A failure in ‘end-of-life’ care


Deputy Health and Disability Commissioner Rose Wall has found a private hospital and two registered nurses in breach of the Code of Health and Disability Services Consumers' Rights for the treatment provided to a man receiving palliative care.

A 74-year-old man with terminal prostate cancer and bowel cancer was admitted to a private hospital for pain management and palliative care.

He remained there for 23 days.

His medications at admission included the controlled drugs OxyContin, methadone and haloperidol.

During the man's admission there were a number of errors made regarding his medication, including a failure to administer methadone for six days in accordance with his prescription, and the administration of oral haloperidol for five days despite the prescription having been discontinued.

On multiple occasions staff also failed to record the administration of his medications correctly.

The man was not informed about the medication errors, and there was a 10-day delay in notifying his family of the haloperidol errors. In addition, there were numerous delays in the man being provided with appropriate pain medication.

Rose considers this to be an example of poor end-of-life care and believes the hospital failed woefully in its duty of care to the man and his family at a critical time in his life.

She says consumers in such circumstances require holistic care, including, but not confined to, the provision of adequate pain relief. Furthermore, staff need to be trained appropriately in palliative care, and to be alert to the changing requirements of consumers.

She found staff consistently failed to adhere to relevant policies, and to manage the man's pain and medication adequately. As a result, staff made multiple errors in relation to the ordering, storage and administration of the man's medication.

Despite the man experiencing high levels of pain, there were multiple occasions on which his pain assessment and management were suboptimal.

Furthermore, once the medication errors were identified, staff failed to respond appropriately in documenting and notifying the man of the errors.

Rose also found the clinical manager (also a registered nurse) failed to ensure staff complied with relevant policies and procedures, particularly regarding pain and medication management.

The clinical manager did not act promptly when administering pain relief to the man. In addition, the clinical manager did not follow up to ensure that corrective actions had been carried out following identification of the medication errors and failed to inform the man's family of the errors in a timely manner.

The commissioner recommended the hospital management provide ongoing training to all registered nurses with regard to its policies and procedures, communication with residents and their families, medication management, and professional standards regarding documentation; conduct an audit with regard to the corrective action plan; and disseminate the learnings from this case to all its facilities nationwide.

The hospital has provided a written apology to the man's family.