Mistakes Keep Happening

Mistakes Keep Happening 2 May 2007

“The Health and Disability Commissioner may be encouraging families and caregivers to ask more questions and be more assertive when it comes to hospital care but we did everything possible. We did what the HDC is now suggesting and it didn’t do any good at all.” Ali Jones.

David Jones died following a wholly preventable incident at Christchurch Hospital last July.

Not only is his family still waiting for confirmation that changes have been made to ensure no-one has to go through such a thing again including the suffering and lack of dignity Mr Jones himself went through in the final weeks of his life, they are also concerned at what they see as a lack of support and advice for families dealing with such incidents.

“We had to request ACC forms twice from the hospital following dad’s fall. Once they been completed and given back to the hospital, we noticed they were still in dad’s file four days later and asked why? They seemed unconcerned but said they would send them away as soon as possible,” says daughter, Ali Jones.

Every step of the way, the family found the processes to be confusing, the information they were given by ACC was inconsistent and in many cases incorrect, and dealing, at the same time, with their father’s injuries suffered while in Christchurch Hospital, created a huge amount of stress and distress.

“I have a suitcase filled with forms, files and paperwork,” says Siân Jones. “We had to know the system better than those working in it, to stay one step ahead. On several occasions, if we had accepted information we were given as being correct, our father would not have received the care needed after he suffered the terrible injuries at Christchurch Hospital,” she says.

“At one stage, the information we were getting from ACC and what they were recording in my father's file, was so inconsistent and basically wrong, I asked Ali if she thought they were being deliberately obstructive so that we would go away,” Siân says.

"We have had extensive interaction and met with ACC on several occasions, both while dad was still alive and after he died, and this is ongoing. When we asked if ACC worked with the hospital to ensure this did not happen again, we were told, “sorry no”. ACC told us they only deal with rehabilitation and day to day claims not injury prevention,” says Siân Jones.

The daughters say they were incredulous to be told this when the word "prevention" is in ACC's mission statement.

"How can things be prevented if there is no communication between the organisation responsible for "preventing" accidents and the place where the "accident" occurred. It is mind boggling," Siân Jones says.

The family is still awaiting confirmation from the CDHB that recommendations made by the HDC early last month, relating to the brain contusion and broken femur their father suffered while in the care of Christchurch Hospital, have been implemented.

“We will continue to fight for justice for our father. The ACC system in this country allows a culture of "no blame or accountability" to operate in our health sector and that is wrong,” Ali Jones says.

"It is all very well being "transparent and open", as the health spin machine is so keen to remind us, however, if recommended changes are not acted upon and there is no-one to ensure they are, what will change? Who will be next to lose a loved one in a situation where the risk had already been clearly identified?” she adds.

“The Health and Disability Commissioner may be encouraging families and caregivers to ask more questions and be more assertive when it comes to hospital care but we did everything possible. We did what the HDC is now suggesting and it didn’t do any good at all,” says Ali Jones.

BACKGROUND:

In early July 2006, after his GP prescribed codeine for pain, 67 year old David Jones became disorientated and sedated to the point of stupor.

Although he had been living with prostate cancer for almost 14 years, prior to taking codeine on this one occasion, he had only been taking Panadol and Voltaren for pain if and when needed. Prior to the codeine, David Jones was an articulate, intelligent, mobile man who, among other things, often cared for his grandchildren - aged 7, 3 and 1 year old.

In July, he was admitted to Christchurch hospital and soon afterwards, it became obvious to his family that his confusion, hallucinations and physical instability, meant David could injure himself, if he was left alone.

“Dad was trying to get out of bed while confused and weak on his legs, so Ali and I (supported by mum), took turns over three days, 24 hours a day, sitting with dad, to ensure his safety,” says Siân.

Fortunately Alison was on pre-arranged holiday leave and Siân's workplace was very accommodating with her request for some time off.

After three days, the hospital told the family they were able to provided a "special", a dedicated, 24 hour, round the clock sitter for their father / husband. The daughters provided 24 hr contact details for themselves and reiterated that should there be any need to get in touch, for whatever reason, they were to be contacted.

Siân made it clear that she lived literally around the corner from the hospital and had made arrangements with her employer to work from home, in case she was needed at the hospital as had been the case on one previous occasion when she had been called in at 2am. Assurances were given that they would be contacted if necessary.

A few hours after the family left the hospital on the day the hospital had assigned a sitter, Pat (David’s wife) received a phone call with the dreadful news that David had climbed off the end of his bed and fallen headfirst, causing swelling and extensive bruising. The sitter had been called away and not been permitted to return as she was required in another part of the hospital.

In the following days, weeks and months, it became apparent that this respected, retired barrister, a man described by friends and colleagues as an "absolute gentleman", would never survive this massive assault on his body.

His system stared to shut down. Not straight away, but gradually over the next 4-6 weeks. A broken femur and brain contusion, suffered when he hit the ward's concrete floor face first, meant he would never again return to his pre-hospital admission condition. What followed was a slow and undignified decent into his eventual death on September 26th, 2006.

"He had fought his cancer so bravely and selflessly," Pat Jones says. "What happened to him is inexcusable. Everyone has the right to fight to live. Everyone has the right to expect to be safe in hospital. No-one should have to suffer, particularly when an outcome is entirely absolutely preventable. This should not ever happen to anyone, ever again," she says.

ENDS