Page Section: Centre Content Column
Public hospital services
Persistent
infection
The shock
of a very sudden death
Young
person needing information
Failed tubal
ligation
Discharged early
from ED
A traumatic
birth experience
Keeping families
informed
Reporting
concerns about discourteous treatment
Confusion
over administration of medication
Getting
information about ED visits
Respectful
communication
Concerns regarding missed
swab
Claiming ACC
following surgery
Respect for
patient in hospital
Results of
thyroid surgery
Explanation for
cancelled surgery
Maintaining effective
communication
Getting things to
work from a distance
Coping with
fear
Keeping children
safe
A consumer solution
Left uninformed
Proactive
provider
Respect and
mental health issues
A
strong woman feels vulnerable
Dealing
with a sensitive situation
When fear
immobilises
Change in dialysis
regime
Appropriate
treatment for haemorrhoids
Misdiagnosis at
emergency department
Assistance
with questions prior to specialist
appointment
Communication
with the family of a terminally ill man
Vision impairment
following surgery
Information regarding follow-up
care
Care following an
operation
Appropriate standards in the radiology
department
A problem following an
operation
When it is
important to have care provided by a particular
gender
Young person needing
information
Difficulty
inserting luer prior to CT scan
The value of face-to-face
meetings
Plastic surgery by a
general surgeon
Access to pregnancy testing
services
Disappointing Accident
and Emergency care
A consumer
solution
Sorting
out an incorrect clinical record
Learning
from a mistake
Persistent Infection
A middle-aged man had a very serious fall with various injuries.
In the course of treatment at the hospital he picked up two serious
infections in one foot, which meant that 18 months later he
required a district nurse to dress the infected foot every second
day.
He had to give up his successful physical career as he couldn't
put weight on the leg or wear a shoe. He became socially isolated
as he felt he had to live alone for fear of spreading the
infection.
He was determined to have the leg amputated due to the distress
of the persistent infections. This outcome was not supported
by medical staff. ACC was working with him and he was
receiving psychological support but he was very low in mood
and desperate for the hospital to amputate.
He contacted his local advocacy service and the advocate worked
with him, ACC, his psychologist and staff at two hospitals to
eventually secure the outcome he wanted.
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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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Young person needing
information
A 14-year-old high school student, boarding away from home, was
diagnosed with a condition that she was told required urgent
surgery.
She contacted the local advocate about a lack of information
about her condition and when the surgery was to take place.
Following discussion with the advocate the consumer wrote to the
surgeon outlining her concerns, including not fully understanding
the condition or its seriousness. She received a response from the
surgeon but unfortunately the response did not provide the
information she needed or answer her questions.
After further discussion with the advocate the consumer decided
to complain to the hospital, enclosing copies of the letter to the
surgeon and the surgeon's reply.
The next day the manager of the service contacted the student
and arranged for the surgery to be performed by another surgical
team straight away.
Following the successful surgery and her recovery the consumer
visited the advocate to say the support and options provided by the
advocate had helped her to decide on actions she felt comfortable
with and that they had ended with a great result.
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Failed tubal
ligation
A woman had had a tubal ligation procedure, and following a move
overseas discovered she was pregnant. The couple made a decision to
go through with the pregnancy but they had many questions including
the effect the failed procedure could have on the pregnancy.
The couple returned New Zealand for a family wedding and
contacted advocacy. As they were only in NZ for a few days,
and the surgeon was on leave, they met with the clinical director
of the hospital with the advocate for support. The surgeon
concerned had emailed a letter to the couple a day before the
meeting. The clinical director was very understanding of
their situation and had information ready. Many of their questions
were answered with an understanding that the remaining questions
would be answered in a comprehensive letter to the couple when they
returned home.
Although the couple would have preferred a face-to-face meeting
with the surgeon, they appreciated advocacy support to be able to
tell their story and ask questions, and felt they had been
heard.
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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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A traumatic birth
experience
A woman underwent a caesarian section, and the attending
obstetrician sought and obtained the consumer's permission for
students to attend the birth. During the birthing process the
obstetrician was engaged in a commentary to the students, although
the woman did not recall the content of this. At one point,
however, a cell phone rang and the obstetrician answered it, with a
nurse holding the phone to his ear. A joke was made to the
effect that his 'banker' was on the phone.
Within minutes of being taken to a nearby recovery area, she was
advised that she may have had a surgical swab left inside
her. A bedside x-ray confirmed that this was the case and she
was taken back to theatre to have it removed.
Over the next four days she received visits from apologetic
staff and the obstetrician who assured her that an investigation
had been done to make sure that what happened would not happen
again. Upon her return home, she made a complaint and was assured
that she would be advised of the outcome of the investigation, and
that this process should take a couple of weeks. After five
weeks, having heard nothing, she contacted a local advocate. By
this time, an infection of the wound had developed, requiring
antibiotics.
In discussing her complaint with the advocate, the woman
reported being extremely traumatised by the whole experience, and
thought that she may never be able to expose herself to giving
birth again. She wrote another letter to the provider asking for a
response to each of the following:
- a review of swab count procedures,
- concern that the presence of students may have led to
carelessness,
- the laid-back, jokey atmosphere in the theatre,
- a more disciplined protocol regarding the use of cell phones in
theatre,
- consumers to be advised of the Code of Rights and of the
availability of advocacy assistance,
- where an event of this nature occurs there should be an
offer of counselling, and
- the length of time it took to deal with the complaint.
