Page Section: Centre Content Column

Accident and Emergency

To and fro between a GP and the local emergency service

Continuity and timely information

Getting the diagnosis wrong

Delayed compartment syndrome diagnosis

DHB resolution meeting at a consumer's home

Making sense of a child's death

Support wanted for scary procedure

Complaint about a midnight discharge

Treatment at accident and medical centre

Disappointing Accident and Emergency Care

Misdiagnosis at emergency department

Respect for patient in hospital

Getting information about ED visits

Discharged early from ED

The shock of a very sudden death

Poor care in an emergency department

To and fro between a GP and the local emergency service

DHB ~ Accident & Emergency ~ Right 1~ respect ~ Right 4 ~ appropriate standards ~ Right 5 ~ effective communication~ breast abscess ~ GP

A consumer and her family arranged to meet an advocate to discuss issues she had with a number of providers within the hospital.  She explained that she had gone to see her GP with pain in her breast. Her GP examined it and found an abscess, and referred her to A&E for a scan. A doctor aspirated the abscess and she was happy with this service.  

A couple of weeks later she experienced the same pain and returned to her GP. She was again sent to the hospital where a consultant told her the cause of the abscess was her smoking and that she should be breast feeding as it is good for her baby and is also a form of contraception.  She told him that she was pregnant again and was upset even further by him saying 'that's one too many' in response.

She returned again to her GP who once again sent her to A&E, this time with the intention of getting the abscess drained.  However upon arrival she was seen by the consultant who admitted her to hospital. She was led to believe that her abscess would be drained, but when she awoke from the anaesthetic she discovered it had not been drained but aspirated again. She questioned whether it was necessary to have an anaesthetic and be in hospital for two days when previously this procedure had been performed in A&E with minimal discomfort and disruption for her family.

Issues:

• The consumer felt the consultant had not listened to her and she had been misled about what procedure would be done. 
• She felt communication between those involved in her care was poor and as a result led to a misunderstanding which resulted in her self-discharge. 
• The consumer was not happy with the response from the DHB as she felt information from the consultant was misleading. 

The consumer chose to meet with the consultant and others involved in her care to discuss the care and communication. She also wanted to discuss compensation and was advised the advocate would be unable to assist with this outcome. 

The providers agreed to meet with the consumer, her family, and the advocate to discuss the consumer's concerns. The consumer was very happy she had been heard and also with the explanations given by the providers. At the end of the meeting she asked the advocate to close the file. 

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Continuity and timely information

DHB ~  emergency service ~ Right 1 ~ respect ~ Right 4 ~ appropriate standards ~ Right 5~ effective communication ~ Right 6 ~ timely information

A consumer contacted the advocacy service with concerns about a specialist's appointments not being sent out from the hospital. She was also reluctant to be admitted to hospital because of her previous experience with A&E staff.

Issues

1. The consumer felt she should have been contacted by phone rather than learning of her appointment being changed through the post. When she contacted the hospital regarding this the receptionist was rude to her.

2. She had been taken to A&E by ambulance where a nurse had performed a heart test. Three quarters of an hour later a doctor  popped his head through the curtain and asked the consumer if she had been seen. The doctor  then asked what the problem was and when the consumer said back pain the response was "you look alright to me". At no stage did the doctor  examine the consumer. She was discharged shortly after.

3. The discharge letter contained incorrect information around the time of discharge and the consumer stated she was told she did not have kidney stones. She passed one the following day which she took and showed to the doctor. 

With the help of the advocate the consumer laid a complaint with the provider. While the provider was investigating the matter the consumer contacted the advocate to say that there were further issues with appointments. She had been given only 24 hours notice of one appointment and another had been cancelled as a result of the auditors visiting the hospital. Then while talking to the receptionist, (who was rude again), she had received a call from the hospital reminding her of an appointment for that day which she had not previously been notified of.

At the consumer's request these incidents were also brought to the attention of the Quality and Risk Manager at the hospital. 

The consumer received a written response to her concerns outlining the actions that the DHB was taking as a result of her concerns. The consumer was invited to be part of a consumer forum with providers on an ongoing basis.

The consumer felt her concerns had been taken seriously, and investigated thoroughly. She advised the advocate she was very happy with the outcome. 

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Getting the diagnosis wrong

Right 4 ~ Appropriate standards ~ Appendicitis ~ Emergency after hours clinic

An advocate was contacted by a man concerned about the standard of care provided to his daughter at an After Hours Emergency Clinic. The man said his daughter had presented at the clinic with nausea, vomiting and stomach pain.

