09HDC01565 - Health and Disability Commissioner

Health and Disability Commissioner
74. At 10.30pm, RN Ms J came on duty and received a handover of Mr A‘s care. 23 The
handover took place in the SCU. At the same time, the duty house surgeon was with
Mr A, inserting the catheter.
75. RN Ms J states that following handover, she remained at the desk, read Mr A‘s notes,
and checked the medications that were held in the SCU.
76. At 11pm, the PCA treatment record shows that Mr A‘s pain level was one, his
sedation score was zero, and he had used the PCA three times in the previous hour.
RN Ms J recorded Mr A‘s neurological observations and his vital signs, excluding his
respiratory rate.
77. RN Ms J subsequently told HDC that although she did not record Mr A‘s respiratory
rate during her shift, she checked this while she was taking his blood pressure. She
states that checking respirations without Mr A being aware enabled her to get an
accurate count, that she counted for at least 30 seconds each time, and that she
observed the mechanism of his breathing and saw no use of accessory muscles,
tracheal deviation, or cheek puffing. Each time she assessed the rate as being within
the normal parameters.
78. In a statement for the Coroner, RN Ms J recalled that Mr A was awake between 11pm
and 1am.
Continuing postoperative care, Day 3
79. At 1am on Day 3, RN Ms J recorded Mr A‘s vital signs excluding his respiratory rate:
temperature 36° celsius, pulse 98 bpm, blood pressure 126/72 and oxygen saturations
98% on 3L/min. Neurological observations were normal and his sedation score was
four. RN Ms J gave Mr A his last dose of IV antibiotics. Mr A had used the PCA
pump throughout the afternoon and evening, receiving a total of 46mg up until 1am,
after which he did not use it again. At 1.30am, RN Ms J left the ward to collect a
patient from the PACU. She told her colleagues on the ward that she was leaving, and
was away for about ten minutes. The patient she returned with went into bed space
three.
80. RN Ms J recalls hearing Mr A snoring between 1.30am and 3am, and that this was at
a regular rate with no apparent apnoeas. She thought he sounded as though he had a
blocked nose, but this did not alarm her as his observations were all within normal
limits, and he was easily awoken and often did so spontaneously. RN Ms J states that
Mr A awoke as she approached to take his recordings at 3am. Mr A asked if he had
been snoring because his throat was sore. RN Ms J said that it would be sore from the
endotracheal tube inserted in theatre. Mr A responded that he usually snores anyway.
RN Ms J recalls that from then until she checked his vital signs at 5am, he could be
heard snoring. Vital signs at 5am were recorded as: temperature 36° celsius, pulse 96
bpm, blood pressure 138/73, and oxygen saturations 94% at 3L/min. RN Ms J
subsequently stated that the drop in Mr A‘s oxygen saturations did not concern her
23 RN Ms J was also a Level 3 RN.
5 September 2012 14
Names have been removed (except Canterbury DHB and the experts who advised on this case) to
protect privacy. Identifying letters are assigned in alphabetical order and bear no relationship to the
person’s actual name.