Hospital doctors’ instructions not recorded in the notes…

The Health & Disability Commissioner has found that the Waikato District Health Board failed to provide services with reasonable care and skill in breach of the Code of Health and Disabilities Services Consumers Rights.

An elderly patient fractured her leg and was admitted to the public hospital where a leg brace was fitted and she was placed on bed rest.  A doctor directed that the skin under the brace was to be monitored for pressure sores, but this instruction was not recorded in the patient’s care plan.  In addition the doctor asked that the patient be referred to the pain clinic, but this referral was not made.

The patient was discharged to a rest home, but developed a urinary tract infection and was readmitted to the public hospital.  The doctor in the hospital noted a pressure sore under the brace and instructed that the brace be removed and the wound reviewed on a daily basis.  However, this instruction was also not recorded in the patient’s care plan and no notes were made to show whether the instructions were ever carried out.

The patient was then discharged to the rest home again, but the staff at the rest home did not remove the brace for some time and when it was removed the patient had a serious infection and died the next day.

The Health & Disability Commissioner’s findings were that the instructions from the doctors were not adequately recorded and the hospital failed to provide the rest home with adequate instructions on care of the wound.  The instructions given by medical staff during the two admissions were not properly recorded in the patient care plan and were not undertaken by the staff.  Their failure to record key information in the notes and therefore the failure to action those instructions meant that the services by the hospital were not provided with reasonable care and skill.

The Waikato DHB is to conduct an audit of staff compliance and provide an apology to the patient’s family.

The rest home staff were criticised for not challenging the hospital’s instructions in regards to treatment of the patient and seeking clearer instructions as to what should have been done.




Alan Knowsley
Medical Lawyer
Wellington