A pregnancy test came back negative, and the consumer was prescribed pain relief and told to come back if things got worse. She returned to the clinic the following day as her condition had not improved and was told to continue with the pain relief. Following that consultation and concerned about his daughter, the man had taken her to the hospital emergency department where she was diagnosed as having appendicitis and was taken straight to theatre. 

The man wanted advocacy support to meet with staff from the clinic. He said his daughter was an adult who had given permission for him to act on her behalf. The advocate confirmed this with the daughter who said she was recovering from surgery and wanted both her parents to be involved in resolving the matter on her behalf.  

The advocate supported the man to write a letter stating what his daughter's and his concerns were. He also requested a meeting with the practice manager and the doctor who had seen his daughter. The providers agreed to meet. 

Despite having been well prepared for the meeting the man became angry when discussing the issues. The providers did not interrupt allowing the man to express his anger and when he had finished speaking they addressed his concerns. They provided an explanation about what had occurred at the time of the consultation and how appendicitis can sometimes be difficult to diagnose. Both provided an apology.

The advocate and complainant debriefed following the meeting. The father advised that he was satisfied with the explanation and apology and would convey the information to his daughter who he believed would also be satisfied with the outcome of the meeting. His daughter was happy and asked for the file to be closed. 

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Delayed compartment syndrome diagnosis

DHB ~ Emergency Department ~ Vascular Surgeon ~ Right 2 ~ discrimination ~ Right 4 ~ Appropriate standards

A 19-year-old man told an advocate that when he broke his arm and sought treatment at the local Emergency Department staff they had displayed discriminatory behaviour. He believed this was a result of a neck tattoo he has. Following the treatment he developed compartment syndrome, which has resulted in his arm being withered with little function. The consumer, supported by his father, was very clear that they were seeking a meeting with the vascular surgeon and the emergency department doctor involved with his care.

The advocate assisted the young man to write a letter to the hospital outlining his complaint and his request to meet with the doctors involved. Upon receipt of a response from the hospital about proceeding with the meeting the advocate checked the consumer was comfortable attending a meeting at the DHB and with his agreement the hospital customer service manager organised a meeting with the relevant staff.

Prior to attending the meeting the advocate assisted the consumer and his father to prepare a list of questions they wanted responses to, as well as discussing the meeting format.

While the meeting was emotional, the consumer was able to have his questions answered with the doctors providing a detailed explanation about the extent of his injury. They apologised for both the delay in diagnosing compartment syndrome and for the behaviour which had led to the consumer feeling he was being discriminated against. The consumer was pleased to receive both the information and apology.

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DHB resolution meeting at a consumer's home

DHB ~ Emergency dept ~ Oxygen ~ Terminal condition ~ Right1 ~ Respect ~ Right 4 ~ Consistent with needs

An assessment in the emergency department of a terminally ill consumer resulted in her being sent to the short stay ward. In the ward she felt marginalised by a senior staff member who told her she wasn't sick enough to be there and arranged for her to be sent to a rest home for respite care. Upon her arrival at the rest home she discovered the home had not been advised of her need for oxygen and as they didn't have any her family took in oxygen tanks from her home.

Because of this experience she became very fearful about what would happen if she returned to the emergency department short of breath in the future. She wanted an explanation of why she had been treated that way as well as what to expect in the future if she needed to go to hospital.

When she contacted the advocate she was quite unwell. After considering the options she said she would like to receive an apology but did not feel well enough to attend a meeting. She asked the advocate to contact the provider on her behalf.

After a number of attempts, the advocate made contact with the Emergency Department Service Manager who offered to meet with the consumer at her home. Along with the advocate the meeting was attended by the Respiratory Nurse, DHB Pharmacist, Care Coordinator, Manager for ED, Maori Advocacy, the consumer and her son.

The consumer received an apology for the way she had been treated during her last hospital admission and a plan was agreed to for future care. The plan included extra oxygen cylinders being supplied including a portable tank giving her more freedom to leave her home, a home visit from the oxygen nurse, a review of all her medication, regular review by a local doctor in her home town, and an admission care plan for any future hospitalisation.

In addition she was provided with the contact details for the care coordinator, who would oversee her care.

She was very happy with the outcome of the meeting and no longer felt anxious about returning to the hospital if necessary.

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Making sense of a child's death

DHB ~ ICU ~ Right 6 ~ Fully informed

The father of a three-year-old boy who died in the intensive care unit at the local hospital phoned the advocacy service for assistance to get information about his son's last five days in ICU. His son passed away after many seizures and the father wished to talk to the paediatric neurologist who was involved with his son's care at the time. The father said he was so distraught at the time his son was in ICU that he did not retain all the information that was given to him and the rest of the family. Although he knew his son had a particular syndrome, he wanted to know why his son had died and what efforts had been made to save him.

