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A disabled man choked and died after hospital staff didn’t pass on instructions from his carers to puree his food. (File photo)
A disabled man choked and died at Waitākere Hospital after he was given food that hadn’t been pureed because his dietary plan got lost in handovers, a report finds.
The man – who had a high risk of choking – needed supervision while eating and could only have pureed foods.
But in hospital, he was given a full meal and was left to his own devices to eat. Less than an hour later, the man died.
In a decision released on Monday, health and disability commissioner Rose Wall found the hospital had a “pattern of poor care” of the man and had breached the Code of Health and Disability Service Consumers’ Rights
“Hospital staff did not give sufficient attention to a significantly disabled patient who was unwell in an unfamiliar environment,” she said.
In 2021, a carer noticed one of their disabled patients’ catheter bag wasn’t draining properly.
The patient was taken to ED at Waitākere Hospital and the carer gave the hospital all his medical records – including the man’s dietary plans.
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The man was at risk of choking, needed supervision while eating and could only eat puréed foods.
The man – who was in his 80s – had dementia and a severe language impairment with minimal capacity for communication.
During his short stay in hospital, he was transferred between four different units.
When he first moved, the man’s dietary plan was not included in the handover. In the second move, his dietary information was recorded incorrectly.
The handover said he needed to be on a soft mechanical meal – which includes easy-to-chew food – rather than pureed meals.
When he transferred to the last ward, there was no handover documentation at all.
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This “communication breakdown” meant staff got his meal mixed up and the information about his choking risk and need for supervision was not passed on.
A healthcare assistant brought the man a soft mechanical meal.
They sat him in an upright position, place a food tray in front of him, and left him so they could hand out dinners to other patients.
“Shortly afterward, [the man] appeared to be choking. He then became pale and unresponsive and subsequently suffered a respiratory arrest and died,” the report said.
The Coroner found the preliminary cause of the man’s death was an aspiration event.
A Te Whatu Ora review found that there was a “lack of clear documentation” in the handover of the man’s dietary requirements.
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Health and disability commissioner Rose Wall found the hospital had a pattern of poor care.
It also found that there was a “lack of provision of adequate supervision and assistance”.
The man’s information was not documented clearly and properly handed over between teams, Te Whatu Ora admitted.
Wall made several recommendations, including that the hospital train all relevant staff on handover practice expectations and the importance of following patients’ dietary requirements.
Wall also recommended Te Whatu Ora review the quality of clinical documentation across all departments to ensure patient requirements are being recorded accurately.
Since this incident, Te Whatu Ora has reviewed its handover documentation and included specific field were patient dietary requirements must be recorded.
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