Braemar Hospital <\/a>told HDC that the patient\u2019s skin must be in direct contact with the mattress sensors.<\/p>\nThe control unit, which operates the mattress, has several audible and visual alarms to indicate issues with the mattress and\/or control unit.<\/p>\n
If an alarm is triggered, an error code appears on the screen and the heating function automatically turns off.<\/p>\n
When the mattress is set and\/or reset, it starts a gradual \u201cwarming-up process\u201d, during which it can \u201cspike\u201d up to a temperature of 43C before settling at 39C.<\/p>\n
![\"Health]()
Health and Disability Commissioner Morag McDowell investigated the woman’s complaint. Photo \/ HDC<\/p>\n
The hospital was unable to determine the exact cause of the woman\u2019s burns. <\/p>\n
But an internal investigation found the most likely explanation was the placement of a saline bag under the woman\u2019s armpit.<\/p>\n
This could have affected the heat regulation sensor on the mattress, causing it to alarm, which, when reset and reheating, caused a spike in temperature briefly to 43C.<\/p>\n
Another explanation was that it could have been a combination of heat and pressure from the woman\u2019s hip area, when positioned in the right lateral position for an extended period, which could have heated that area above the usual 39C, the decision said. <\/p>\n
Alarm sounded twice during surgery<\/p>\n
Braemar Hospital told the HDC that the mattress alarm was triggered twice during the surgery.<\/p>\n
Instead of determining why the alarm had gone off, the staff turned the mattress back on.<\/p>\n
The hospital said this was common practice and had previously not led to any problems.<\/p>\n
However, it acknowledged this was concerning and that theatre staff did not follow standard process.<\/p>\n
In an emailed statement to NZME Braemar Hospital chief executive Fiona Michel said the hospital was \u201cdeeply concerned\u201d that a patient was harmed while in its care.<\/p>\n
\u201cWe apologised to the patient both in person and in writing at the time of the incident, and again this year through the Commissioner\u2019s office. We remain very sorry for the injury and the impact it had on our patient\u2019s recovery. <\/p>\n
\u201cThis case has continued to inform how we deliver care to the thousands of patients we see each year. <\/p>\n
\u201cConsistent with our Braemar Way, we have shared an anonymised case study with our staff and the specialists who practise here, reinforcing a culture of transparency, learning and continuous improvement, with patient safety as our constant priority.\u201d<\/p>\n
Commissioner McDowell said Braemar Hospital breached the Code of Health and Disability Services Consumers\u2019 Rights, which the hospital accepted.<\/p>\n
\u201cBraemar Hospital had a duty to provide an adequate standard of care to its patients while adhering to its internal processes and to the Code, which unfortunately did not occur.\u201d<\/p>\n
She recommended that Braemar Hospital provide a written apology specifically related to the identified failings and the breach of the Code identified in this report to the woman.<\/p>\n
She also recommended that staff be trained on the appropriate management of machine alarms, as well as the management of pressure relief for patients, when positioned in a certain way for extended periods.<\/p>\n
Brianna McIlraith is a Queenstown-based reporter for Open Justice covering lower South Island courts. She has been a journalist since 2018 and has had a strong interest in business and financial journalism.<\/p>\n","protected":false},"excerpt":{"rendered":"\u201cThis failure involved several people within the theatre team, and it is appropriate for Braemar Hospital to be…\n","protected":false},"author":2,"featured_media":421866,"comment_status":"","ping_status":"","sticky":false,"template":"","format":"standard","meta":{"footnotes":""},"categories":[5],"tags":[64865,806,11065,28527,138,2241,22122,78,31048,111,139,69,1597,1516,6290,51463],"class_list":["post-421865","post","type-post","status-publish","format-standard","has-post-thumbnail","category-business","tag-alarm","tag-as","tag-braemar","tag-burned","tag-business","tag-hospital","tag-ignore","tag-in","tag-mattress","tag-new-zealand","tag-newzealand","tag-nz","tag-patient","tag-staff","tag-surgery","tag-warming"],"_links":{"self":[{"href":"https:\/\/www.newsbeep.com\/nz\/wp-json\/wp\/v2\/posts\/421865","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/www.newsbeep.com\/nz\/wp-json\/wp\/v2\/posts"}],"about":[{"href":"https:\/\/www.newsbeep.com\/nz\/wp-json\/wp\/v2\/types\/post"}],"author":[{"embeddable":true,"href":"https:\/\/www.newsbeep.com\/nz\/wp-json\/wp\/v2\/users\/2"}],"replies":[{"embeddable":true,"href":"https:\/\/www.newsbeep.com\/nz\/wp-json\/wp\/v2\/comments?post=421865"}],"version-history":[{"count":0,"href":"https:\/\/www.newsbeep.com\/nz\/wp-json\/wp\/v2\/posts\/421865\/revisions"}],"wp:featuredmedia":[{"embeddable":true,"href":"https:\/\/www.newsbeep.com\/nz\/wp-json\/wp\/v2\/media\/421866"}],"wp:attachment":[{"href":"https:\/\/www.newsbeep.com\/nz\/wp-json\/wp\/v2\/media?parent=421865"}],"wp:term":[{"taxonomy":"category","embeddable":true,"href":"https:\/\/www.newsbeep.com\/nz\/wp-json\/wp\/v2\/categories?post=421865"},{"taxonomy":"post_tag","embeddable":true,"href":"https:\/\/www.newsbeep.com\/nz\/wp-json\/wp\/v2\/tags?post=421865"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}