09HDC01565 - Health and Disability Commissioner
09HDC01565 - Health and Disability Commissioner
09HDC01565 - Health and Disability Commissioner
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Opinion <strong>09HDC01565</strong><br />
CDHB‘s RCA notes the possibility of ―progressive ventilatory failure‖. It is not my<br />
role to determine the cause of Mr A‘s death. The Coroner has indicated that he will<br />
consider this further.<br />
179. We do not know whether Mr A‘s death could have been prevented. However, in its<br />
investigation, CDHB identified a number of factors each of which represented a ―lost<br />
opportunity‖ to prevent his death. 35 As outlined below, I consider there were indeed a<br />
number of deficiencies in the care provided to Mr A, both by individual staff <strong>and</strong> by<br />
CDHB. In my view, no one action or inaction can be singled out, but together these<br />
failings significantly reduced the likelihood of recognising <strong>and</strong> responding effectively<br />
to any deterioration or change in Mr A‘s condition prior to 7.30am on Day 3.<br />
180. The key issues considered in this investigation are whether Mr A was given sufficient<br />
information regarding the proposed treatment to enable him to give informed consent,<br />
<strong>and</strong> whether he received an appropriate st<strong>and</strong>ard of care at the hospital over three days<br />
in 2009.<br />
Opinion: Breach — Canterbury District <strong>Health</strong> Board<br />
Introduction<br />
181. I consider that there were failings in the care provided to Mr A by individual staff, <strong>and</strong><br />
these are outlined below. However, there are also several respects in which Mr A was<br />
let down by the processes <strong>and</strong> practices in place on the ward, <strong>and</strong> particularly in the<br />
SCU. These compromised the ability of staff to provide an appropriate st<strong>and</strong>ard of<br />
care, <strong>and</strong> CDHB must bear responsibility for them.<br />
182. My concerns relate particularly to the postoperative monitoring of Mr A, including:<br />
the conflict between Dr F‘s monitoring instructions <strong>and</strong> the SCU protocol; the failure<br />
of nursing staff to check <strong>and</strong>/or document his respiratory rate; the practice of ending<br />
―specialling‖ prior to the morning medical review; the circumstances in which Mr A<br />
was changed to two-hourly observations overnight; <strong>and</strong> the practice of conducting<br />
morning h<strong>and</strong>over for SCU patients in another room. Collectively, these factors<br />
resulted in suboptimal care being provided to Mr A.<br />
Failure to document respiratory rate<br />
183. Mr A‘s respiratory rate was not documented after 5pm on Day 2, <strong>and</strong> I will comment<br />
later on the two nurses directly responsible for this. However, it is concerning that<br />
there was no specific place on the ―Neurosurgery Observation Chart‖ to record the<br />
respiratory rate. There is reference to respiration at the top of the chart, but unlike the<br />
other vital signs noted — blood pressure, pulse, <strong>and</strong> temperature — no clearly<br />
identifiable place to document this. CDHB states that it was usual practice for nursing<br />
staff to record respirations as a number at the bottom of the chart. I note that on Mr<br />
A‘s chart, it was recorded (prior to <strong>and</strong> at 5pm) on three occasions in one place <strong>and</strong> on<br />
two occasions in another place.<br />
35 See paragraph 114.<br />
31 5 September 2012<br />
Names have been removed (except Canterbury DHB <strong>and</strong> the experts who advised on this case) to<br />
protect privacy. Identifying letters are assigned in alphabetical order <strong>and</strong> bear no relationship to the<br />
person’s actual name.