Dave Macpherson – Being part of the Health Establishment means never having to say sorry

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A leading suicide prevention campaigner published a social media post on the weekend asking why the Southern District Health Board had yet to apologise to her family over the poor care for her son, who was a victim of suicide 4 years ago.

Over 3 months ago, the Mental Health Commissioner ruled that the care Corinda Taylor’s teenage son Ross received at Dunedin Hospital “was a significant deviation from expected standards”. The DHB was supposed to apologise within one month, but unless NZ Post has completely shut up shop (always on the cards with that lot), nothing has been received.

The Southern DHB, one of the worst in the country for this sort of prevarication, has apparently written some sort of challenge to the findings, not that the Taylor family have been shown it.

The Mental Health Commissioner, a position so toothless that a dentist’s visit would never be needed, is of course letting the DHB challenge take its course, and not worrying about the feelings of the Taylors,  let alone the one-month time limit for apologies. That position is now a faceless one within the overall Health & Disability Commission, which itself is renowned for the slowness with which it investigates any health sector complaints.

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My own family received a Clayton’s “apology” from Waikato DHB, after it investigated itself, and found that multiple care and treatment policies had not been followed when our son Nicky died while in their care. They weren’t sorry for the policy breaches, and didn’t admit to poor care (because it wasn’t deliberate), but were just sorry that he had died – and that took two years.

When the Police investigated the DHB’s care for our son, following his death, they got a peer review of Nicky’s care from a completely independent psychiatrist, one of the very few in New Zealand or Australia not currently contracted to the state healthcare system. Police told us that the review was critical of the DHB’s care for Nicky, but not so that the poor care broke the ‘criminal intent’ threshold.

Despite the Police promising a copy of the peer review to our family, that has not been given to us, over a year after it was produced.

In our opinion, the hiding of the truth, the weaselling out of apologies, the failure to take any meaningful actions and the huge delays in any investigations are symptoms of a health establishment culture where no-one and no organisation ever takes responsibility in a meaningful way, where the worst punishment, for parts of the establishment in good standing, is a slap on the wrist with a wet bus ticket.

Thanks to social and other electronic media, there are other ways to hold the feet of those responsible to the accountability fire, and many of us will be using them.

 

Dave Macpherson is TDB’s mental health blogger. He became a Waikato DHB member after his son died from mental health incompetence.

4 COMMENTS

  1. Sadly I’m not batting an eyelid reading this. I ceased to be remotely surprised by the system at least 15 years ago, around the time I conceded defeat, especially when it came to the idea of a simple apology following several very justified formal complaints around my hospital treatment. Even once when prescribed an antibiotic I was allergic to 1 minute after asking me if I was allergic to said antibiotic, an on the spot, simple “sorry” wasn’t forthcoming.

    This was a junior ED doc so I guess they train them in med school to never apologise and the culture grows from there? If they’re indoctrinated from day one to never admit fault to the patient or family for a prescription error ( I do accept human error can happen, especially when docs are exhausted), then of course they’ll be incapable when it comes to the death of a patient.

    Keep up the good fight Dave.

  2. Quote from the post above:
    “That position is now a faceless one within the overall Health & Disability Commission, which itself is renowned for the slowness with which it investigates any health sector complaints.”

    Indeed, the HDC is mostly useless, operates under a Health and Disability Commissioner Act 1994 that offers him endless discretion to only do some very limited things, or to do virtually nothing much at all. Here is just one provision showing this:

    http://legislation.govt.nz/act/public/1994/0088/latest/DLM333973.html

    “38 Commissioner may decide to take no action or no further action on complaint

    (1) At any time after completing a preliminary assessment of a complaint (whether or not the Commissioner is investigating, or continuing to investigate, the complaint himself or herself), the Commissioner may, at his or her discretion, decide to take no action or, as the case may require, no further action on the complaint if the Commissioner considers that, having regard to all the circumstances of the case, any action or further action is unnecessary or inappropriate.”