After considering his options the father chose to meet with the specialist with the support of the advocate. The specialist willingly agreed to a meeting which was held at the advocate's office. The specialist was well prepared, bringing clinical notes as well as scans of the little boy's cerebral activity, taken over the five days he had been in ICU. The father asked many questions and received clear information from the specialist who was willing to stay as long as it took

After the meeting the father said he felt well informed about what had happened and why. He was pleased to have had the support of the advocate to get the information he needed. He has since become very active in a support group and is educating other parents about having a child with this syndrome. He is also working hard for the ICU to raise funds to purchase a new machine to measure brain activity while a patient is in a coma.

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Support wanted for scary procedure

DHB ~ Emergency Department ~ Right 5(1) ~ Effective communication ~ Right 8 ~ Support person of choice

A woman contacted an advocate for support to make a complaint about her care at the local hospital. She had arrived at the emergency department with an elevated heart rate. She was told by the doctor she had to immediately have a special procedure to lower it. She wanted to have her husband there for support as she did not understand the process described or what was being said to her. She did remember being told "she might feel like she was dying and not to worry as they could resuscitate her," and was very alarmed by this.

She insisted they wait until her husband arrived as she was afraid she might die and wanted him to be there. When he arrived the procedure went ahead, but only after discussion with the staff after a nurse suggested she be moved from the emergency department to a cardiac ward where more appropriate equipment was available in the event of any complications.

The consumer was concerned about the information provided by the doctor and that he had wanted to proceed without her husband being present. She felt particularly strongly about this as based on the comment about resuscitation and dying she felt she might not get to see her husband again. After considering the options, she chose to write to the doctor.

Upon receipt of the complaint the doctor concerned contacted the woman by phone and apologised. He also told her "the complaint had given him things to ponder over." She felt the apology was genuine and hoped the outcome had made him a better doctor. She said she had told him that the rights were not there to decorate hospital walls but to provide a safe and successful hospital stay for patients.

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Complaint about a midnight discharge

A man in his mid 80s contacted an advocate for assistance to complain about his treatment at the local hospital.

He had experienced a number of nose bleeds over several days which had been treated by his GP. Eventually his GP advised him to ring the ambulance to be taken to the emergency department if it happened again.

When the next bleed occurred the man took the GP's advice and called an ambulance. When he arrived at the emergency department he was examined and told he would be seen again. After waiting several hours he was again seen by a doctor. By this time the nose bleed had stopped, so he was told he could go home. By then it was after midnight. As he lived alone, had no transport or any one to collect him, he requested to stay the night. He was told there were no beds available and to take a taxi.

After considering his options he asked the advocate to help him write a letter to the hospital. He complained about the process around his discharge including the poor communication. He received an apology, an acknowledgement that the correct discharge procedure had not been followed and reimbursement of the $60 taxi fare.

The man was very pleased with this outcome.

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Treatment at accident and medical centre

Accident and medical centre ~ Self-advocacy ~ Respect ~ Appropriate standards ~ Effective communication ~ Complaint process

A consumer went to the local accident and medical centre for treatment after binge drinking. The doctor who was treating him became very judgemental, telling him he was a 'drug seeker', and writing this on the medical notes. The consumer had had previous treatment for binge drinking and knew what worked for him. He was not seeking drugs and felt very offended by the doctor's attitude.

The consumer initially took his own action by writing a letter of complaint to the director of the accident and medical centre. After failing to get a response to his complaint he contacted a local advocate.

The consumer asked the advocate to write a letter to the director on his behalf, to remind him of his responsibility in relation to right 10 (the right to make a complaint and receive a timely response). A copy of the consumer's original complaint letter was included.

The consumer's letter of complaint outlined the following issues:

• He felt that the doctor he had seen was rude and disrespectful towards him, judging him as a 'drug seeker' and writing this on his medical notes
• The doctor did not actually examine him.

He also advised the outcome he was seeking:

• An explanation and apology for what had occurred.
• A refund of the $65 treatment cost, as the doctor had not examined or treated him.
• The words 'drug seeker' removed from his medical notes.

The director responded in writing to the consumer with a sincere apology and an offer to meet in person, with the support of the advocate. The director said he had removed the drug-seeking behaviour caution from the system and agreed to refund the fee for the consumer's visit.

The consumer decided not to meet as he was extremely happy with the written response. He thanked the advocate for the professional and empathetic way that his complaint had been handled.

