"Communication between health professionals and across health centres"

About: Box Hill Hospital / Emergency Department Box Hill Hospital / Intensive Care Unit Maroondah Hospital Maroondah Hospital / Emergency Department Peter James Centre Wantirna Health

(as a relative),

My father was a strong, intelligent and reasonably healthy a few months ago. Within a few days, his behaviour became challenging. My mother rang one morning because she was quite distressed and unable to manage him. We sent him to Maroondah Hospital in an ambulance. He was admitted to undergo assessment and placed on a general ward. Two days later he 'escaped' from the ward and walked an extremely long distance home without anyone knowing. The family were out looking for him but he managed to get home. He found the admission to Maroondah distressing, constantly worrying that the alerts over the microphone meant that someone in the family was dying. It seemed Maroondah Hospital was unable to provide my mother with any support so a few days later she took him to his local GP. The whole time we were in the GP's room Dad was chatting away. The GP turned to him and said he needed to go back to Maroondah for assessment or he could go to Box Hill Hospital. He chose Box Hill. While he was in the Emergency Department he was increasingly agitated, so eventually, he was sent to Peter James Centre for observation and assessment. His behaviour became increasingly agitated and he was breaking things and he told us he was in a war zone and the only way his family could survive was for him to die. It was heartbreaking. After a week or so he was assessed as having pneumonia. He was then sent back to Box Hill Hospital. While he was in BHH his pneumonia turned septic and his heart started going bad (AF - atrial fibrillation). He was placed in the Intensive Care Unit at this stage as they were having to call an emergency code on a regular basis. From this time on the family kept telling the doctors and nursing staff that his behaviour was a new thing and he had been a strong and reasonably healthy man. We also told them about our experience with Maroondah so he wouldn't end up in an unsafe environment. We had to tell them the story every day. After over a week in the ICU, he was transferred to a regular ward at BHH and we continued to tell them about his walk home from Maroondah and that he had been reasonably strong and healthy before all this happened. It was several weeks into his care. Eventually, they assessed him as medically stable and referred him for rehab. Despite our many warnings, he was sent to an open ward at Wantirna Health. I spent half the day on the phone that day trying to have him moved to a more safe environment at Peter James. But we also spent the day with Dad, trying to keep him safe, to not give him a chance to walk home. His transport started in the morning that day, and we got him safely to Peter James by that evening. He had just come out of the ICU! We were exhausted, my mother could barely walk and my father....well I do believe he slept well that night. We are all still recovering; frankly, we are all exhausted. The problem was twofold. There seemed to be a distinct lack of communication between staff about the whole story, and my mother couldn't get information about what was happening. I had to ring and persist until our concerns were heard. I can only hope Dad and Mum recover. The care day to day was wonderful. But every day we had to tell the staff our story. In addition, the barrier in communication was made much harder by, we believe, the staff standing behind their computers, not looking up or providing a safe environment for Mum to ask questions or answer questions. As time progressed, that communication barrier became even more of a problem.

Responses

Response from David Plunkett, Chief Executive, Eastern Health

picture of David Plunkett

Dear communication breakdown,

I was very concerned to read your story on Patient Opinion and would like to apologise for the experience you and your family had across a number of the Eastern Health services. I found your feedback distressing on a number of fronts, but particularly that you needed to repeat yourselves every day with what sounds like the same information regarding your father.

Could I please ask if you can make contact with the Eastern Health Centre for Patient Experience on 1800 EASTERN or feedback@easternhealth.org.au so we can undertake a full investigation of your father’s care?

Once again, I am sorry that your experience fell well short of expectations and I too hope your parents are able to move forward.

Kind Regards

David

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Update posted by communication breakdown (a relative)

Hi David

Thank you for your concern. I'll be in touch.

Response from David Plunkett, Chief Executive, Eastern Health We are preparing to make a change

picture of David Plunkett

Dear communication breakdown

Thank you again for providing your comments and feedback and also for making contact with the Eastern Health Centre for Patient Experience. I understand in addition to the discussions you have had with the staff in the Centre for Patient Experience, a member of the Eastern Health Executive team spoke with you where you were able to again highlight these concerns.

I would again like to offer my sincerest apologies for the experience you and your family have had.

As mentioned in yesterday's discussion, a full investigation will be undertaken and we will make contact again with you when this has been completed to talk through our findings and actions we will be taking so other families don't have the same experience you and your family have had.

I hope this provides some assurance we are taking your comments and concerns seriously and will be doing all we can to implement these improvements.

Thank you again

David

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Update posted by communication breakdown (a relative)

Thank you David. The concerns expressed I believe are a systematic problem. Our family’s experience highlights where things can go seriously wrong despite strong advocacy by my family. I am pleased that our story has been taken seriously. I have studied this issue in great depth and would be happy to share an insight into how these complex cases can be better managed during the review, if I may. Again I appreciate your response and the day to day care given to my father. I know EH has been a forerunner in improving patient experience.

Response from David Plunkett, Chief Executive, Eastern Health We have made a change

picture of David Plunkett

Dear communication breakdown

Thank you again for the opportunity to review the care experience for your family when your father was a patient of Eastern Health.

We appreciate the time you took to not only provide your feedback here on Patient Opinion but also in meeting with our staff to discuss your experience in person.

The Eastern Health Patient and Family Care Standard guides our staff on communicating effectively with patients and their families. From the information you have provided, it is clear that your experience has not been one of where the expected standard has been met and we apologise to you for this.

Your feedback has not only enabled us to review the care provided to your father but to look for improvements in the care we provide to all patients and their families. As a result, we will use the examples you have provided in a de-identified way to remind staff of the importance of ensuring that communication is open and clear and responsive to the individual needs of each patient and their family.

Thank you again for taking the time to report your concerns and meet with us so that we can improve.

Kind regards

David

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Update posted by communication breakdown (a relative)

Thank you Eastern Health for your comprehensive response. I hope that communication across different parts of the organisation as well as between services is improved. I understand it is hard. But the result of the breakdown in my father's case was extended time in hospital and trauma to my family that continues today. The care given to my father during his stay was excellent. So it really was the communication breakdown that was key to his care needs. Thank you again for your comprehensive review and feedback.

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