09HDC01565 - Health and Disability Commissioner

Opinion 09HDC01565
Additional information from RN Ms I
136. RN Ms I states that she began working in the ward in March 2008, and has previous
experience in neurological intensive care, medical and surgical nursing. At the time of
these events she was a level 3 nurse. She recalls being advised during her orientation
to the SCU that it was usual ward practice to hold morning handover in the seminar
room, as long as all patients were stable.
137. RN Ms I notes that if patients are active and alert, recording respirations at prescribed
intervals may not reflect actual respiratory status. She states that it is not difficult to
assess if a patient is having difficulty breathing, and that throughout her shift it was
clear that Mr A was not distressed in his breathing. She states that on reflection, she
―could have written a more comprehensive narrative of [her] entire shift, including the
fact that [Mr A] was fully interactive and showed no sign of respiratory distress‖.
138. RN Ms I notes that since these events she ensures that:
handover in the SCU is always conducted at the patient‘s bedside;
the curtains are not drawn for any length of time unless the patient is attending
to hygiene matters or using a bed pan;
observations are recorded by way of free text in the clinical notes;
for patients using a PCA pump, observations are recorded on both the PCA and
observations charts.
139. RN Ms I‘s legal counsel, Mr P, sought expert advice from Nurse Practitioner Alison
Pirret. Ms Pirret states that respiration rate is an extremely important vital sign for the
early recognition of respiratory depression due to narcotic narcosis or increased
intracranial pressure. Accordingly, she considers that the failure to record respiratory
rate in this situation reflected an unacceptable standard of nursing care. However, Ms
Pirret states further that departmental or organisational factors may have contributed
to RN Ms I‘s failure in this regard. She notes that the neurosurgical observation chart
does not have a specific place to record this and states that ―this risks sending
messages to nursing staff that the respiration rate is of less importance when
compared to other neurological observations‖. She also states that respiration rate has
historically been poorly documented by nurses, and that the introduction of the early
warning scoring systems into New Zealand hospitals in recent years has been ―an
attempt to ensure all vital signs are documented, and if abnormal, trigger a timely and
appropriate response‖. Ms Pirret notes that there was no such system in place on the
ward at the time.
Additional information from RN Ms J
140. At the time of these events RN Ms J had three years‘ postgraduate experience, most of
which was in acute hospital nursing. She had worked on the ward since March 2007.
141. RN Ms J acknowledges that she should have documented Mr A‘s respiratory rate. She
states that she was confident in her ability to recognise respiratory distress or
deterioration in a patient, but appreciates that she must document the respiratory rate
regardless of whether the patient is in respiratory distress, and especially when the
patient is on IV narcotics.
25 5 September 2012
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.