09HDC01565 - Health and Disability Commissioner

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Health and Disability Commissioner 196. On Day 3, RN Ms J had no concerns about the patients in SCU and accordingly went to the seminar room at 6.45am to give the handover. (We do not know whether Mr A‘s respiratory rate would have constituted a concern had this been checked and documented throughout the night.) Her actions were therefore consistent with usual ward practice. 197. However, this suggests a laxity that was not appropriate for the SCU. While holding handover in a different room may be preferable in terms of optimising patient confidentiality and privacy, these issues can be managed by the nursing staff. My nursing expert notes ―a picture of delays in ‗seeing‘ the patients first thing‖. The handover practice that had evolved on the SCU did not support nurses to maintain an appropriate level of surveillance. Oxygen saturation monitoring 198. There is an important matter that I have been unable to resolve. RN Ms J states that Mr A was on an oxygen saturation monitor throughout her shift, and she believes he was still on the monitor during morning handover. She recalls that the monitor was set to alarm if Mr A‘s oxygen saturation levels fell below 92%, and the fact that the alarm did not sound during her shift indicated that his oxygen levels did not fall below this level. RN Ms J last saw Mr A at 6.15am. RN Ms K recalls that when she found Mr A at 7.30am, the monitor was switched off and not attached. 199. CDHB states that it is possible for patients to turn monitors off if they have observed staff doing this. Mr A had had a disturbed night and was awake on several occasions. There is nothing in the records or information provided by staff subsequently to indicate that the monitor bothered him. 200. I have been provided with no information to indicate that the monitor was faulty and it is known with certainty that the monitor was on at 5am as recordings were taken at that time. There are a number of other possible explanations as to what occurred subsequently: Mr A got up and turned the monitor off; someone else turned the monitor off; RN Ms J‘s recollection that Mr A was connected to the monitor throughout her shift is incorrect; or RN Ms K‘s recollection that the monitor was off is incorrect. 201. It is unlikely that RN Ms K was mistaken. If Mr A had been connected to the monitor and it was on, it would presumably have alarmed when Mr A stopped breathing, some time between 6.35am (when RN Ms J heard Mr A snoring) and 7.30am (when RN Ms K found Mr A unresponsive). 202. Further than this, I have insufficient information to resolve this matter. 203. I note that my neurosurgical expert, Dr Nye, considers continuous oxygen saturation monitoring to be ―desirable‖ for the first 24 hours postoperatively. Ms Hewson refers to the decision as to whether continuous monitoring is necessary as ―generally resting with the nurses‖. She states further that continuous monitoring is desirable in patients who may not breathe deeply, who may breathe too slowly, or who have periods of no breathing. There is no evidence in the records that any of these applied to Mr A. 5 September 2012 34 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 Nevertheless, according to RN Ms J, her intention was for Mr A to be on continuous monitoring throughout her shift, including when she left the SCU for morning handover. Summary 204. In my view, a number of practices had evolved in the SCU that were not consistent with the unit‘s purpose and objectives and did not support the provision of an appropriate standard of care to patients. I accept that the SCU did not provide for the same level of monitoring as an HDU, but it was intended to provide a high standard of specialist nursing care for patients who were ―seriously unwell, have the potential to deteriorate rapidly, or who require ongoing and/or escalating physiological monitoring‖. 37 My breach finding is not based on the premise that Mr A required a more intensive level of monitoring than was expected within the SCU. 38 Rather, it is based on the fact that he did not receive the level of care the SCU was designed and set up to provide. As outlined above, there were a number of organisational issues that impacted adversely on the quality of the postoperative care provided to Mr A in the SCU, and conspired to create an unsafe situation, in which appropriate monitoring did not take place. I note in particular the observation chart with no specific place to document 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, including the conflict between Dr F‘s instructions and the SCU protocol; and the practice of conducting morning handover for SCU patients in another room. Accordingly, I find that CDHB did not take reasonable actions in the circumstances to ensure that services were provided to Mr A with reasonable care and skill, and breached Right 4(1) of the Code. 39 205. The efforts made by CDHB to identify the factors that may have caused or contributed to suboptimal care in this situation, and the changes it has initiated to improve patient care, are to be commended. Opinion: Dr E Diagnosis and proposed treatment— No breach 206. Dr E diagnosed Mr A with a Chiari malformation in 2008. It is evident that there is a lack of consistency in the literature and among clinicians with regard to the categorisation of Chiari malformations. I accept the advice of my neurosurgical expert, Dr Darryl Nye, that Mr A was diagnosed correctly by Dr E and that the proposed treatment was appropriate. 37 See footnote 17. 38 Although I note that the decision has now been made to admit all patients undergoing cranio-cervical surgery to ICU for 24 hours postoperatively. 39 See footnote 3. 35 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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