All these matters were acknowledged by the provider and
appropriate apologies were given. She felt the changes to theatre
protocols that were implemented were appropriate, and she was
offered counselling.
She was pleased to have received information from the advocate
that allowed her to self advocate and knew the advocate was
available for support throughout the
process.
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Keeping families
informed
An advocate was contacted by the wife of a man who had died in
hospital. She and her family had been unaware of the seriousness of
his condition and had not been advised of his diagnosis or
treatment.
After discussing options with the advocate, the family wrote to
the provider outlining their concerns. They received a written
response, and decided they would like to meet with staff from the
DHB with the advocate for support.
At the meeting the family raised their concerns and advised that
in addition to the answers they sought, wanted the hospital to
review their protocols in regard to keeping families informed. The
DHB staff responded to the family's concerns and apologised for the
lack of communication, which the family accepted.
The DHB staff also agreed to look at the protocols for
communicating with families, bearing in mind the need to respect
privacy, and if any changes were made, said they would inform the
family. The family was happy with the outcome of the meeting.
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Reporting
concerns about discourteous treatment
A consumer contacted an advocate expressing concern about a male
nurse who had cared for him during a recent hospital admission. He
required medication to stop tremors, and the timing of this is
important. When he relayed this to the nurse it was clear from his
abrupt and response that the nurse was not going to accommodate
this timing requirement. The same nurse left him unsupervised in
the shower despite the consumer being shaky on his feet, ignored
his concerns about swollen and sore heels, and was discourteous and
off-hand with his comments when the consumer requested a wheelchair
to get to the carpark when he was being discharged.
The consumer felt the hospital needed to be made aware of this
nurse's attitude as he was concerned that other elderly and sick
people would be treated similarly. After hearing about the Advocacy
Service, the man and his wife drafted a letter to the DHB and asked
the advocate to look it over prior to it being sent.
The consumer was pleased to receive a response from the DHB
advising that the nurse was a 'bureau' nurse and no longer worked
at the hospital. The consumer's concerns had also been passed on to
his employer.
The consumer was pleased to have the opportunity to discuss his
concerns and the process of his complaint with the advocate.
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Confusion
over administration of medication
A woman was in hospital being treated with IV antibiotics. Her
daughter noted on one of her visits that the IV was disconnected,
and when she returned the next day it was still not connected. Upon
questioning the staff, the daughter was told there had been a
change made to the administration of the antibiotics and as there
was confusion about the charting of the medication it had not been
given. When the woman transferred to another ward she did not
receive her heart medication as there was confusion about the way
this had been charted.
The woman and her daughter sent letters to both wards asking
about the confusion over medications, seeking an apology. When no
response was received, they asked an advocate to follow up.
The provider was unable to find any record of the complaints and
requested a copy be re-sent. The provider advised they would
undertake a full investigation and provide a written response that
would be followed with a meeting with the consumer, her daughter
and the advocate.
They wrote with the outcome of their investigation and offered a
meeting. Upon receipt of the provider's letter the consumer advised
she and her daughter were happy with the apology and the
information provided and did not require a meeting.
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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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Respectful
communication
A mother contacted an advocate to discuss her concerns about her
10-year-old child's treatment by a staff member of the
Ophthalmology Department. She explained that a technician had told
her there was nothing more they could do to correct her child's
double vision. She sought a second opinion which confirmed the
double vision, but when they returned to the Ophthalmology
Department the technician did not treat them respectfully.
The mother was reluctant to complain as she thought a complaint
may affect ongoing care, but was so upset by her experience she
said she needed to do something. After discussion with the advocate
she decided to pursue her concerns by writing a letter, which she
was assisted with as English is not her first language. She asked
for an apology from the technician and asked that other people
would not have the same experience.
Apologies were received from both the technician and the
customer services manager and the complainant and her son put the
incident behind them.
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Concerns
following missed swab
The consumer contacted advocacy for assistance as English is her
second language and she needed help with writing a letter to the
DHB. She said that four days after the birth of her child, five
months earlier, she had passed a swab when passing urine. The
midwife sighted the swab and documented the incident in the
consumer's obstetric notes and said she would speak with the
doctors who had been present at the birth. The midwife later
advised the doctors had apologised.
The consumer told the advocate she was still experiencing
abdominal pain and abnormal symptoms and was very scared that there
was possibly another swab inside her. She decided to write a letter
with advocacy assistance. In her letter she expressed her concern
and requested a scan to ensure that all of the swabs had been
removed.
Shortly after sending her letter she received an appointment for
the scan and was very relieved to be told there was no evidence of
any other swabs. The hospital wrote an apology and gave a written
assurance that they had changed their policy and procedure
regarding the removal of swabs. The consumer is now in good health
and she and the baby are doing well. She was pleased to have had
the support of the advocate when addressing her concerns.
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Claiming ACC following
surgery
The wife of an elderly man came to the Advocacy Service seeking
assistance to resolve a complaint with the hospital. Her husband
had undergone a simple surgical procedure to repair a hernia. While
in recovery he vomited, there was a delay in aspirating him, and he
was subsequently found to have some brain damage.
