Keeping patients safe

A woman who had suffered a stroke sustained a serious burn as a result of a hot water spill from her meal tray. The burn – which required a skin graft – had an adverse impact on the woman’s recovery and extended her stay in hospital. Her son complained to the Commission.

In its response, the Area Health Service advised that, as a result of a review called the ‘tea cup project’, all stroke patients were now assessed for their suitability to be served hot beverages. This project found that about 30% of patients admitted to the hospital’s stroke unit should not be drinking hot beverages without assistance.

The complaint was assessed as being suitable for assisted resolution. As part of the resolution process, hospital staff met with the family and explained its tea cup project. They also offered further feedback in three months time about how the project was progressing.

At the resolution meeting, the family raised an additional concern about the delay in attending to their mother after she was burned. The hospital subsequently addressed this through a system to escalate the handling of emergency situations. This new system, known as PACE – Patients with Acute Conditions for Escalation – is currently being implemented across all hospitals in the Area Health Service.

After receiving a further report from the hospital on the progress of the tea cup project, the family was satisfied that their concerns had been addressed, and that effective changes had been made to prevent similar incidents in future.

More case studies

Read more about how the Commission was able to assist people with their health care concerns.