Red News Readers,
We get to know about these deaths because of the Root Cause Analysis system that was required of all hospitals after the Campbelltown Camden saga. In years gone past, these events would have happened and never seen the light of day. But these are reported incidents, so care has to exercised in interpreting whether there has been and increase or decrease in the number of fatal incidents in SWAHS.
Natasha Wallace Health Reporter, smh
August 26, 2008
DAMNING internal reports into 85 deaths at western Sydney hospitals over two years has revealed that at least 49 of the patients did not receive adequate care.
Poor standard of care was a "significant contribution" to the deaths of 14 patients last year and may have contributed to up to 25 deaths in 2006.
Most of the avoidable deaths were due to a delay in responding to a rapidly deteriorating patient.
Most of the 110 investigations into adverse outcomes of patients under the care of Sydney West Area Health Service occurred at Westmead Hospital. This was followed by suicides of mental health patients after they had left hospital, then investigations at Nepean and Blacktown hospitals.
The NSW Health reports were released after repeated requests under freedom of information laws by Channel Seven News.
The revelation comes as Commissioner Peter Garling, SC, investigates a series of systemic problems affecting public hospitals in NSW.
The Special Commission of Inquiry into Acute Care Services was so inundated with complaints from Westmead staff that it held an extra sitting day at the hospital.
Only 20 per cent of cases in both the 2006 and 2007 reports were not due to systemic or individual failures.
The 2007 report, completed in April this year, said a "major issue still relates to recognition of the deteriorating patient".
Despite the alarming figures, 40 per cent of recommendations arising from the 2007 report are yet to be implemented. Twenty per cent were implemented late.
Twenty-five per cent of the most serious cases - where the level of care was associated with death - had not had their recommendations implemented.
The two reports are titled Annual Review Of Root Cause Analysis 2006 and 2007. An investigation is conducted where there are concerns regarding the standard of care.
The 2007 report found that of the 37 non-suicide deaths investigated only 10 patients were treated adequately. For 14 patients, there was a "variation from expected standard of care which had significant contribution to death", the report said.
It said this category, "which contains potentially preventable deaths, is the greatest cause for concern and should be the highest priority in relation to ensuring recommendations are implemented".
There was also a variation from expected care for another 13 patients, "but with minimal impact on outcome," the report said.
In analysing last year's deaths, the report said three patients had been discharged from emergency with the wrong diagnosis, two had been treated or admitted for the wrong diagnosis, 12 had experienced a delayed response and two had experienced a "complication of medical management".
Nineteen of the investigations in 2006 and 2007 related to procedures on the wrong patient or the wrong part of the patient. These related mainly to imaging procedures. Three last year related to surgical material or instruments being left in patients.
The top three causes of adverse outcomes from 2004 to 2007 were communication, "knowledge, skills and competence" and procedures.
Key issues identified in the 2007 report included insufficient scheduling for workloads, policies being ignored, delays in relaying important clinical information, multiple teams not communicating effectively and missing or inadequate documents.
The 2006 report into 48 cases (43 deaths), said that 31 were not related tomental health.
Of the 31 cases (three of which did not relate to deaths), for 25 patients "it was determined that aspects of the provision of health care may possibly have contributed to, or exacerbated the patient's outcome."
"Communication; delays in sharing clinical information and documentation were the most common causal factors," the 2006 report said.
Common themes included the management of acutely deteriorating patients, including assessment and access to more senior staff and assessment in emergency wards.
* 49 western Sydney patients who died were not properly cared for.
* Poor care was a significant factor in 14 deaths.
* Poor care may have contributed to the deaths of up to 25 others.
* In the remaining cases, poor care had little effect on the deaths.
* Poor communication and slow responses to rapidly deteriorating patients were common.