The man experienced ongoing effects of the incident, so the
advocate assisted the woman to prepare an ACC Claim but hospital
medical staff declined to sign the form. Eventually a locum GP
agreed to sign the form so the consumer would get a hearing from
the ACC. The claim was accepted as the wrong type of tube had
been used to keep the airways clear in case of the patient
vomiting.
The couple are bright and positive about the future and are
appreciative of the help given by the advocate.
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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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Results of thyroid
surgery
A woman had a lump on her throat removed by a specialist. He
advised her that he would remove the thyroid only if it was
cancerous, but after the surgery informed her that even though
there was no cancer present he had removed her thyroid and that it
would never grow again.
The woman was concerned that she was not told about the side
effects of the removal of her thyroid, which includes a change in
the voice. Since the operation she had been unable to sing,
which she had previously enjoyed.
She had tried to address her concerns directly, but felt that
the specialist did not listen to her. With the assistance of
an advocate, the client was able to formulate a letter to the
outlining her issues and desired outcomes. As a result of this a
meeting took place between the parties, facilitated by the
advocate. The specialist provided answers to the queries she had in
regard to the risks, and agreed to pay for a voice therapist in the
private sector. She also received reimbursement for her follow-up
visits to the clinic.
She was very satisfied with these outcomes.
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Explanation for
cancelled surgery
A woman in her late eighties contacted advocacy as she had
received a phone call advising her surgery had been postponed, a
couple of hours before she was due to go in to hospital. She had
asked the hospital why her operation was cancelled and how long she
might have to wait for another appointment but these questions were
not answered. The woman felt that the surgery had been cancelled on
the basis of her age and that she was not being given the same care
and treatment as others.
The woman asked the advocate to contact the provider for the
information for her. The hospital said that an internal
investigation would be carried out and they would contact the woman
to let her know the outcome.
It was found that the short notice was due to the doctor being
sick and the woman should have been advised of this. She was
contacted and received an apology along with a new date for the
surgery, and was very happy that the advocate had been able to
assist her to get answers in a timely way.
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Maintaining
effective communication
A woman with learning difficulties, whose youngest child was in
remission from cancer expressed concern that the relationship
between her and the nurse co-ordinator heading the hospital team
had deteriorated to an extent that she thought her child's care was
being compromised. She sought assistance to resolve her concerns as
she recognised that it was imperative to have a good relationship
with the hospital team caring for her child.
A meeting was arranged between the parties with the advocate
supporting the woman. The woman expressed her concerns about the
communication breakdown.
The provider acknowledged that they were aware of the mother's
own learning difficulties but had not taken account of this when
communicating with her about the care of her child. They offered
her additional support. Following the meeting, the woman felt
that the relationship had been sufficiently repaired that the care
of her child would not be compromised.
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Getting things
to work from a distance
An elderly woman, who usually lived in a rest home, was in
hospital as her health had rapidly deteriorated following a
fall. Her daughter felt that she was being well looked after
but that the communication between the hospital and herself was
poor. She was not able to visit her mother every day because
of the distance and she found that she didn't get clear messages
about her mother's progress and treatment when she contacted the
hospital by phone.
She asked the advocate to contact customer services at the
hospital to raise her concerns. The hospital contacted the daughter
later that day. The daughter reported that she now knew how best to
get information about her mother, and was very happy with this
outcome.
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Coping with fear
A young woman was admitted to hospital to undergo tests to
determine the cause of the severe pain she was experiencing. The
results of the tests were inconclusive and the hospital was going
to discharge her but she was extremely frightened about returning
home not knowing what was happening to her. She felt there had been
poor communication by some hospital staff.
After discussion with the advocate the consumer decided she
would be discharged. She felt able to advocate on her own behalf to
pursue her complaint about the staff communication at a later
stage.
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Keeping children
safe
The mother of a two-year-old boy was referred to the local
advocacy service by the team leader of the children's ward at a
local hospital. The child had been admitted to hospital overnight,
and slept in a hospital bed with his mother in another bed
alongside. He fell out of bed during the night, suffering an injury
to his face and lip and damaging a tooth. The mother felt that she
should have been offered cot sides for her son's bed and that the
nurses should not have assumed the child was safe without these.
The mother was also upset at the attitude of the nurse following
the incident and unhappy at the way the child's father was treated
when he arrived at the hospital after hours.
The team leader met with the family following the incident to
apologise and had thought the matter resolved. She later heard that
the family was still unhappy and referred them to an advocate.
The advocate suggested the mother write to the provider
outlining her issues in detail as well as her desired outcomes, and
consider a face-to-face meeting. The manager of the service sought
advice from the advocate about how to respond to the complaint. The
advocate suggested that she offer to meet with the complainant and
her family to try to resolve the issues.
Subsequently, the manager advised the advocate she had met with
the family and the issues were resolved. A follow-up letter to the
family was sent apologising for the incident and providing
information about a new policy that had been implemented to ensure
that all children under the age of three years have beds with
fitted rails.
The mother advised she was happy with the outcomes achieved.
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A consumer solution
A woman sought the help of advocacy services after she was
misdiagnosed with a breast lump which resulted in a total
mastectomy. A meeting was arranged with the staff of the DHB so the
woman could tell her story and discuss her concerns. The DHB staff
present told her that they were very sorry this had happened and
wanted to know what they could do to make it better.
