13 June 2024

Multiple system failures by Health NZ in managing woman’s echo test

The Aged Care Commissioner has found multiple system failures in Waikato DHB (now Health New Zealand) resulted in delays in actioning GP referrals and notifying the results of an echocardiogram to a patient.

As a result, the Commissioner found Health New Zealand breached Right 4 – the right to an appropriate standard of care, of the Code of Health and Disability Services Consumers’ Rights for failing to provide services with reasonable care and skill.

The woman at the centre of the report, was initially referred by her GP to Thames Hospital for an echocardiogram. She experienced significant delays in getting the echocardiogram done and learning the results which indicated severe heart valve disease and other heart disease. Given the history of delays with Health New Zealand, the woman then sought private medical treatment for her heart condition.

The breach covered several shortcomings in care. First, there was a delay in triaging the first referral and performing the echocardiogram. Later, there was a delay in communicating the echocardiogram results to the woman’s GP. Finally, there was a lack of action taken once errors were identified.

According to Carolyn Cooper, the first referral exceeded the recommended timeframe for triage by 10 working days. It then took around six months for the echocardiogram to be performed, which ideally should have been undertaken within six weeks.

In addition, the echocardiogram results were not sent directly to the GP who referred the woman for the test. This resulted in an additional delay in the woman learning of the results and treatment being scheduled.

“Without the woman’s active participation in following up her echocardiogram appointment and then result, it is possible that Health New Zealand would not have identified the omissions, which could have caused significant harm to her.”

No further systemic investigation was undertaken by Health New Zealand for the errors and delays once they were clear.

“There appears to have been no urgency shown by Health New Zealand for the lack of action taken on the echocardiogram and no escalation for any investigation once Health New Zealand was aware that the woman’s significantly abnormal results had not been actioned,” Cooper said.

The Commissioner also made adverse comment about Health New Zealand for not actioning the event monitor after the second referral, and about the cardiologist who reviewed the woman’s report for failing to make the appropriate management recommendations in the echocardiogram report.

Since the events, Health New Zealand, the cardiologist and medical centre have reportedly made changes to their practice. 

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