In the health services, and clinical environment in particular, we are sworn to; “First, do no harm” as the cornerstone in the delivery of health care. However, unintentional harm does occur at all levels of the health system, both public and private. Despite the recognition that patient safety as a fundamental part of the drive to improve quality of care, insufficient attention had been invested to address the problem in a concerted and consequential manner.
Yesterday; we were alerted by Addington Hospital Management that on 2 August 2010 at 14h45 an unknown corpse was found in the plumbing duct on the fifth floor by an air conditioner technician who was requested to investigate a foul odour emanating from the fifth floor toilet. The decomposing body was of a female, whose identity has not yet been established. No inpatient identification bands were found on the body. The person was dressed in private clothing and not hospital attire.
A full inspection of all 15 floors was done by management. This revealed that only two doors to plumbing ducts were found to be unlocked viz. Ward 9A and 11A of the 15 floors. It seems as though the deceased may have dropped from the higher floors (presumably the 15th) of the building and landed on the fifth floor.
The structure of Addington hospital in the tower block is such that plumbing ducts traverse through all 15 floors to basement in a continuous column. The ducts are located adjacent to specific patients’ toilets near the nurses’ station. A door accessing the duct leads from each of these toilets on each floor.
The circumstances surrounding her death have not yet been established neither has any person come forward. We are working closely with the South African Police Service (SAPS) in putting together details.
You would know that recently a body of a patient was discovered at Ngwelezane Hospital three days after she disappeared from the ward. Again, another body was discovered at Madadeni Hospital and some of you were with me when I visited Prince Mshiyeni Memorial Hospital, a few months ago, where also body of a female was discovered, also in a state of decomposition.
These incidents are worrisome when the World Health Organisation expects all nations to; “to pay the closest possible attention to the problem of patient safety and to establish and strengthen systems necessary for improving patients’ safety and the quality of health care”.
A number of questions flood one’s mind when we hear of these unfortunate incidents. How can a patient disappear from the ward for days? When an hour passes, what do the ward nurses say? How does a person lie in a place dead, in a busy hospital, without anybody noticing? Are security officers doing patrols? So, these are some of the questions that need to be answered.
Hospital security is a combination of many factors. The proper system, carefully chosen, installed and implemented, combined with employee awareness and education, insure that risks are kept to the minimum and protection and safety are the rule rather than the exception.
A hospital presents its own unique set of security challenges. However; more than any other type of institution, a hospital must convey a sense of safety and security. Patient safety requires competent, careful and safety conscious individuals in all departments. Ensuring patient safety is a key component of management.
In this regard; to ensure that we “pay the closest possible attention to the problem of patient safety and to establish and strengthen systems necessary for improving patients’ safety”; the following is to be done:
- We regret the loss of life, under any circumstances
- We are have taken a decision to use our staff for security functions so that the CEO is able to account for breaches in security rather than a service provider who, in most instances has many areas to look after. This also helps in the department taking responsibility for correct training of security personnel to do what is expected of them
- Working together with the South African Police Services (SAPS), our Forensic pathology unit and the management at the hospital; we are investigating the circumstances that led to her plunge to death, the lapses in person control into and around the wards and to trace the next of kin.
- Where we find that nurses have do not do a roll-call on intermittent intervals on patients admitted, disciplinary steps will be taken against those responsible, i.e. senior nurse in the ward.
- Management requires the support of all staff to ensure the security and safety of patients. In this regard, we will recommend that all staff are regularly trained on security measures and all new employees to be inducted on security policies and measures in all hospitals and clinics.
In closing; quality and patient safety are essential attributes of good health services. Delivering health care which minimises risks and harm to service users is our commitment. Quality and patient safety is one of the department’s priorities. We are committed to continue our focus on patient safety, and systems and procedures that improve safety.
Thank you!
For more information contact:
Chris Maxon
Cell: 083 285 0567