The woman asked the DHB to pay for her husband to travel with
her, and for him to be accommodated in a motel when she went to
another region for a breast reconstruction. As she had no relatives
living close by, she also wanted a family member flown from another
part of the country to look after their two children. When the
woman was well enough to return home she wanted home help provided
and for these costs to also be met by the DHB. This was agreed to
and was provided as planned. The woman recovered from her
reconstruction surgery and was able to return to work.
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Left
uninformed
A woman was referred by her GP to a specialist and received an
appointment for her assessment. A few days prior to her
appointment she received a phone call to say that her appointment
had been cancelled and that a new time would be sent to her in the
mail.
Weeks passed and she heard nothing, apart from rumours and
occasional newspaper reports about "trouble at the hospital".
Her health continued to deteriorate and she returned to her GP who
suggested she contact an advocate.
She contacted the local advocate and having discussed the
options made direct contact with the clinic. She was told that the
specialist was not currently holding clinics due to some internal
staffing issues. She was also told that if she needed to see
someone urgently she would need a new referral from her GP to see
someone outside the area.
The woman wanted to know why no one had contacted her to let her
know about the situation as they had her contact details and she
was expecting to hear from them. As a result of her comments, the
service immediately advised others in the same position so they
were informed of the situation and the options for assessment and
treatment elsewhere.
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Proactive
Provider
A consumer received a call from a specialist whom he had seen
over a year previous. The doctor asked to meet with him and his
wife to discuss the results of an x-ray taken while under his care.
The doctor suggested they may like to make contact with the local
advocate who could support them at the meeting. The consumer acted
on the doctor's suggestion and contacted the advocate. At that
stage the consumer was unsure of the purpose of the meeting.
At the meeting the doctor explained that the pre-operative x-ray
report, from a year ago, had recorded an abnormality and
recommended a CT scan which had not been followed up. The doctor
had learned of the error as a result of the consumer requiring
another x-ray and radiology personnel reviewing the original
report. He accepted responsibility, as the consultant surgeon, for
the failure to follow up on the original recommendation. He
explained he had called the meeting to offer an apology and
determine what support he could offer the consumer. The doctor
offered to fill out an ACC form with a supporting report and was
prepared to assist the consumer to take his complaint to the Health
and Disability Commissioner if he chose to. The parties agreed to
meet again in a week after the couple had had time to reflect on
the situation. In the meantime the doctor would forward his report
to them.
Prior to the second meeting the couple met with the advocate to
clarify the issues and discuss their expectations.
At the second meeting the doctor agreed to complete the ACC
form. If the consumer required further treatment he agreed to make
every attempt to expedite such treatment including assisting with
any travel costs if treatment was provided outside of the area. He
also gave an assurance that the system for checking results would
be reviewed.
The couple chose not to take their complaint to the Commissioner
as they were happy with the outcome of the meeting. The advocate
had assisted them to have their personal needs meet as well as
instigating a systemic change to prevent others from suffering a
similar fate.
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Respect and mental
health issues
An advocate was contacted by a friend of a consumer who was
receiving treatment at the local hospital for fractures after
falling from a building. The friend had concerns about her care in
the orthopaedic ward and was keen for the advocate to visit the
consumer.
When the advocate arrived at the ward she was told the consumer
was being specialled because of behavioural problems. The staff
nurse said that the consumer was "subnormal" and that when she
misbehaved they made her lie on a mattress on the floor. The nurse
then looked at his watch, said that her punishment time was over
and the advocate could go and see her. When the advocate commented
that the consumer was not being treated with much respect she was
told by the staff nurse "She doesn't treat us with much
respect".
After spending some time talking with the consumer it was clear
she would prefer to be in the familiar surroundings of the
psychiatric ward, where she had previously been an inpatient.
A review of the consumer's care was undertaken with input from
mental health services. As the appropriate clinical support for her
orthopaedic injuries would not be available in a psychiatric ward,
the consumer accepted that the best place for her was the
orthopedic ward with changes to her management plan.
She was also happy that there would be education provided to
staff on the orthopaedic ward on mental illness and managing
challenging behaviour.
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A strong woman feels
vulnerable
The daughter of a deceased consumer contacted an advocate as she
felt her mother had not received adequate pain relief during her
final days. Although she had already written to the hospital she
found their response disappointing.
After discussing the situation with the advocate, she decided to
write another letter to the hospital with some specific questions
she wanted answers to. The most important question was how, as a
family, could they have communicated more effectively with the
oncologist and helped their Mum communicate with him more
effectively regarding her needs and the knowledge of her
approaching death.
In her letter the daughter requested a meeting with the
oncologist as she felt the unanswered questions were impacting on
her work as a nurse. She said that if a meeting was agreed to she
would be bringing the local advocate for support.
The oncologist agreed to meet and was very receptive to
concerns. She felt his responses to her were open and honest. She
was also pleased to hear that he would use this situation as a
learning experience with other members of his team.
She found the advocacy support very helpful as although she is
usually an empowered person this very personal situation and the
initial response from the hospital had left her feeling
disempowered and vulnerable.
