Middlemore Hospital emergency department crisis much wider than ED and Middlemore

The public have much to be grateful for the quality health reporting which, more often than not, is provided by mainstream media. Largely shaped by the assessments of those doctors, nurses and other health professionals working at the clinical frontline, these journalists are successively revealing the true state of Aotearoa New Zealand’s health system, warts and all.

In terms of an essential ingredient of a functioning democracy, this reporting is often a good example of the Fourth Estate in action. It strengthens the transparency and accountability of the health system.

Among these journalists is Steve Forbes from Local Democracy Reporting. Based in Auckland he has extensively covered issues at the former Counties Manukau District Health Board, including Middlemore Hospital. Invariably his articles are based on insights provided by frontline health professionals and documents obtained either through official channels or leaks.

Quality health reporting by ‘Local Democracy Reporting’

Forbes’ most recent article (17 October) covers an independent inquiry into the tragic death of a female patient in Middlemore Hospital’s emergency department on 15 June: Independent investigation slams hospital patient death in damning report.

His well-written article centres on the independent report (30 September) into the women’s death by Dr André Cromhout, an emergency medicine specialist based at Wellington Hospital. This death followed her leaving the department upon being told it would take hours to be seen (triaged). His conclusion is that the emergency department of New Zealand’s biggest hospital is unsafe for both patients and its staff.

Scathing report

The five-page report is scathing. On the night concerned the emergency department was “…at least 30% over-capacity, leading to a large number of patients awaiting assessment and/or treatment in the waiting room…”

Dr André Cromhout has produced an excellent independent report into Middlemore Hospital’s emergency department: revealing and heart-breaking

The data “…painted a stark picture of a hospital system under enormous pressure…” But 15 June was “…not an isolated day.” Again the data revealed a “…stark rise in presentations, reaching record numbers.”

Dr André Cromhout then observes:

Overcrowding, long  delays in ED assessment and delays to ward transfers are sadly far too common in hospitals and Emergency Departments across Aotearoa New Zealand. Overcrowding, which refers to the situation where ED function is impeded because the number of patients exceeds either the physical and/or staffing capacity of the ED, is the most concerning issue facing Emergency Medicine across Aotearoa New Zealand and is a critical indicator of a system dysfunction.

The report is adamant that neither the patient nor the emergency department staff were at fault. Cromhout affirms that the staff acted in good faith consistent with acceptable practice. The issue was that they were under significant pressure.

In response to this report Te Whatu Ora (Health New Zealand) chief executive Margie Apa (also former Counties Manukau DHB chief executive) stated that she recognised the issues it raised. She advised that Te Whatu Ora is carrying out a national review to look at what it can do to better support staff and prepare services for winter next year.

Margie Apa, Health NZ and former Counties Manukau chief executive: not responsible for tragedy but must be central to its solution

A national health system systems failure

It is good that Te Whatu Ora appears to be accepting that the patient’s death is a tragic symptom of systems failure. It is easy to take a pot-shot at Margie Apa because she was in charge of Middlemore Hospital from 2018 until this year. However, that would be cheap and unjustified.

Although Middlemore is our biggest hospital and, due to the poor health status of much of its population, the busiest for acute admissions, the systemic issues apply not only to beyond its emergency department but beyond Middlemore itself. The patient’s death is symptomatic of a national rather than local systems failure.

The severe pressures on Middlemore Hospital and its emergency department exist in all the country’s public hospitals. On 5 November Stuff reported how this crisis is effecting patients at Nelson Hospital’s emergency department: Nelson Hospital emergency department’s crisis leads to parked ambulances and patients in corridors.

For some years public hospitals have been caught in a vicious vice. At one end they are faced with increasing acute admissions (treatment too dangerous to be delayed) owing to increasing illness in communities. This is largely due to worsening external social determinants of health such as poverty.

At the other end of the vice is the impact of protracted and worsening health workforce shortages due to neglect by both National and Labour led governments. Hospitals therefore are caught between increasing demand that they have no control over and too few health professionals  to cope.   

In normal circumstances when patients present to an emergency department they will either be diagnosed and treated before discharged (within three hours) or because of the complexity and seriousness of their condition admitted into the relevant part of the hospital (within six hours).

But, in the abnormal circumstances (which are being cruelly normalised by the political leadership of the health system), it means that inpatient wards are jammed full of patients meaning that emergency departments can’t refer into the hospital those who need to be referred.

The net effect is that, in the first instance, this is hospital-wide systemic failure. This failure is made worse by  the extreme circumstances of EDs being unable to even triage patients in a timely manner. But it is also a national health system failure for which its leadership must take responsibility for.

What government must do

Health New Zealand’s national review might be genuine. But there have been many previous reviews of different forms over several years. Rather than a review the health system, health professionals and the public need a practical action plan.

The answers are three-fold and clear.

  1. The government needs to address the external social determinants of health that are increasing the pressures on public hospitals (including their emergency departments) beginning with poverty (incomes).
  2. The government should require Te Whatu Ora to develop, in conjunction with the relevant health unions, strategies to address the shortages in the different health professional occupational groups. This includes the need to be internationally competitive (particularly with Australia because of its proximity).
  3. The government should ensure that Te Whatu Ora is sufficiently funded to ensure this requirement happens.

 If these three basics are not done then New Zealanders will continue to put up with more of the same. Over to you Labour and National. See what you can do!

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