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Disappointing Accident and Emergency Care

Emergency service ~ Wrong diagnosis ~ Lack of information ~ Support person

Background
A concerned mother rang the local advocate to discuss the treatment her daughter had received from the public hospital over a number of visits. The daughter, who was 15 years old, confirmed the same concerns and that she wanted her mother to address them on her behalf.

Initially, the daughter had been sent to hospital with suspected meningitis. During her admission she was diagnosed with an ovarian cyst. However she was not treated for this and was discharged. Her pain continued and after a number of further admissions, and an internal examination which her mother was not permitted to be present for, she was diagnosed with pelvic inflammatory disease (PID). The consumer's mother felt that her daughter was not being treated appropriately and sought help privately which resulted in surgery for an acute appendicitis and a very large bill.

Issues outlined by the mother
1.    Should her permission have been sought prior to the internal examination being done and why wasn't she asked to be present when the procedure was carried out?
2.    Why were they not given any written information about PID?
3.    The medical file was incomplete so when they saw another Dr he did not have full information about what had been happening.
4.    Why was appendicitis not diagnosed by the public hospital staff?
5.    The A & E department was inadequately heated and they had to get a rug from the car to keep warm while they waited over an hour to be seen.

Desired outcome
1.    A response from the health professionals and staff involved.
2.    Reimbursement for the cost of the private treatment and surgery.

Options explored and actions taken
The advocate met with the mother to hear the full story, clarify the issues she and her daughter had as well as their expectations. A letter was sent to the providers involved outlining the issues so they could be properly prepared for a meeting if one went ahead.

The outcome
After faxing through a consent form from the daughter saying she authorised her mother to act on her behalf, a representative of the hospital provided a response addressing each of the issues raised. Following receipt of this letter the mother met again with the advocate to discuss the response.

Although not happy about not being compensated for the cost of the private treatment and surgery, the mother felt that all other responses and the actions that were being taken as a result of her raising their concerns were satisfactory. She advised she no longer wanted to meet with the providers and that her complaint could be closed as she was satisfied with the outcome.

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Misdiagnosis at emergency department

A woman went to A&E in extreme pain. She was advised she had gastroenteritis, was given a prescription and discharged. She returned the following day as her pain had not lessened and she was diagnosed with a ruptured gangrenous appendix, and subsequently developed and was treated for peritonitis. She was discharged some weeks later in to the care of her flatmate and the district nursing service. She felt that as a result of not being correctly diagnosed on her first visit to A&E, she was dependant on others for care for some time. She attempted to address these issues through the complaints co-ordinator but was not happy with the result.

With advocacy support, the woman met with the provider. As a result, the medical director wrote an educational letter to the doctor concerned and requested an apology. The quality manager agreed to ensure that education would take place with regard to written responses to complaints, and advocacy was invited to provide education on the Code of rights and advocacy to the quality team.

Following confirmation that the agreed actions had been taken, the woman felt she was in a position to move on with her life.

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Respect for patient in hospital

A woman went to an emergency department complaining of numbness in her legs. The doctor could not find anything wrong and discharged her. The next day she was re-admitted having lost full movement of her legs. The doctor who tended to her again said that there was "nothing to worry about" and discharged her. The daughter insisted that her mother be seen by a neurologist, who found that a virus had attacked her nervous system resulting in a loss of muscle movements.

During the woman's stay in hospital, her daughter reported that the nurses made comments about the consumer's size and said that she was using too much linen. She also complained that staff were not monitoring her every four hours as recommended by the doctors, and family stayed overnight to ensure that their mother received proper care.

The advocate working with family arranged for a meeting between the charge nurse manager, two nurses from the ward and a consultant. The family was able to relay their concerns including that they were being treated disrespectfully because of their ethnicity. The staff apologised to the woman and her family. The consultant was also able to explain that the diagnosis of her illness had taken longer than expected due to its rarity.

The woman and her family were happy with these outcomes.

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Getting information about ED visits

A consumer with a long-standing medical condition had been advised by his GP to go to the Emergency Department if the condition worsened outside the GP's practice hours. This happened twice and the consumer was very unhappy about how he was treated on both occasions. He felt the GP's advice was ignored and his own wishes and explanations were not listened to.  Powerful pain relief was administered and the consumer was discharged with no understanding of what was treated, why, and what future treatment should be. Despite the consumer following this up and requesting the notes from these appointments be sent to the GP, this did not happen.

The consumer asked an advocate for support to raise these concerns with the DHB. He wanted copies of the notes from these appointments for themselves and for the GP. He also wanted explanations, a treatment plan and a summary to take with his in case he needing emergency care while out of the district.