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Dealing with a
sensitive situation
A middle-aged man contacted the advocacy service concerned that
he was being discriminated against for disclosing previous
lifestyle issues to a pain specialist. The man had corresponded
extensively with the specialist, having researched medication
options on the internet, and was unhappy with verbal and written
interactions with the specialist.
He compiled an agenda, with the advocate's assistance, which was
emailed to the specialist for the forthcoming appointment, noting
that the advocate would be attending in support. The meeting was
very beneficial although it was at times challenging and
emotional.
However, the specialist stayed for over two hours and agreed to
trial a course of action, requiring him to set up supports because
of the nature of the man's work. The trial proved to be a total
success to the delight of the man and his partner, and the surprise
and delight of the specialist.
The specialist subsequently emailed the advocate to thank her
for her valuable role in securing this outcome.
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When fear
immobilises
A man with a needle phobia contacted advocacy after he attended
a pre-anaesthetic clinic where the specialist nurse and
anaesthetist did not take his phobia seriously, even though the DHB
had been advised of the phobia by his GP. They tried to joke and
jolly him through the appointment, and insisted he watch a video on
anaesthetics saying it would be beneficial for him. He was
traumatised by the pre-anaesthetic procedure.
This experience left the consumer in extreme distress and unable
to go ahead and have the scheduled operation two days later.
As he was so traumatised, he asked the advocate to contact the
DHB and raise his complaint. The DHB wrote a letter of apology but
the man did not think this fully addressed his problem, so he wrote
another letter to his consultant and the manager of surgical
services reiterating his concerns.
This resulted in a very positive and professional
pre-anaesthetic appointment and his operation was scheduled for the
following week. The man was very pleased with the outcome and
thanked the Advocacy service for their assistance.
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Change in dialysis
regime
For four years I had been on dialysis for four years. I got
there because I have arteriosclerosis (blocking of the arteries by
plaque). The first, dramatic, intimations I had the disease was
when I sustained a heart attack sixteen years ago. Blocked arteries
do not, of course, unblock - indeed they get worse and there came a
time when the arteries to my kidneys got bunged up, stopping the
blood flow, thus rendering my kidneys ineffective. Hence
dialysis.
All had been going well for those four years. Apart from the tie
of having to go to the hospital three afternoons a week (I'm not a
suitable case for home dialysis) I was doing well for a 74 year
old. My particular pleasure was to walk for an hour by the sea
every day - weather permitting.
Then, without warning or explanation, things changed. My
dialysis requires the insertion of a needle into the arm (quite
painless) to allow the blood to flow through the machine. I had
been on a gauge 14 needle but it was changed to a narrower gauge
15. This meant that the four hours I was accustomed to being hooked
up was not long enough to effect a good dialysis. I found myself
puffing and getting sore legs when I was walking. I could have
opted to be on the machine longer - but four hours is quite long
enough!
I also needed extra iron from time to time and this was done
once a fortnight, intravenously, while I was dialyzing. No problem.
Then the consultant physician ordered this practice to be stopped
(long term effect, I was later informed. Long term? When I was
74?).
My efforts through the hospital management to get my former,
perfectly satisfactory to me, treatment regime explained to me and
reinstated were unsuccessful. In desperation I sought the help of
my local advocate.
I am glad to say that her efforts to assist me were successful
and my former treatment was resumed. I am now feeling much better.
And enjoying those seaside walks once more!
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Appropriate
treatment for haemorrhoids
A young man contacted advocacy stating that he was desperate for
surgery as he was on the waiting list for ruptured haemorrhoids. At
a previous consultation with his hospital specialist he was given
the options of surgery or banding. He chose the second option but
when the bands came off he was advised by the medical staff on duty
that they were to busy to attend to him and he would have to come
back to have the procedure re-done.
The pain became unbearable he was unable to walk, and was taken
to the local emergency department by ambulance. On his arrival the
bleeding had stopped so he was given medication and discharged. In
total he went on five occasions and each time he was discharged
without any further procedures being carried out.
After discussing the advocacy process the man asked that the
advocate support him to meet with his GP to clarify what steps had
been taken to get appropriate treatment for him. Having heard what
the GP had done it was agreed that a letter should to the local
hospital with a cover letter from the GP. The man advised he had
received treatment. He was very pleased with the support advocacy
had provided as prior to their involvement he had been attempting
to get treatment for ten months.
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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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Assistance with
questions prior to specialist appointment
Following chemotherapy and radiation on a nasal tumour, a man
was advised surgery could not be performed for three months while
the swelling subsided. The swelling had not gone down after three
months and the consumer was unsure of what was to happen next, and
contacted advocacy for support. He advised that he had an
appointment later in the week for a CT scan, and an appointment
with a specialist.
The advocate spoke to the consumer about his rights under the
Code, and the support an advocate could provide. She assisted him
to document his questions. The man said he would take his family to
his appointment and that he felt confident to ask his
questions.
Following the appointment, he advised the advocate that the
specialist had provided explanations, answered his questions and
discussed his ongoing treatment plan. He felt that his discussion
with the advocate prior to the appointment had assisted him to feel
empowered enough to get the information he needed.
