including a formal apology to the man’s family by Health New Zealand, auditing the completion of admission documentation for the past six months and surveying nursing staff on their understanding of falls risk,

In the report, Health New Zealand said it let the man down on this occasion.

“His admission documentation was incomplete and a baseline assessment pertaining to his activities of daily life and home situation was not assessed.

“This is a nursing responsibility.”