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Australia 'Incredibly distressing': Minister intervenes over patient death and bungled records

02:31  07 august  2020
02:31  07 august  2020 Source:   smh.com.au

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Bungled medical records given to the family of a man who died following treatment in a western NSW hospital mistakenly contained confidential notes belonging to another patient, listed the wrong surgeon and were missing a key blood report.

These mistakes come amid revelations a ministerial review team investigating the patient's death interviewed his family the day before their reporting deadline and were then denied requests for more time to "adequately investigate" concerns raised at the meeting.

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Health Minister Brad Hazzard has now intervened after the Herald put questions to his office this week asking for an explanation of the pressing time constraints that prevented the review team's deadline from being extended.

The patient's family say Mr Hazzard telephoned on Tuesday evening and reassured them directly he would look into their concerns.

A Herald investigation exposed serious questions over the death of Cobar man Allan Wells, along with a series of troubling near misses at Dubbo and Cobar hospitals, both within the Western NSW Local Health District.

Mr Wells died after he was discharged from Cobar hospital against his family's wishes last year. His treatment was branded "Third World" in May by his daughter, Jamelle Wells, a Sydney-based journalist.

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While Mr Wells was in Dubbo Base Hospital he went without food or water for three days because it was too expensive to roster staff on, in a ward that ran out of morphine and Panadol, his family said.

The state of his medical records was slammed as a "shambles" by Lorraine Long of the Medical Error Action Group.

The Western NSW Local Health District disputes the claims made by Mr Wells' family.

Mr Hazzard ordered the health district to conduct a review of the patient's experiences and make its report available to him upon completion.

The Herald understands the review is being carried out by Dr Clare Skinner, the director of emergency medicine at Hornsby Hospital, and Dr Melanie Berry, the clinical director of quality and safety at the Western NSW Local Health District.

They met with Mr Wells' family during the afternoon of Thursday, July 9, one working day before their report was due on Monday, July 13.

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At the meeting, which ran for 90 minutes, the reviewers acknowledged they were presented with detailed evidence and information, some of which they noted was "incredibly distressing" and "highly irregular".

Ms Berry told Mr Wells' family at the meeting she would seek an extension of time to report to Mr Hazzard because she needed to "look further" into the concerns they had raised.

"We need to get the whole story across and I don't want it to be limited by time," she said.

Adrian Fahy, the executive director of quality and clinical safety with the Western NSW Local Health District, confirmed that the reviewers had sought extra time because they did not believe all the family's concerns could be "adequately addressed" by their reporting deadline.

The request was knocked back, Mr Fahy said in a letter to the Wells family.

"Unfortunately, it was not possible to delay the submission of the report any further," he wrote.

Mr Fahy said the review team would instead respond directly to the family and could offer a follow-up meeting.

"We are committed to completing a thorough review of your concerns and make any necessary improvements to the care we provide."

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Mr Fahy "sincerely apologised" for an administrative error that meant the wrong doctor was listed on Mr Wells' medical records.

He said the reason blood transfusion notes were missing was not clear and would be reviewed.

There is no suggestion Mr Fahy was personally responsible for any error made in the record-keeping or Mr Wells' treatment.

Mr Wells' family were astonished to later discover that one page of the medical records belonged to another elderly patient who lived in Narromine in Western NSW.

Ms Long of the Medical Error Action Group, who made the discovery, said the bungle was an unlawful breach of patient privacy.

"The state of Mr Wells' records was a shambles, particularly noting missing records, gaps in records, records out of chronological order and procedures done without notes being recorded," she said.

She accused Dubbo Base Hospital of "robbing the dead" by charging more than $600 for the records and said the usual fee was $30.

A spokesperson for the Western NSW Local Health District said it had investigated the incident, spoken to the Narromine man's carer and apologised.

"We sincerely regret any distress this may have caused," the spokesperson said.

"As a result of the investigation we have updated and improved our processes so this does not happen again."

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