Hawke’s Bay Hospital recorded three deaths that were deemed to be preventable during the 2010/2011 year, according to a report released by the Health Quality and Safety Commission into serious and sentinel events.

Two of the deaths at the hospital were listed as falls. One fall resulted in a fractured hip and the patient died three days later.

The report said a staff member left the patient unsupported for a short period of time.

One other death was also listed as a fall that resulted in a fractured hip, as well as arm and head injuries, with the patient dying 23 days later.

The report said the fall was the result of “impulsive behaviour” and aspiration pneumonia was a contributing factor to death.

The third preventable death was of an infant who died several hours after birth. The commission’s report said there was a failure to identify maternal and foetal deterioration during labour and a miscommunication between the independent midwife and medical staff.

The deaths were classified as “sentinel events” by the report, events defined as life-threatening or which had led to an unexpected death or permanent major disability.

Hawke’s Bay Hospital also recorded four serious events, which led to extra treatment but were not life threatening.

The figures could be compared to the commission’s 2009/10 report, which said there were six deaths and four serious events.

The hospital’s chief medical officer and co-chairman of the Hawke’s Bay District Health Board’s clinical council, John Gommans, said each event was thoroughly investigated.

“These events are very distressing especially for patients and families, as well as the clinicians involved,” Mr Gommans said.

“The report helps us improve the quality and safety of our clinical services to reduce the risk of them happening again.”

The DHB had decided to set up a Falls Minimisation Committee responsible for reducing injuries from falls in hospital and the community.

Nationally, injuries related to falls were up from 130 to 195. It was one of the leading causes of morbidity and mortality in older people. Falls in the community were the single biggest reason for people over the age of 65 visiting emergency departments.

The new committee, which was led by director of nursing Chris McKenna, would develop ways to prevent injury from falls and report monthly to the clinical council.

Dr Gommans said the hospital was now screening patients for their risk of falling and was using wrist bands to identify patients most at risk.

The DHB had also bought beds that could be lowered to floor level so if a patient did attempt to get out of bed unsupervised, they would not fall from a height.

Nationally, 11 patients had surgery on the wrong body part, received the wrong procedure, or missed treatment altogether when it was performed on the wrong patient. In one mishap, a patient had their digestive system treated – a procedure meant for another patient – because the name label was attached to the wrong person’s form.

Auckland DHB topped the list for medical mishaps in 2010/11, with 56 events, followed by Waikato, 53, and Canterbury, 49.