The Office of the Health and Disability Commissioner today released a report finding a district health board (DHB) in
breach of the Code of Health and Disability Services Consumers’ Rights (the Code) for failures in the care it provided
to a woman who developed pressure injuries in hospital.
The woman was in her sixties and had multiple medical conditions. She was admitted to hospital after suffering a major
stroke and was assessed as being at high risk of developing pressure sores. The woman developed pressure injuries three
days later. She spent several weeks in hospital over the next four months, in between being discharged to a rest home
for ongoing care. Her pressure wounds and overall condition deteriorated, and on her last admission to hospital she was
diagnosed with sepsis from an infected pressure injury. Although surgery was undertaken to try to clear the infected
tissue, the woman became clinically unstable and sadly died.
Former Health and Disability Commissioner Anthony Hill was critical of the delayed assessment and poor management of the
woman’s risk factors for skin integrity. He considered closer monitoring of her deteriorating wounds was necessary.
Although the woman had been given an air mattress to help prevent pressure injuries, there were clear indications that
the air mattress was not operating correctly and staff did not investigate or escalate the issue. Mr Hill was also
critical that wound care or palliative specialists were not involved in the woman’s care sooner, and that the hospital
discharged the woman back to the rest home without providing sufficient information regarding her pressure wound status
or instructions for monitoring her injuries.
"In my opinion, [the woman] was let down by various aspects of the care provided to her by numerous staff at [the DHB].
As a consequence, her pressure injuries were not managed appropriately, and opportunities to prevent further pressure
injuries from developing were missed," Mr Hill said.
"It is important to ensure that a patient’s end-of-life care is provided in a way that seeks to mitigate the upsetting
circumstances for both the consumer and the consumer’s family, and I consider that in this instance, that did not
occur."
The DHB has taken numerous steps to improve its service since these events, including implementing a range of
educational initiatives and process changes around pressure injury care. Mr Hill also recommended that the DHB apologise
to the woman’s family.
The full report for case 17HDC01382 is available on the HDC website.