Medical mishap almost killed man

In my post “One Year On” I stated that we held Wellington Hospital CCDHB responsible Derek’s CAPS event, and that they could have taken measures to prevent it.

After months of investigating, in March 2014 we contacted the CCDHB to tell them our thoughts on what happened.

Several months ago we were told that there was to be a full investigation into the event to see if they could work out what happened.

That investigation is now complete and they have agreed with us that they failed Derek at every turn.

We received a copy of the report 2 weeks ago, but didn’t agree with what it said, and many of the assumptions they made. We went to a meeting with the writers of the report and as a result, they have re-written the report and accepted even more blame.

Under Findings it states:

The review team consider the root cause of the adverse event was communication failure. The final plan was neither communicated to the patient in full in a manner that ensured the patient had received and understood the final plan, nor was his understanding of the plan checked. It was not identified during the admission for surgery that the pan was not being followed as expected.

There is a system in place in all hospitals that, when an adverse event happens for whatever reason, it should be investigated.

Also under Findings:

The review team note that the reportable event was indicated but not entered when it was identified that the patient had developed CAPS and that the anticoagulation plan had not be fully implemented.

In the Cover Letter they acknowledge:

Due to the failures in communication of the plan to Derek, and the lack of detailed documentation in his clinical record, we did not recognise that the intended plan had not been completed until Derek wrote to the CCDHB in March 2014 with concerns.

Our goal in complaining, was to ensure there are processes in place to try and prevent this happening to anyone else. They now have to put in place, set procedures which must be followed.

Hopefully this will not happen again.

At the same time we asked that a very special Dr got mentioned. Her name is Dr Helen Myint, I may have named her before, but we firmly believe it was her diligence that saved Derek’s life.

The final part to their admission of errors, is the public report they must do.  As a result Derek ended up on the front page of the Dominion Post in Wellington.

Medial Mishap

MEDICAL MISHAP: Upper Hutt man Derek Edson developed a chronic illness when doctors failed to note his blood-clotting condition before cancer surgery.

MEDICAL MISHAP:

The medication Derek Edson needed to survive cancer surgery was waiting to be picked up from his local pharmacy – but no-one from Wellington Hospital told him about it.

As a result, the Silverstream resident nearly died, and will now have chronic exhaustion and ill-health for life.

The 56-year-old computer programmer brought a complaint against Capital & Coast District Health Board – one of 454 cases of medical misadventure recorded nationwide in the 2013-14 year.

Because of a pre-existing blood-clotting condition, he should have been taking a drug called Clexdane before his prostate cancer surgery in September 2012. The drug had been ordered and was waiting for him – but he didn’t know.

After surgery, his health went into a rapid tailspin, and his adrenal glands permanently died – a condition known as Addison’s disease. He suffered severe liver and kidney damage, pneumonia and fluid in the lungs. “I kept going downhill.”

On a good day, he crashes into bed at 8pm after a day of work. On a bad day, he is in the emergency department, facing a coma or death within 72 hours.

He said: “I don’t have the initial upset I used to have – I can’t afford to.”

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