St John would like to respond to claims in the New Zealand Herald this morning that three patients lost their lives after St John life-saving defibrillators failed in a blunder linked to the ambulance service's poor record keeping.
This is incorrect.
What is correct was that St John staff raised concerns in these incidents mentioned, because of defibrillator issues. This was clearly explained to the New Zealand Herald. St John reviewed those incidents and determined that in three of the four incidents the defibrillator failures did not impact on the patient outcome. In the fourth, we could not rule out that possibility entirely. In that instance St John contacted and met with the family of the patient to share the findings of the investigation.
As part of our investigation process we always ask ourselves the question is this a case where it is both right thing to do and transparent to share directly with relatives and loved ones. St John’s threshold is very low to trigger this as we are committed to transparency fairness and openness.
St John has since issued every front line ambulance in NZ with a backup Automated External Defibrillator (AED) to completely mitigate this risk in future which is a step that not all Ambulance services have done internationally but such is St John’s commitment to patient safety.
St John Clinical Director Norma Lane advised the NZ Herald last week “We have to acknowledge the nature of our business is emergency care where unfortunately some patients lives are hanging by a thread and sometimes, with every best effort and endeavours, we lose that very last battle through no fault of anyone. In these circumstances the underlying clinical condition is such that we couldn’t affect or reverse that tragic outcome. That was the case in the three incidents where the defibrillators did not work properly.”
St John deals with over 350,000 incidents per year and on average we investigate 20 ‘reportable events’. These are incidents which result in harm or death to a patient or ‘near miss’ incidents which under different circumstances could have caused harm to a patient but did not.
“It is crucial that St John has a learning culture which doesn’t make anyone involved afraid to report an incident whatever the scale or level. Learning lessons and striving to improve care, improves patient safety so we mustn’t push it underground.”
What the NZ Herald did get right is that St John is focussed on finding ways to serve patients better – as Chief Executive Peter Bradley says “For me, the biggest thing is putting the focus on patients.”
Additional information:
St John is like other parts of the Health sector e.g. Hospitals in that we investigate our reportable events internally and report to the Ministry of Health. External scrutiny is provided where appropriate from the Health & Disability Commission and for us when we participate and contribute to Coronial hearings where we share very openly all of our information from call recordings to patient records and staff statements.
For further information please contact:
Robyn Bern
Head of Communications
St John
T 09 526 0528 X 8095
M 021 364 484
E robyn.bern@stjohn.org.nz