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Communication with the
family of a terminally ill man
The family of a terminally ill man had requested that nursing
staff advise them immediately if his condition deteriorated, as
they wanted to be with him at his time of death. At 8.10am the
family were notified and returned to the hospital, and their father
died at 9am. The family were disappointed to later learn that their
farther had started to deteriorate at 5.30am and they had not been
notified.
They sought advocacy support to raise this issue with the
provider.
The provider agreed to meet with them to discuss the issue. An
advocate attended to provide support. The provider acknowledged
that the situation could have been managed differently, apologised
and agreed to review processes and procedures around communicating
with families in this type of situation.
The family was satisfied that their concerns had been heard and
that the provider had shown a willingness to look at how they could
prevent a similar situation occurring.
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Vision impairment following
surgery
The man was contacted by a hospital nurse who told him to stop
taking his blood thinning medication two days prior to his planned
surgery. On admission, the same nurse told him she had been
incorrect and he should not have stopped his medication.
After the operation, he noticed his vision had become impaired,
and thought this may have been the result of a blood clot
travelling from his leg. After discussing his concerns with an
advocate, he wrote asking why he had been instructed to stop taking
his medication and why, when the error was discovered, he was not
contacted and told to recommence the tablets. He wanted an apology
and to know what action would be taken to avoid something similar
happening in the future.
The man decided he would like to meet with the provider, with
the advocate's support. The nurse was there and offered an apology.
A doctor was also present and advised that stopping the medication
such a short time before surgery was unlikely to have caused a
clot, that the clot behind the eye was not a result of the
surgery.
At the conclusion of the meeting the consumer said he had
received the information he required and was pleased to have
received an apology.
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Information
regarding follow-up care
A consumer was discharged from hospital feeling very unwell and
in a great deal of pain. She contacted her GP and was referred back
to hospital where it was discovered that as a result of the surgery
she had urinary leakage requiring the insertion of a urinary
catheter. The consumer felt that she was being given different
information by each doctor she saw, and there was no clear plan for
her care and treatment. Surgery had been presented as the best
option. The family's private health insurance would not cover the
proposed surgery and the consumer was becoming desperate as her
health issues were affecting her ability to care for her young
family.
The consumer requested an urgent meeting with the DHB, with
advocacy support. The provider was made aware of the issues and
desired outcome prior to the meeting and so was fully prepared when
the meeting occurred. At the meeting the provider advised the
consumer that her health concerns were a result of a treatment
injury. An ACC form would be completed by the provider and surgery
would be organised.
The provider was able to provide full information and
explanations about what had occurred, and the proposed surgery, and
the consumer left the meeting feeling happy that she had the
information she required.
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Care following an
operation
A consumer sought the assistance of an advocate as he had
ongoing pain following an operation. He had raised the issue of the
pain with the orthopaedic consultant when attending follow-up
appointments and had been referred for physiotherapy, but continued
to experience pain.
After discussions about advocacy process the consumer elected
to, with advocacy support, write to the provider outlining his
questions and seeking a meeting to discuss his concerns.
At the meeting the provider explained all the options that had
been available at the time of the consumer's admission and why that
particular treatment option had been chosen. He outlined the
expected time for healing and was offered options for medication
which could ease the pain while he continued with his
rehabilitation.
Following the meeting the consumer felt that he had received
answers to all his questions and that he considered the matter
resolved.
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Appropriate standards in the radiology
department
A consumer had a chest x-ray at her local hospital. The report
was sent to her GP who recommended urgent biopsies of her lungs. As
the waiting list was two weeks, she requested a referral to a
specialist. The specialist advised her of the prognosis, and she
and her family began organising for terminal care.
Ten days later, the specialist reviewed her x-ray and discovered
her lungs were clear. It transpired that the results were those of
a person with a similar name who also received care from the same
GP. The consumer wanted to know why the provider had not checked
the x-ray report against the x-ray, NHI number and other
identifiers, and wanted the provider to understand how this mistake
had affected her and her family. She wanted to be reimbursed for
the cost of the specialist consultation.
With the assistance of an advocate, a meeting was set up with
the specialist, radiologist and the clinical director of medicine.
The consumer and her family were able to talk about the impact this
mistake had had on the family. The doctor apologised and explained
that a digit had been entered incorrectly into the computer. The
hospital was in the process of having a new computer system
installed and the doctor believed the new system would prevent this
type of error occurring again. The DHB agreed to pay the cost of
the specialist consultation if ACC did not accept a claim.
The consumer was pleased to have had the opportunity to meet and
hear this explanation.
A problem
following an operation
A consumer complained to an advocate that when in hospital for
surgery an epidural was administered with both arms above his head.
He believes they remained there throughout the operation leaving
him with limited sensation - paralysis in one arm and partial
mobility in the other arm. He was unable to hold anything with the
paralysed hand and required assistance with eating and dressing. He
was previously self employed and was no longer able to do his
job.
His complaint highlighted the following issues:
- He was not told what caused this problem and the clinical
people involved in his care did not respond to his requests for
information.
- He was advised he did not fit the criteria for home support yet
he required help with activities of daily living.
- He needed information to lodge an ACC claim for personal
injury.
After considering the options, the consumer decided the best way
to progress the matter was to use advocacy assistance to write to
the Complaint Manager at the hospital. In his letter the consumer
suggested he would like to meet if the written information he was
requesting was not forthcoming. He also wanted a copy of his
medical records to see what had happened.
