In addition, the ADHB wound assessment form was not designed to capture objective parameters that would indicate wound progress over time, and district nurses were not recording objective assessments of Mrs A's wound consistently.
The Aquacel rope was not used appropriately and the wound was not investigated adequately, and Mrs A was not asked whether she had removed the dressings herself. The ADHB DNS screening tool categorised patients according to complexity, but lacked the requirement for specific information that would indicate potential problems the triage assessment lacked consideration of social or cultural factors that could impact on healing. It was the responsibility of ADHB to have in place adequate systems and oversight of staff to ensure that Mrs A received appropriate care. District health boards are responsible for the operation of the clinical services they provide, and can be held responsible for any service-level failures. Following the procedure Mrs A was informed that the reason her breast wound had not been healing was the presence of a 5cm foreign body, which was later identified as a piece of Aquacel rope dressing. On 24 Month5 Dr M performed an excision of Mrs A's wound. On 7 Month5 Dr N referred Mrs A to a general surgeon, Dr M. The nurse advised Mrs A to see her GP, Dr N, to obtain a referral to the surgical team. On 4 Month5 a district nurse noted that there was an increased amount of green exudate and that the wound was hypergranulated. At times the district nurses relied on Mrs A contacting her general practitioner (GP) for review rather than making the contact for her. The district nurses made regular changes to the products being used to treat Mrs A's wound, but the reasons for each change of product are not recorded. After 17 Month2, although there are comments in the clinical notes about the healing of Mrs A's wound, there is no objective record of the dimensions of the wound. However, when the district nurses visited, the end of the rope was not always visible, and it was assumed that Mrs A had removed the rope when she had not done so. When packing a wound with Aquacel rope, the end of the rope should remain outside the wound. On 17, 18, 19 and 20 Month2 the district nurses used Aquacel rope to pack Mrs A's wound. The triage form contains no reference to Mrs A's other health issues or her social and cultural factors. That day, the DNS received the referral and triaged Mrs A as a "low acuity rating", indicating that she required simple wound care management with no perceived complications. On 16 Month2 she was discharged and referred to the District Nursing Service (DNS) for ongoing wound care. 
Mrs A later developed a breast abscess and, on 15 Month2, underwent surgery to drain the abscess. Consequently, Mrs A was unable to leave the house easily, and she had limited family support in New Zealand. The delivery was forceps assisted and Mrs A suffered a third degree tear, which resulted in urinary and faecal incontinence. 
In 2013, Mrs A gave birth to her first child. Opinion: Auckland District Health Board - BreachĪppendix A - Independent nursing advice to the Commissioner Information gathered during investigation Auckland District Health BoardĪ Report by the Health and Disability Commissioner Identifying letters are assigned in alphabetical order and bear no relationship to the person's actual name. Large item freight charges apply for heavy, large or sensitive items (i.e.Names have been removed (except Auckland DHB and the expert who advised on this case) to protect privacy. 
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