Notes on Culture, Management and Standards of Clinical Care at the
Whanganui Hospital
Introduction
A successful health care organisation is one that has positive client outcomes as its highest
priority. Such an organisation will be committed to constant improvements in the care it
offers, through ongoing training, and the establishment and regular review of 'best practice'
processes and procedures in both management and clinical care.
The Whanganui Hospital is a regional base hospital offering acute medical and surgical care,
emergency services, maternity services, and a residential psychiatric unit.
Some errors and oversights are inevitable in any organisation of this size and complexity. A
healthy organisation will respond to those errors and oversights in a way that maximises
opportunities for learning and improved patient care.
In my experience in health care governance, complaints have been welcomed, and seen as
opportunities to improve the quality of care. Organisations have responded to incidents and
complaints by working to resolve issues for clients, to redress any harm done, and to ensure
best possible outcomes for those involved. In addition, organisations have conducted multidisciplinary reviews of incidents, encouraging input from patients, complainants, and where
appropriate other practitioners and community members, to see what could be learned, and
how future problems could be prevented and service improved.
Culture
There could not be a deeper contrast between the practice and culture of healthy, mission
focussed health care organisations, and that of the Whanganui Hospital.
In my experience the response to an incident or complaint in Wanganui is more like that of a
playground bully. Harm or error is denied or minimised, and the victim or complainant
blamed or discredited.
To give some examples, I have been told by mental health clients who have felt abused or
mistreated by staff, including being subject to bullying or inappropriate sexual advances, that
they were advised it would not be good for their health to proceed with a complaint. Some of
those who nonetheless attempted to proceed reported being subject to harassing phone calls,
or threats to remove their care.
In our own case, after I complained about the behaviour of a member of the mental health
team, I was told by a senior staff member that if I was who she thought I was, she would be
'lining me up.' I was not able to clarify what this meant, but it sounded like a threat. In any
case, it was clear that my complaint was regarded as the problem, and not the behaviour
which lead to the complaint.
Medical staff have told me that they have been 'put on notice' after pointing out inadequate
procedures leading to failures in care, or that they have been instructed not to talk with
patients who have experienced failures in care. Some have made comments like 'Thank you
for speaking out. Something has to be done. But for heaven's sake, don't tell anyone I said so.'
Instead of being seen as friends of the hospital because they are assisting in its mission of
providing high and improving standards of health care, staff, patients and family members
who complain or point out problems are regarded as the enemy.
It was made clear that if we told people what had happened to Amanda, the hospital would
'have to' release personal information about her and her illness in order to defend itself. It did
so, but also published information that was misleading if not outrightly untrue, and which was
clearly designed to exonerate hospital staff while discrediting Amanda and her family.
For example, the General Manager, Jeanette Black, claimed in the Wanganui Chronicle that
Amanda was a 'challenging and complex mental health client,' as if this provided an excuse for
the hospital's failures in its duty of care to her. It would not be an excuse, but in any case is
simply untrue. Amanda is a very easy client to manage. She is intelligent and honest, with
good insight into her illness. All that is required is that people take note when she says she is
at risk – something that competent mental health professionals would do without fail.
Ms Black also said that Amanda's family disagreed with the hospital's decision not to put
Amanda into the secure unit at Te Awhina. In fact Ms Black would have no way of knowing
what Amanda's family thinks, since neither she nor any other board member or senior staff
member has ever asked.
Finally, Ms Black claimed publicly that although Amanda had repeatedly been made by
nursing staff to stand and walk on her multiply fractured pelvis despite her notes indicating
this would cause further damage, this weeks early mobilisation had done no harm. This was
not the advice of orthopedic and physiotherapy staff, and again, without x-rays before and
after, she would have no way of knowing whether this was true or not. This is a minor matter
in comparison with other massive injuries Amanda received while in the care of the hospital,
but it is part of a pattern of carelessness, coupled with a willingness to stretch the truth to
deny or minimise harm done, while attempting discredit or blame the client.