He was very pleased to receive all the information he required
including the claim form for ACC so a meeting wasn't necessary.
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Knowledge of
rights leads to self-advocacy
DHB ~ Public hospital ~ Surgical ~ Oncology ~ Rights 5, 6
and 7
A 60-year-old consumer diagnosed with
cancer contacted advocacy for advice as he felt his surgeon was not
listening to what he really wanted. The consumer wanted to delay
his surgery for two years but the surgeon was in favour of
immediate surgical treatment. He was frustrated that the surgeon
was always talking about what was clinically best rather than
listening to what he wanted, and his reasons for postponing the
surgery.
The advocate advised the consumer of his right to be listened to
as well as his right to full information on treatment options and
to make his own choices. The advocate also informed him about his
right to have a support person present.
The consumer contacted the advocate after meeting with the
surgeon to say he was very happy with the outcome. The surgeon
finally understood his needs and arranged for him to see a
specialist to discuss non-surgical treatment options while delaying
his surgery.
He said that knowing his rights had helped him during the
consultation with the surgeon and he now felt better prepared for
future consultations with medical specialists.
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Complainant seeks apology
after Coroner's findings
A woman sought advocacy support to write to a district health
board. She wanted both an apology and an assurance that the
Coroner's findings in respect of her husband's death would lead to
changes in procedures to prevent a similar incident in the
future.
The complainant was happy with the district health board's
response, which included an explanation of what had happened, what
was being changed and an apology.
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When it is important to have
care provided by a particular gender
A man complained to the advocacy service about the way he was
treated when he was admitted into hospital for a sensitive
procedure. In particular his complaint was that he was not treated
with respect by female nursing staff; and that his request for a
male nurse was ignored and minimised. As a result of this
experience; he asked to work with a male advocate and to only meet
with male staff from the hospital.
With the support of a male advocate, the consumer met with
senior management staff from the hospital to discuss the concerns
about his experience, in particular the behaviour and attitude of
female nursing staff. He was able to articulate his concerns
clearly; and requested changes to procedures to ensure that a
patient's need for respect and privacy were met; and that requests
for gender-appropriate staff could be met wherever possible.
He was satisfied with the sincere apologies given by the
hospital staff; and their plan to review procedures.
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Young
person needing information
Student ~ Fully informed ~ Effective communication ~ Surgeon
~ Hospital
A 14-year-old high school student, boarding away from home, was
diagnosed with a condition that she was told required urgent
surgery. She contacted the local advocate as she felt she didn't
have enough information about her situation. She also wanted to
know when the surgery was scheduled to take place.
Following discussion with the advocate the consumer wrote to the
surgeon outlining her concerns, including not fully understanding
the condition or its seriousness. She received a response from the
surgeon but unfortunately the response did not answer her questions
or provide the information she needed.
After further discussion with the advocate the consumer decided
to complain to the hospital, enclosing copies of the letter to the
surgeon and the surgeon's reply.
The next day the manager of the service contacted the student
and arranged for the surgery to be performed by another surgical
team straight away.
Following the successful surgery and her recovery the consumer
visited the advocate to say the support and options provided by the
advocate had helped her to decide on actions she felt comfortable
with and that they had ended with a great result.
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Difficulty inserting luer prior to CT
scan
Public hospital ~ Radiology department ~ CT scan ~ Effective
communication ~ Anaesthetist
A consumer advised the nurse before her CT scan that from past
experience she anticipated difficulty with inserting a luer in her
arm. She was assured the anaesthetist was very skilled. However, it
took a painful forty minutes to insert the luer and the doctor was
still holding it in place until the final second before the
consumer entered the machine.
The consumer said that seconds into the scan she was in a lot of
pain and her arm swelled alarmingly. The attending nurses seemed to
panic, not knowing what to do, and this further alarmed the
consumer. Two doctors were called in and checked what had been
done, but seemed uninterested. They did not explain what was
causing the pain and said everything seemed to be ok.
The consumer sought advocacy support to make her complaint to
the hospital. After discussion with the advocate she chose to have
assistance with writing a letter of complaint. She was keen for the
radiology department to look into their procedures for dealing with
patients who anticipate problems.
The consumer was very satisfied with the response from the
hospital. She said:
"I feel that they treated the matter with the right amount
of seriousness, they addressed all the issues that I mentioned and
promised to have the right tools to cope with a similar event
happening again … I feel I can put it all behind me."
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The value
of face-to-face meetings
A consumer contacted her local advocate after a disappointing
response to her complaint from a hospital. Despite receiving a
twelve-page response, the key points of her complaint were not
addressed and the letter contained conflicting information. After
discussing the options, the consumer decided she wanted advocacy
support to meet with the provider.
The advocate assisted the consumer to clarify the issues that
had not been addressed in the provider's letter as well as the
additional issues arising from the response. The advocate then
assisted her to write to the provider with an outline of the issues
to be discussed at a meeting with the advocate to support her.
At the meeting the consumer was able to discuss her concerns. As
the provider had been given information in advance of the issues to
be discussed and what would resolve the matter, they were able to
respond in a positive way. This included coming prepared with a
written response which they were able to discuss with the consumer
and which she was able to take away at the end of the meeting. When
the advocate and consumer debriefed following the meeting, the
consumer said she was delighted with the result.
