09HDC01565 - Health and Disability Commissioner

Health and Disability Commissioner
Additional information from RN Ms K
142. RN Ms K is a senior registered nurse, who had worked on the ward since 2006. She
has a postgraduate qualification in neuroscience nursing, ten years‘ postgraduate
experience in nursing in the neurosciences and two years‘ experience in mixed
general medical nursing.
143. RN Ms K told HDC that she felt confident in relying on RN Ms J‘s report that there
was no cause for concern in relation to Mr A and that he had been stable all night. She
notes that by this time it had been 18 hours since his surgery. With regard to the
prioritisation of patients, she states that the patient she needed to prioritise was the
patient who had returned most recently from surgery, and who was showing obvious
signs of being in pain on waking.
144. RN Ms K states further that at handover, ―you are relying on the handover nurse to
provide you with all vital information about the particular patient‖, and that this
reliance is ―very much an act of trust‖.
145. RN Ms K has also been represented by Mr P, and the advice of his nursing expert, Ms
Pirret, is noted on this matter also. Ms Pirret states that she has no criticism in relation
to RN Ms K‘s prioritisation of patients. Ms Pirret considers that with the information
RN Ms K had, she had no reason to be concerned about Mr A and to assess him
earlier. Accordingly, Mr P submits that RN Ms K‘s actions at this time were entirely
reasonable.
146. RN Ms K notes that when she found Mr A, he was ―extremely cold‖. She does not
consider that he would have been this cold had he died while she was in the SCU,
especially as he was covered with a sheet and at least one blanket.
147. RN Ms K notes that since these events she:
asks for specific figures when discussing a patient‘s vital signs at handover;
checks all patients at the start of shift, before recording individual observations;
always makes sure that curtains are not drawn for lengthy periods of time, and
raises this issue in ward meetings if she notices this happening;
raises in ward meetings any failures she observes of documentation of the
respiratory rate;
conducts and receives handover for all SCU patients.
Responses to provisional findings
148. A number of points raised in the responses to my provisional findings have been
incorporated above. The following submissions are also noted.
CDHB
149. CDHB notes that, subject to some specific comments, it accepts the finding that it
breached the Code. However, it considers the adverse criticism of the individual staff
should be reconsidered.
5 September 2012 26
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.