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Care of rural hospital patient granted home leave with compromised lung function (07HDC11548)

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(07HDC11548, 24 April 2009)

Rural hospital ~ Health service company ~ Public hospital ~ District health board ~ Medical officer ~ Physician ~ Respiratory failure ~ Informed consent to biopsy ~ Weekend leave ~ After-hours specialist consultation ~ Responsibility of district health board to monitor delivery of funded services ~ Rights 4(1), 4(5)

The wife of a 66-year-old man complained about the care he received at a rural hospital run by a health service company contracted by the DHB to provide secondary health services in the small town.

The man suffered worsening shortness of breath, thought to be caused by fibrosing alveolitis or pulmonary fibrosis. The man's condition deteriorated and he was admitted to the rural hospital as an inpatient. A respiratory physician performed a transbronchial biopsy to assist diagnosis, and the man was sent home on weekend leave by a medical officer. He became breathless early the next morning and returned to hospital via ambulance and was diagnosed with a pneumothorax (a collection of air in the space around the lungs), a known risk of transbronchial biopsy.

The man's condition continued to deteriorate and he was airlifted to the public hospital in a main centre two days later. Despite intensive care, he died of respiratory failure.

It was held that the health service company failed to ensure that the rural hospital had appropriate policies in place in relation to patients going on weekend leave, or appropriate specialist support (in the form of appropriate specialist cover and/or clear protocols for contacting public hospital specialists). Such policies are particularly important for rural hospitals, which often do not have local specialist cover and rely to a large extent on locums. While such policies (and earlier consultation with a specialist) may not have altered the outcome for the man, given his complex condition, the health service company did not provide services with reasonable care and skill, and did not sufficiently facilitate co-operation between its staff and the public hospital specialists to ensure quality of care. In these circumstances, the company breached Rights 4(1) and 4(5).

Given the lack of appropriate arrangements for consulting with specialists, it was accepted that the medical officer took reasonable actions to provide appropriate care to the man and therefore did not breach the Code.

This case highlights the important responsibility of a district health board to monitor the delivery of services that it funds within its district, particularly where those services are secondary care/hospital services. A fundamental prerequisite is that adequate systems are in place for consultation with, and referral to, a higher level of service when the severity or complexity of the condition is beyond the technical and clinical capacity of the local service.