The Health Quality and Safety Commission New Zealand recorded 631 serious adverse events across the 20 DHBs this year.

Baby deaths, delays in cancer diagnosis and items left inside bodies after surgery were among the "adverse events" recorded at Auckland hospitals in the past year.

Across the country, 631 adverse events – unintended or unexpected events that result in a patient being seriously harmed – were recorded by district health boards in the 12 months to June this year.

That was up from 542 the previous year, according to the Health Quality and Safety Commission's annual report.

Stuff looked at how Auckland, Counties Manukau and Waitemata DHBs fared.

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AUCKLAND DISTRICT HEALTH BOARD

Auckland DHB reported 96 adverse events, including 34 falls causing serious harm and 10 serious pressure injuries.

Included in the report was a delay in recognising seizures in a baby, resulting in a brain injury.

Fourteen people suffered deteriorated vision due to delayed treatment, the DHB said.

Jason Oxenham Auckland District Health Board had the highest number of serious adverse events, with 96. Four were not included in HSQC's number.

A number of patients experienced a delay in the detection, diagnosis or treatment of cancer; two put down to delays in radiology imaging and reporting.

A delay in recognising and treating high blood sugar levels in a patient with multiple illnesses contributed to their deterioration and death, the report said.

In another case, medication was given to a patient with a "known risk", landing them in the intensive care unit, while another died as a result of complications from medication.

Incorrect contraceptive advice was given to another patient, resulting in an unwanted pregnancy.

At least four events were to do with foreign bodies, swabs or vaginal packs left in patients after surgery.

Reviews were in progress for a patient who suffered "several complications" after brain surgery and died; a patient who unexpectedly died while being transferred wards and an incident where a patient injured another, resulting in a fracture.

COUNTIES MANUKAU DISTRICT HEALTH BOARD

Among CMDHB's 42 serious adverse events were the death of four babies, up from three newborn deaths last year.

In its report, the DHB stated inadequate assessment and management of a high-risk pregnancy resulted in the death of a baby before birth.

A "lack of oversight" and "inadequate continuity of care" meant risk factors for the baby and mother, who had pre-eclampsia, were not recognised by staff.

A second baby died after a "breakdown in co-ordination of care", while another baby, who had severe growth restrictions, died because of inadequate monitoring during pregnancy.

ABIGAIL DOUGHERTY/STUFF Counties Manukau DHB reported fewer adverse events in 2017/18 than the two years prior, HQSC said.

A person suffered a heart attack after having an allergic reaction to iodine.

Two patients became infected with a antibiotic-resistant bug while in hospital. The investigation found personal protective equipment usage and the containment of contaminated items, such as medical equipment and linen, was inadequate.

A patient was given a nerve block on the wrong side of their body, and two women had vaginal packs left inside their bodies after surgery.

This year, 25 patients were seriously injured after a fall in hospital at Counties Manukau. These injuries included "significant" head injuries and broken bones.

WAITEMATA DISTRICT HEALTH BOARD

In 2017/18, there were 41 confirmed serious adverse events investigations at Waitemata DHB, down slightly from 45 last year.

Among this year's reports was the death of a twin 32 weeks into a pregnancy.

While the pregnancy was appropriately monitored, the fetal heart beat was "not reassuring" and the "suspected demise" of one baby was "not communicated appropriately to the family", an investigation found.

Piotr Stryjewski 123RF At Waitemata DHB (North Shore Hospital and Waitakere Hospital) falls accounted for the majority of adverse event reports.

A patient who died of a pulmonary embolism after surgery was found to have not been given blood-clotting medication when discharged.

Another patient died from an internal bleed, while another had skin lesion surgery performed on the wrong area.

Falls with major harm accounted for the majority of Waitemata DHB's reports (18), resulting in fractures and leaving one patient with a concussion.

LEARNING FROM ADVERSE EVENTS

HQSC chairman Professor Alan Merry said adverse events could have a "devastating effect" on patients and their whānau.

"Every event described here has a person at its centre.

"Adverse event reporting makes it possible to review each event, discover the reasons behind it and put recommendations in place with the aim of preventing anything like it from happening again."

Merry said the significant increase in reported events reflected changes in reporting requirements, and the Commission placing a "spotlight" on specific areas.

A total of 232 MHA adverse events were reported by DHBs across the country.