09HDC01565 - Health and Disability Commissioner

Health and Disability Commissioner
86. The nursing handover took place in the seminar room at approximately 6.45am. RN
Ms J told HDC that this had already become usual ward practice by the time of her
orientation to the SCU two years earlier. Mr A‘s care was handed over to RN Ms K,
who recalls being told that all of the postoperative patients had had uneventful
nights. 26 The only point of note in relation to Mr A was that he snored heavily but was
easily roused. RN Ms K recalls that she was told Mr A‘s vital signs were stable.
Specific figures were not reported, as was usual when signs were normal and there
was no apparent cause for concern.
87. RN Ms J subsequently told HDC that it was usual practice for one nurse to remain at
the nurses‘ station during handover, and that it was possible from there to hear the
alarms on the oxygen monitors in SCU. She states that following handover that
morning, she relieved the RN at the nurses‘ station for a few minutes while that nurse
gave her handover, and that Mr A‘s monitor did not alarm during this time. This
indicated to her that Mr A‘s saturation levels were above 92%.
88. RN Ms K states that handover finished at approximately 7.05am, after which she and
her colleagues went to the nursing office, where they discussed their workload, teams,
and staffing for the shift. RN Ms K states that there were no specific concerns about
workload or patient allocation, so she was in the nursing office for approximately one
minute. She collected the clinical records and drug charts for the patients under her
care, checked that none of the medications due at 7am required checking by two
nurses or were medications not held in SCU, and proceeded to SCU.
89. All three patients were due to be observed at the same time. RN Ms K recalls that
when she entered the room, she noticed that the curtain was pulled around Mr A‘s
bed, although from her position in the room she could not tell whether it was
completely drawn or whether there was a gap near Mr A‘s head. She later said it was
not unusual for curtains to be closed for short periods, for example when a patient is
having a catheter inserted, or has visitors. RN Ms K recalls that she did not hear any
snoring, which she took to mean Mr A was either awake or sleeping in a position that
did not partially obstruct his airway. His snoring had been reported as intermittent.
90. As she entered the room, the patient from bed space one was coming out of the
bathroom. She spoke with this patient, who was keen to be discharged and had some
questions about this. RN Ms K said at the same time she noticed that the patient in
bed space three appeared to be sleeping. The sleeping patient‘s monitor was switched
on, and indicated that his pulse and oxygen saturation levels were within acceptable
levels. She therefore proceeded to record the observations of the ambulatory patient
first. RN Ms K estimates that she would have been with this patient for approximately
five minutes.
91. She then moved on to the patient in bed space three, who by this time had woken up
and appeared to be in some pain. She was about to record his limb strength when she
realised she had Mr A‘s chart. She crossed out the recordings she had already made in
Mr A‘s chart, and re-entered the information on the correct chart. RN Ms K recalls
26 RN Ms K was a Level 5 RN.
5 September 2012 16
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.