There were 61 adverse events in total, 74% more than in the previous year.
It includes the cluster of 30 ophthalmology cases admitted last week by the SDHB. The patient who died after the ultrasound machine failed had been recovering from major head or neck surgery.
"On calling for and getting the ultrasound machine in order to establish the exact position of the airway, the ultrasound machine did not function appropriately, and so time was lost while another machine was provided."
Another patient died after a delayed diagnosis of a chest malignancy. The failing was blamed on "poorly integrated" systems in radiology. A patient with sepsis lost fingers and toes because of a delay receiving antibiotics.
The diagnosis itself was delayed, but even when it was established, there was a "long delay" before the patient was given antibiotics. It prompted a reminder to health staff about the need for urgency in sepsis cases. An investigation of the third patient death had not been completed, but it involved a delay following up a patient admitted to hospital with vomiting and diarrhoea.
The fourth death was caused by a fall, and an investigation found that not all reasonable actions to prevent the fall were taken.In another case, a child protection failure led to a recommendation that clinicians be reminded to follow up inconclusive radiology reports.
"Important clinical information was not communicated to clinical teams and was not included in the clinical details section of radiology request forms.
"SDHB paediatric radiology service should implement a district radiology policy for non-accidental injury to children."
Other cases included a referral delay for metastatic cancer (investigation pending), a lost breast cancer referral, and a significant haemorrhage in a home dialysis patient.
Nationally, 520 events were disclosed by the 20 DHBs yesterday, which was five fewer than in 2014-15. The DHBs report adverse events to the Health Quality and Safety Commission, which co-ordinated the release of the 20 reports. Commission chairman Prof Alan Merry, of Auckland, said 44 events relating to ophthalmology were reported nationally. Nelson Marlborough DHB was the other board with a cluster of harm among eye patients; it reported 11 adverse events in ophthalmology.
The Royal Australian and New Zealand College of Ophthalmologists has warned patient harm caused by resource constraints is likely to be under-reported in the sector, and yesterday the commission commended the two DHBs.
"This year, Southern and Nelson Marlborough DHBs both reported a number of individual ophthalmology events, including a delay in follow-up appointments,’’ Prof Merry said.
"The commission commends these DHBs for showing leadership in this reporting.
"These DHBs are currently reviewing these events, and will make improvements based on the findings.
"This is a prompt for other DHBs to look closely at their ophthalmology services to ensure people are being seen in a timely manner, with high-risk patients prioritised. We anticipate more of these events will be reported next year, as DHBs focus on improving reporting in this area," Prof Merry said.
Only two of the SDHB ophthalmology cases have been formally reviewed, and the board has commissioned a mass external review of cases, which is yet to start.
