A WOMAN who went to a Queensland hospital with breathing difficulties, and was sent home complaining health workers had not taken her seriously, was found dead in her bed the next day, a report says.
The case is detailed in a Health Quality and Complaints Commission document, Failing Health: A Spotlight Report on Complaints About Clinical Deterioration in Queensland Hospitals, released yesterday.
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Her death was later found to have been caused by a pulmonary embolism – a blockage in the artery to her lung.
The unnamed hospital had sent the woman home, scheduling an X-ray for the following week, but she died before it could take place.
Her husband later complained to the commission about the standard of care.
“The man said his wife felt hospital staff were not taking her seriously,” the report said.
In another case, a woman complained that a hospital had incorrectly diagnosed her burst appendix as constipation.
“The woman said she had been vomiting and in extreme pain for 24 hours when she presented to the hospital,” the commission report said.
“She was told she was constipated and given drinks and enemas to help her move her bowel, none of which worked … and sent home.”
She returned to the hospital but after a few hours was sent home a second time and told “to come back in a week if the pain had not settled”.
The woman went to her general practitioner instead, who ordered an ultrasound and blood tests, referring her to another hospital where she was diagnosed with a burst appendix and abscess.
Health Quality and Complaints assistant commissioner John Rivers said independent research showed people could die or be seriously harmed if hospital staff failed to recognise and act on a patient’s deterioration.
“Hospitals should have a process in place that encourages patients and their families or carers to raise concerns about observed clinical deterioration and ensure these are appropriately addressed,” Dr Rivers said.
He said St Andrew’s War Memorial Hospital in Brisbane had medical emergency response teams which could be called upon if health workers, with input from family, felt a patient had taken a sudden turn for the worse.
“I think more and more hospitals are trying to move to these systems where if someone raises a concern that this patient is getting sicker quickly, we need some sort of urgent response,” Dr Rivers said.
“People can get sick incredibly fast, particularly children. What you need is a system that reacts then and there. Early recognition of patient deterioration and prompt action can improve patient outcomes.”
The commission analysed 172 complaints and 205 root cause analysis reports into cases of clinical deterioration received between July 2009 and June 2012.
One in five complaints involved a failure to address concerns about a patient’s worsening condition.
More than half were about care during a hospital admission, a quarter were about pre-admission care, including misdiagnosis in an emergency department, and 21 per cent were about deterioration following discharge.
Source: couriermail.com.au