The consumer was delighted with the response received back from the hospital. Not only did he get the information requested but an immediate appointment was made with a specialist and future treatment was arranged. The consumer showed the GP the documentation around this process and was impressed he had the advocate's business card and recommended our service.  The consumer was very complimentary about the process and will be recommending advocacy to others.

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Discharged early from ED

A consumer was taken to the Emergency Department by ambulance at 4.30pm. She had had diarrhea and her last memory was of going to bed the night before. She was very drowsy, unco-ordinated, had a severe headache, light hurt her eyes, had a painful neck, lost control of her bowels and bladder and felt very confused.

She was initially seen by a triage nurse. After a three-hour wait, she was given tests, told her x-ray showed pneumonia and was given oral antibiotics. At 10.30 pm, although she was not feeling well, she was sent home. The following morning she received a call from her GP, advising her that her chest x-ray was normal, and to stop taking the antibiotics.

The consumer said the experience had traumatised her, and despite being a retired registered nurse she found it difficult to complain, but did not want anyone else to suffer a similar experience. 

With the support of an advocate she detailed her concerns in a letter and requested a meeting with the advocate for support. The provider apologised that her experience had not been a good one, as this was not the way they wanted people to experience the ED.  They agreed that it was not appropriate that she was sent home. The provider sought agreement to discuss the issue with staff in ED at their next meeting.

The provider confirmed that the Volunteers Service had now been extended to the ED to ensure that people who come in alone have someone to assist them.

The consumer was extremely pleased with the way the provider dealt with her complaint. 

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The shock of a very sudden death

A woman was admitted to the emergency department with severe respiratory problems. She was put on oxygen immediately and admitted to the ward the next morning. A cardiologist assessed her condition and advised staff to take further tests in order to assess her capability of using oxygen when discharged home. The cardiologist discussed resuscitation with her and  she agreed for him to sign the 'not for resuscitation' (NFR) form on her behalf.

The woman's daughter arrived after the assessment, and said that while her mother was on oxygen she was calm and stable in bed for a couple of hours. Staff arrived to begin the tests and her mother became agitated when her oxygen was removed, saying she could not breathe. She collapsed and resuscitation attempts began, until it was realised that she was NFR. As soon as resuscitation efforts ceased she passed away. 

The daughter was shocked at the suddenness of mother's her death and made a complaint about the incident. With advocacy support she met with providers on three different occasions to resolve the complaint.

She was not satisfied with their responses so the advocate assisted her to send a complaint to the Commissioner.

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Poor care in an emergency department

Emergency Department ~ Rights 1, 4, & 5 ~ Respect ~ Standard of care ~ Communication ~ Stroke

A consumer contacted the advocacy service after making a complaint with the local DHB. She was unhappy about the way she was treated when she had a stroke as a result of a rare syndrome. Her father had died from the same condition some years earlier. The consumer was aware of the symptoms and had been advised to seek urgent medical attention if she developed any.

Although she was vomiting when she arrived at the emergency department (ED) no one offered her a bowl, nor was she offered anything to clean herself up with. She was barely able to focus, had tingling on the right side of her face and various other symptoms including dizziness. She was initially diagnosed with an inner ear infection by the ED doctor, but knew something was seriously wrong. When seen by the consultant the following day, he identified she had suffered a stroke.

The consumer felt a lack of respect and little compassion from the ED nurses who were not very pleasant to her. They did not appear to take her seriously and failed to provide her with an appropriate standard of care. In addition, communication was inadequate as neither the doctor nor the nurses listened to her. She also felt that the actions documented by the nurses were not an accurate reflection of her experience, and that they did not spend the time with her that was indicated in the notes.

She wanted to meet with the ED doctor and the nurses involved in her care to receive an explanation and an apology from them. The advocate was asked to be present to support her.

The consumer talked about her concerns about the nursing care and that the nurses were not as compassionate and helpful as they could have been. She also asked whether the initial diagnosis of an inner ear infection had affected their attitude.

The ED doctor who had made the initial diagnosis apologised and explained why he believed she had an inner ear infection at the time she presented at ED. The head of the ED also apologised and the nurse manager agreed that the documentation by the nurses did not fully reflect the consumer's experience.

As part of the resolution the consumer was asked if she would agree to speak at future ED training sessions so her experience could be used to improve the service. She agreed to this and said she was pleased at such a positive gesture being made by DHB staff.

After the meeting, the consumer said she was satisfied with the outcome of the meeting. She went on to say the support of an advocate had helped her immensely and had given her the confidence to face the providers at the meeting.

DHB ~ Emergency Dept ~ Right 4(3) ~ Services consistent with needs ~ Right 5 ~ Effective communication