    There have in the past been concerns about the process with which the HDC gets selected and appointed. For instance the present and previous HDC both had a long career in the health sector, even working for the Ministry of Health, also in a legal capacity:

    ‘Independence of commissioner paramount’

    ODT, 21 Dec. 2011:

    https://www.odt.co.nz/opinion/independence-commissioner-paramount

    Some other info of relevance:
    https://nzsocialjusticeblog2013.wordpress.com/2016/03/28/how-the-hdc-throws-out-valid-complaints-and-protects-code-breaching-health-professionals-a-true-story/

    https://nzsocialjusticeblog2013.wordpress.com/2015/10/04/how-the-n-z-health-and-disability-commissioner-let-off-a-biased-designated-doctor/

    Here a case, where the HDC actually took “action”:

    http://www.radionz.co.nz/national/programmes/checkpoint/audio/201844740/woman-lost-baby-due-to-hospital-mistake-health-and-disability-commissioner

    http://newsie.co.nz/news/32926-woman-loses-baby-after-dhb-failure.html

    “A pregnant woman has lost her baby following an initial failure by DHB staff to diagnose her diabetic ketoacidosis.

    Health and Disability Commissioner Anthony Hill has released a report finding a district health board in breach of the Code of Health and Disability Services Consumers’ Rights (the Code) for the care provided to the woman, who had diabetes.”

    “The commissioner considers the DHB team had sufficient information to provide the woman with appropriate care.

    However, a series of judgment and communication failures meant that it did not do so.”

    And here is all the HDC ‘recommended’:
    “The commissioner has made a number of recommendations to the DHB, including a review of relevant policies and protocols relating to staffing at the Service, patient information resources on diabetes management in pregnancy and a diabetes assessment and education checklist to include DKA.

    It is also recommended that the DHB review the training provided to resident medical offers on assessing patients, triaging and supervision of junior doctors.”

    Comment:

    Yes, an unborn baby died, due to steps that should have been taken by the DHB staff not having been taken, and all that the HDC apparently can do is offer a ‘slap on the wrist with a wet bus ticket’ kind of ‘recommendation’.

    There are endless cases like this, and only between 1 and perhaps in some years 9 percent of all complaints received are ever investigated, the rest “resolved” by taking a low level kind of approach. In many cases nothing is done.

    And when it comes to mental health cases, yes, while that is a ‘tricky’ area of health and disability care provision, the HDC Office has one Mental Health Commissioner, who rarely takes much action, as the once separate Mental Health Commission was abolished, and a new position created within the HDC, that is poorly resourced, and works under an Act that offers so many holes in it, like a Swiss Cheese, you can drive a truck through.

    Hence DHBs do generally not worry much about complaints to the HDC, see this article for instance, on stuff.co:

    ‘Record number of patient complaints over public healthcare’

    http://www.stuff.co.nz/national/health/74312248/Record-number-of-patient-complaints-over-public-healthcare

    “The commissioner was not available to comment on the increase on Monday but has previously said the rise in complaints should be treated with caution, with little evidence they reflected a deterioration in the quality of treatment.

    And the figures show few complaints are upheld, with only 33 of 410 complaints even investigated during the period. Of those, only 17 were upheld.

    None of the complaints about Wairarapa DHB were upheld and only one was even investigated.

    The Hutt Valley DHB dealt with 25 complaints but only one was upheld after it was investigated.

    Capital & Coast DHB dealt with 40 complaints, only three on which were upheld.”

    A separate report stated this:

    ‘Health board unconcerned about level of complaints’

    Bay of Plenty Times’, 9 Nov. 2015:

    http://www.nzherald.co.nz/bay-of-plenty-times/news/article.cfm?c_id=1503343&objectid=11542177

    “Mr Cammish said the district health board believed an active and engaged complaints system, both internal and external, was the cornerstone of an effective continuous quality improvement and patient safety programme.”

    Comment:
    Is it not rather the fact that the HDC does rather dismiss most complaints as not needing to be investigated, or on the other hand refers them directly to the provider or advocates to “resolve”, that the DHBs and medical and other health practitioners have little to fear?

    And for the rest the Commissioner seems to suggest, it is only due to more complaint happy customers and their relatives that complaints increase?!

    It is time to strengthen the HDC Act (providing for sanctions and firmer actions by the HDC), and to re-establish also a separate Mental Health Commission!

    • It seems few people take interest in REAL issues, as it seems too “complex” or “complicated” for them.

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