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Plastic surgery by a general
surgeon
Historical complaint ~ Media ~ Resolution meeting ~ Being
heard ~ Paediatric plastic surgery ~ General surgeon
A consumer sought the assistance of her local advocate to deal
with unresolved issues relating to plastic surgery performed on her
as a child approximately 50 years ago. After discussing the options
the consumer decided she wanted to meet with representatives of the
organisation where the surgery had been performed. The advocate
assisted her to write and send a letter requesting a meeting. In
their response, the provider organisation declined to meet as the
medical records from the time had been destroyed by fire.
Following this response, the consumer decided that her only way
forward was to have her story told by the media. Her story, along
with photographs, was published in her local paper. Following her
story appearing in the newspaper she was contacted by a lawyer on
behalf of the provider organisation inviting her to meet with them.
The consumer contacted the advocate to support her at the meeting.
She just wanted to tell her story and have someone listen to what
the effects of having a general surgeon doing that type of surgery
had had on her life.
After the meeting she went back to the media to say what a
success the meeting had been. She had been able to tell her story
and felt she had been listened to. The media did a follow-up
article stating a meeting had been held and that the consumer was
very happy with the outcome.
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Access to pregnancy
testing services
Proper standards ~ Maternity care ~ DHB ~ Diagnostic
tests
A woman having her second child contacted an advocate for
support as she had been unable to access the diagnostic support she
felt she required after the complications of her first pregnancy.
Her GP had been unable to progress the matter. With advocacy
support the woman wrote to the local DHB outlining the reasons why
she should have the tests. Shortly afterwards, she was contacted by
telephone and offered a more comprehensive service, due to her past
history.
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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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A consumer solution
Surgeon ~ Public hospital ~ Mastectomy ~ Incorrect diagnosis
~ Reparation ~ Standard of care ~ Right 4
A woman sought the assistance of an advocate after a breast lump
was wrongly diagnosed as cancer, which had led to a total
mastectomy. A meeting was arranged with the provider involved to
discuss the woman's concerns. This face-to-face meeting was very
successful. After the woman told her story, the provider apologised
and asked what could be done to help the situation. The woman was
due to have a breast reconstruction, but this required travelling
to another area. She wanted her husband to be able to travel with
her and to stay at a nearby motel, and for the provider to cover
the cost. She also asked for a family member to be flown from
another part of the country to look after their children as she had
no family living close by. She wanted home help provided following
the reconstruction to assist her recovery. These requests were all
agreed to and provided by the provider. The woman has recovered
from her reconstruction surgery and has returned to work.
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Sorting out an incorrect clinical
record
Incorrect documentation ~ Clinical
record ~ Public hospital
A consumer was stunned to discover during a hospital admission
for a minor procedure that his clinical record referred to a mental
health diagnosis which had been disputed many years ago.
The consumer believed the information to be incorrect and that
it should not be on the file. He contacted the local advocate who
suggested the concerns be taken in the first instance to the
privacy officer at the District Health Board. The consumer did this
but was very unhappy with the response and sought assistance from
the advocate. The advocate supported the consumer at a meeting with
the DHB's Chief Medical Officer to discuss the information either
being removed or to have a statement from the consumer placed on
the file
The consumer was very pleased to be told at the meeting that the
Board had had the file independently reviewed and agreed that the
old diagnosis was inaccurate. The hospital agreed to start a new
file, with the consumer's statement and the review letter to be
placed on the old file to deal with the historical issues. The
consumer was delighted with this result, and also appreciative of
the doctor on the ward who had first drawn the consumer's attention
to the old information on file.
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Learning from a
mistake
Face-to-face
resolution meeting ~ Prescribing risks ~ General practice ~
Fluconazole
A woman who saw a locum doctor for a
fungal infection of her foot was prescribed an eight-week course of
fluconazole (Diflucan). Several weeks later, she found out she was
pregnant. Her usual GP informed her of the possible risks of the
drug causing abnormalities to the developing baby and that the drug
should be avoided during pregnancy unless the fungal infection was
severe or potentially life-threatening.
After weeks of agonizing she and her
husband concluded that the risk was too high and reluctantly
decided to terminate the pregnancy. She complained to HDC:
"If I had been informed from the beginning of the risks, I would
never have put myself in the position of becoming pregnant while on
that drug. I am hoping something can be done to make the doctor
more diligent while prescribing drugs that could possibly change
people's lives forever."
The complaint was referred to an
advocate who supported the consumer at a face-to-face resolution
meeting. At the meeting the consumer said she accepted the doctor
had not deliberately prescribed something that could harm her
unborn child. However, she wanted him to understand the effect of
the termination on her and her family, and her hope that others
would not have to go through the same experience.
The doctor said he had prescribed
fluconazole for a number of years and had not been aware of the
risk during pregnancy. He provided the consumer with a copy of his
revised information sheet on the use of anti-fungal treatment
including the risk when pregnant, and agreed to refund her
consultation fee.
During the meeting, the doctor
expressed his concern about how difficult it is for GPs to stay
abreast of changes in prescribing information. This was passed on
to HDC who informed the Medical Council, Medsafe and the RNZCGP of
the circumstances surrounding the complaint so that they could take
appropriate follow-up action.
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