09HDC01565 - Health and Disability Commissioner

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Health and Disability Commissioner RN Ms J 171. RN Ms J notes she has previously acknowledged that she should have recorded Mr A‘s respiratory rate each time it was taken. She states she has reflected on her practice and now ensures respiratory rate is recorded each and every time she assesses a patient‘s vital signs. She suggests changing the neurological observation chart to include a space for recording the respiratory rate, to ensure that it is recorded by all nursing staff at all times. 172. RN Ms J states she did not change the default settings on the bedside monitor. 173. RN Ms J accepts that there were inaccuracies in her documentation of oxygen administration, again notes that this was a genuine mistake, and states that she now rechecks oxygen settings before documenting these. RN Ms K 174. RN Ms K‘s legal counsel, Mr P, submits that ―the criticisms of RN [Ms K] are unreasonable and unjustified, particularly in regard to the fact that they are not put into context‖. He states that the criticism of RN Ms K seems disproportionate, given the indications that Mr A had died some time prior to the commencement of RN Ms K‘s shift. 175. Mr P also states that it is difficult to comprehend how RN Ms K‘s care could be deemed suboptimal, when the delay in her seeing Mr A occurred because she was attending to a patient in pain. 176. Mr P notes that RN Ms K had been given no cause for concern about Mr A at handover, and she was reasonably entitled to expect that he was connected to the oxygen saturation monitor, which is standard practice, given the surgery that had been performed. Furthermore, RN Ms J had stated at handover that Mr A‘s saturations had been fine during the previous shift. 34 Opinion: Introduction 177. Mr A was a fit and active 21-year-old. In late 2008, he was diagnosed with a Chiari malformation, a condition that prevented him from doing physical work. He reduced his physical activity and the symptoms improved. However, Mr A was keen to resume a more active life and return to work. He decided to proceed with surgery. The operation was performed, and Mr A‘s death less than 24 hours following surgery was wholly unexpected. 178. The exact cause of Mr A‘s death has not been confirmed. The post-mortem report refers to the possibility of a ―functional loss of breathing control while asleep‖, and 34 As noted in paragraph 86, RN Ms K recalls being told that Mr A‘s vital signs were stable. Neither RN Ms J nor RN Ms K advised HDC that the handover information included specific reference to Mr A‘s oxygen saturations. 5 September 2012 30 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.
Opinion 09HDC01565 CDHB‘s RCA notes the possibility of ―progressive ventilatory failure‖. It is not my role to determine the cause of Mr A‘s death. The Coroner has indicated that he will consider this further. 179. We do not know whether Mr A‘s death could have been prevented. However, in its investigation, CDHB identified a number of factors each of which represented a ―lost opportunity‖ to prevent his death. 35 As outlined below, I consider there were indeed a number of deficiencies in the care provided to Mr A, both by individual staff and by CDHB. In my view, no one action or inaction can be singled out, but together these failings significantly reduced the likelihood of recognising and responding effectively to any deterioration or change in Mr A‘s condition prior to 7.30am on Day 3. 180. The key issues considered in this investigation are whether Mr A was given sufficient information regarding the proposed treatment to enable him to give informed consent, and whether he received an appropriate standard of care at the hospital over three days in 2009. Opinion: Breach — Canterbury District Health Board Introduction 181. I consider that there were failings in the care provided to Mr A by individual staff, and these are outlined below. However, there are also several respects in which Mr A was let down by the processes and practices in place on the ward, and particularly in the SCU. These compromised the ability of staff to provide an appropriate standard of care, and CDHB must bear responsibility for them. 182. My concerns relate particularly to the postoperative monitoring of Mr A, including: the conflict between Dr F‘s monitoring instructions and the SCU protocol; the failure of nursing staff to check and/or document his respiratory rate; the practice of ending ―specialling‖ prior to the morning medical review; the circumstances in which Mr A was changed to two-hourly observations overnight; and the practice of conducting morning handover for SCU patients in another room. Collectively, these factors resulted in suboptimal care being provided to Mr A. Failure to document respiratory rate 183. Mr A‘s respiratory rate was not documented after 5pm on Day 2, and I will comment later on the two nurses directly responsible for this. However, it is concerning that there was no specific place on the ―Neurosurgery Observation Chart‖ to record the respiratory rate. There is reference to respiration at the top of the chart, but unlike the other vital signs noted — blood pressure, pulse, and temperature — no clearly identifiable place to document this. CDHB states that it was usual practice for nursing staff to record respirations as a number at the bottom of the chart. I note that on Mr A‘s chart, it was recorded (prior to and at 5pm) on three occasions in one place and on two occasions in another place. 35 See paragraph 114. 31 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.
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09HDC01565 - Health and Disability Commissioner

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