FOUR Tairawhiti babies died because of potentially preventable medical mishaps, according to the third annual release of serious and sentinel events by the Ministry of Health.

Another patient at the hospital died when they deteriorated unexpectedly after an acute hernia repair operation.

Tairawhiti District Health recorded six of the 92 deaths nationwide that occurred because of potentially preventable mistakes.

TDH had a total of seven adverse events.

The report, released yesterday by the ministry’s Quality Improvement Committee, listed 308 adverse events at DHBs which caused, or had the potential to cause, serious lasting disability or death.

Investigations into each event at TDH had either been completed or were under way and staff were in the process of implementing changes and recommendations.

The coroner is investigating four of the six deaths.

Tairawhiti District Health board chief executive Jim Green said events of this kind were tragic for the families and health professionals involved.

“We owe it to them to take every possible step to learn from these events and limit the chance of the recurrence of similar events,” he said.

“We have made every effort to find out the root causes and apply the learnings to the areas where they have occurred, or more widely if appropriate.

“While every event is concerning and one perinatal death is one too many for our community, the 2007 Perinatal and Maternal Mortality Committee report released publically last week shows that Tairawhiti did not have a perinatal-related mortality rate significantly different to the national average,” said Mr Green.

“This is reassuring but in no way reduces our resolve to find ways to eliminate these events where it is possible.”

Last year 258 adverse events were recorded in New Zealand hospitals, three from TDH.

The increase was largely due to a more robust reporting system adopted locally as part of a national programme to increase reporting and learning from these events, said Mr Green.

The increase in events recorded included the four perinatal deaths, which would not have been listed in previous years’ reporting.

Of the four babies who died, one was due to a concealed placental abruption and two were not monitored enough during labour and the babies’ distress was not identified until it was too late.

The fourth was delivered by C-section but this was not done urgently enough. A review found the infant resuscitation equipment needed upgrading and improved categorisations of emergency C-section were needed.

A review into the death of the person who died after an acute hernia operation found patients who were admitted to ICU unexpectedly needed a thorough handover process.

Another recorded death was a person who committed suicide the night before an appointment with the mental health acute assessment team.

The seventh adverse event involved a wrong-side prosthesis inserted during elective surgery. Replacement was not necessary and the patient regained a full range of function.

Each adverse event was investigated by a team of health professionals

MOH’s principal medical adviser David Galler said all deaths and injuries were of great concern to DHBs.

“However, the reality is that even with the best people, processes and systems, errors can occur. When they do, we need to find out what went wrong, whether it could have been prevented and what improvements or changes should be made.”

Each year about 950,000 people are admitted to public hospitals. The report showed about three in 10,000 were affected by a serious incident.

The number was expected to continue increasing as the reporting system was improved.