Following an investigation into the care provided to a 79 year old patient with significant co-morbidities who underwent a total knee joint replacement, but died six days later from a cardiac and respiratory attack, the Commissioner has found that a combination of poor documentation and poor communication led to a failure by both the orthopaedic team and the nursing team to fully recognise the patient's deteriorating condition, and that both teams failed to adequately access and use critical information that was available to them.

Among other things, the Commissioner noted that: the orthopaedic team did not alert the nursing team to the patient's co-morbidities and the complexity of managing the balance between the patient's cardiac issue and his renal impairment; the nursing team failed to alert the orthopaedic team to concerns about his urine output; members of both teams failed to read the patient's notes which highlighted concerns; and a number of calculation and recording errors were made on the fluid balance chart. "In essence there was a pattern of suboptimal behaviour in the care of [the patient]". The Commissioner concluded that the failures of the nursing and orthopaedic teams were service failures and directly attributable to the DHB, and found the DHB in breach of Rights 4(1), (4) and (5) of the Code. 10HDC00419