Without a commitment to welcoming complaints, listening to them respectfully, and acting to
remedy harm done and to prevent future harm, there is little prospect of any improvement in
the quality of care. The response to specific incidents will be like putting band aids on
measles. It may be possible to cover up a spot here and a spot there, but the problem is
sytemic, and unless it is addressed in a systemic way, the Whanganui Hospital will continue to
be unsafe for patients, and continue to be the subject of media enquiry.
Mental Health Services
If one asks a mental health professional about the signs of mental health, common answers
might include independence, creativity and assertiveness. Yet these qualities are actively
discouraged in most residential psych units, and in my experience, nowhere more so than in
Te Awhina.
There are some caring, safe and professional staff. But because mental health workers are
hard to find, standards are low, and many good staff do not stay. I have have spoken to a
number of former staff who resigned from Te Awhina because they could not tolerate the
persistently dismissive and uncaring attitude to clients.
Patients who want to understand and participate in their treatment are treated as if they are
ignorant and incompetent. Patient assessments of their own needs and risk levels, however
rational and well-informed, are routinely dismissed. Irrational behaviour is seen as something
to be punished, and not as a manifestation of illness.
Some staff seem to have difficulty understanding and maintaining professional boundaries. In
Amanda’s case this has meant she has been taken out drinking by staff members, who have
also occasionally borrowed money from her. Records of client property are poorly maintained,
and clients and former staff have suggested there is a habit of staff borrowing money from
client cash kept in storage. All this is indicative of a ‘she’ll be right’ attitude that seems
pervasive not only in mental health but throughout the hospital.
Any mental health unit in which senior staff can tell a distressed patient that she is not at risk
because if she wanted to kill herself she would already have done it, and in which repeated
requests for help by an intelligent and insightful client can be dismissed or ignored by an
entire team of mental health professionals, is seriously dysfunctional.
Communication
A key to successful outcomes in any industry is clear communication of goals and procedures.
Staff in Whanganui Hospital seem to operate in a vacuum in which assumptions are taken as
fact. Staff who came from Te Awhina to care for Amanda when she was transferred from CCU
to Surgical had no idea why they were there. Mental health leadership seemed to have
assumed they would be advised of their duties by surgical staff, while surgical staff assumed
they had been informed by mental health. No one checked. Once it was clear what had
happened, I wrote out clear instructions which I gave and explained to Te Awhina staff then
on duty. I also asked for a copy of those instructions to be made and placed in Amanda's
notes.
Not one of the surgical nursing staff responsible for Amanda's care had read her notes before
attempting to move her. It may be impractical to read through an entire case history before
coming on duty, but there is no reason why a single page of 'Critical Care Notes' could not be
prepared for each patient, which all nursing staff working with or assisting with a patient
would be required to check and initial beforehand. This could include such key information as
mobility, allergies, infection status, feeding and any other information necessary to ensure
safe and competent care. There are wall posters to indicate diet and mobility status, but in
Amanda's case, and in a number of others I noted, these were simply ignored.
Communication with patients is also a key factor influencing healthcare outcomes. Hospital
can be a confusing and distressing environment. Patient confidence in the system is often
simply a product of confidence in the person directly responsible for their care. This is not
helped when nursing staff simply disappear without a word at the end of their shifts.
It would take only a few moments longer to visit each patient in turn, and to say something
like 'Hello Mrs X. I am finishing now. This is x. She will be taking care of you. I have told her
about x and y. Is there anything else you think she needs to know?'
Were it not for the fact that patients at Whanganui Hospital frequently seem to be regarded as
peripheral to the hospital's operation, I would be baffled by the fact that this is not routinely
done, as it is and should be in any patient-centred health care facility.
Infection Control
Infection control procedures at the hospital are haphazard and poorly monitored.
Any patient returning from another hospital should be assumed to be infectious until known
otherwise, with all infection control procedures in place. These would ordinarily include
scrupulous handwashing before and after attending to a patient, unfailing use of gloves, use of
masks and disposable aprons when there is risk of exposure to bodily fluids, sanitisation of
surfaces, and particular care with sharps.
