Report reveals extent of patient deaths, injuries in hospitals

Health authorities recorded 440 patient harm events in six months, including 59 where a patient died, with staff numbers highlighted as contributing to the problem.

In the first report of its kind, Health New Zealand (HNZ) published national data on serious adverse events involving patients using hospital or specialist services between July and December last year.

HNZ’s clinical director Dr Richard Sullivan said serious harm to patients was rare but such events had a significant impact.

Health New Zealand’s chief clinical officer Dr Richard Sullivan says improvements to workforce planning and safe staffing are being made nationwide. Photo / Alyse Wright

“Every serious adverse event has affected a person, their whānau, family and community. HNZ sincerely apologises to every person, whānau, family, carer and friend affected by a serious adverse event, and we are sorry for the harm and distress people have experienced,” Sullivan said.

Serious adverse events are split into two categories.

“SAC 1″ events are those that led to “severe harm”, for example, a patient dying or suffering permanent loss of function after delays, including not recognising a patient had deteriorated, and delays in referrals, diagnosis or treatment.

Falls that resulted in life-saving intervention or death also make up SAC 1 events.

“SAC 2″ events led to “major harm”, for example, a situation where a patient falls and breaks their leg or suffers a head injury.

In June, the Herald revealed a man died after collapsing in a toilet cubicle in the waiting room of Waikato Hospital’s emergency department.

Brent Horsburgh had been waiting more than nine hours for care and his death is the subject of a serious adverse event review.

Brent Horsburgh died after collapsing in a toilet cubicle at Waikato Hospital's emergency department.

When considering patients who died because of delayed referrals, diagnosis or treatment, HNZ’s report points to issues with staffing.

“In those reviews resourcing was a consistent contributory factor in delays with improvement activities being focused on optimising staffing and resource allocation,” the report says.

Other contributing factors included waitlists and referrals, transitions of care from GPs to other providers, and “fragmented” IT systems.

Sullivan said improvements to workforce planning and safe staffing were being made across the country.

“Work underway includes improving referral and follow-up processes, reviewing waitlists, strengthening falls and pressure injury prevention, and rolling out tools such as electronic observations and early warning scores. This is about helping staff spot risks earlier and act sooner.”

Staffing issues have been highlighted as contributing to patient deaths. Photo / Simplefoto

Māori were over-represented in delayed recognition of a patient’s deterioration that led to loss of function or death.

“Further monitoring of this will be required to confirm the trend and understand the contributing factors for these events,” the report says.

Thirty-eight adverse events, 9% of the six-month total, involved maternity care.

Michael Morrah is a senior investigative reporter/team leader at the Herald. He won the Best Coverage of a Major News Event at the 2024 Voyager NZ Media Awards and has twice been named Reporter of the Year. He has been a broadcast journalist for 20 years and joined the Herald’s video team in July 2024.