One of the nursing staff received a needle stick injury within hours of Amanda's arrival in the
CCU. Handwashing and use of gloves was intermittent. There was no use of masks or aprons.
I saw no evidence of any sanitisation of surfaces. In addition, no instructions on handwashing
and other hygiene procedures were given to first time visitors to the CCU, nor did there
appear to be any monitoring of hygiene practised by visitors.
Practice in the surgical ward appeared to be even worse, with no evidence even of minimal
infection control procedures such as regular hand washing or use of gloves.
If such lax practice is allowed to continue, major outbreaks of resistant pathogens are
inevitable.
Resource Management
Just the brief comment that without adequate numbers of staff, it is impossible to provide
adequate care. I understand the difficulties of rostering staff, sharing staff across multiple
departments, and funding adequate staffing on a limited budget. But expecting two nurses to
care for up six critically ill patients, as happened twice while I was present in the CCU, is
practically inviting life-threatening failures in nursing care.
Risk Assessment and Management
It was not possible for me to ascertain what risk assessment and management procedures are
in place at the hospital. But I would question the effectiveness of any existing system. The
enormous and easily predictable risks associated with dramatic understaffing in the CCU are
just one example of failure to recognise and assess a significant level of risk, and take steps to
avoid or mitigate it.
Another area of risk is insufficient attention to critical issues relating to individual patient care
such as medication and mobilisation. As I noted above under communication, this is relatively
easy to overcome through a single page of Critical Care Notes, which nursing staff are required
to read and initial.
Failures in diagnosis, perhaps the most notable recent example of which was the 'flea bite'
meningitis debacle which resulted in the death of toddler Jarius Tobin-Field (the hospital's
ability to find an 'independent' doctor to say its actions were reasonable notwithstanding)
could also be substantially reduced if adequate diagnostic and risk assessment procedures
were in place. This could be as simple as saying 'If a child presents with any three of the
following signs or symptoms, this action should be taken.'
Failures in drug administration can be avoided if patient ID is checked on every occasion
restricted or dangerous medication is administered. Safety is enhanced if medication is
checked by a second staff member, but not when, as seems to be the practice at Whanganui,
the second staff member simply glances at the bottle and agrees with what the first staff
member has said. For checking to be effective, the second staff member must read the
medication name and dosage aloud, independently and without any prompting, and then, also
independently, check the patient ID. While this process takes a few seconds longer, it negates
as far as is practically possible, any chance of incorrect drug administration.
Finally, lack of familiarity by nursing or medical staff with appropriate management of any
given illness, injury or treatment regime carries high risks for the patient concerned. In
Amanda's case this was potentially life-threatening because of staff unfamiliarity with the
need for high levels of attentiveness in tracheostomy airway management.
This problem can easily be overcome if staff are properly briefed on issues and risks relating
to uncommon or unfamiliar illnesses or situations when they occur, and if the culture of the
hospital is such that staff feel safe in asking for more information or support when they need
it.
A key part of risk management is that whatever processes are put in place, some particular
person must be appointed to be responsible for the actual outcome. This would normally
mean ensuring that information is quickly and clearly communicated to those who need it,
monitoring to check that agreed procedures are actually employed and reviewed as necessary,
that proper records are kept, etc.
Conclusion
Current hospital management seems to operate under the view that risk to the hospital's
reputation is the primary consideration. It is not. Minimising risk to patients, and taking
every reasonable step to ensure best practice leading to best possible health outcomes is, or
ought to be, the primary consideration at every point, by every staff member.
As I noted at the beginning, problems at the hospital are systemic, and are rooted in a deepseated and unhealthy culture which is highly resistant to change. If Whanganui Hospital is to
provide the health care services that the people of Wanganui and district deserve and are
entitled to, there must be a genuine, immediate and high-level commitment to change that
culture, and to remedy identified shortcomings in clinical care.
Peter Wales
BTh, MCTS, MCITP, A+ IT Tech, CTT, Project+
74 Pitt St
Wanganui 10/3/09