09HDC01565 - Health and Disability Commissioner

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Health and Disability Commissioner Postoperative care — other comment 246. The postoperative instructions were documented by Dr F, who states that the instructions were consistent with his usual regime. Mr A‘s surgery had been completed without any difficulties, so he found no reason to depart from this. 247. I have commented in paragraphs 235–238 above on the adequacy of the postoperative instructions given to nursing staff with reference to respiratory rate and oxygen saturation monitoring. 248. I have also commented in paragraphs 188–194 on the instructions from Dr F in relation to neurological observations. Dr F requested observations every 15 minutes for one hour, every 30 minutes for two hours, and then hourly. Dr F states that ―in general‖ postoperative orders are effective from the immediate postoperative period until the surgeon‘s ward round review the following morning. However, it was unit protocol and usual practice in the SCU for patients to move to two-hourly monitoring overnight if there was no cause for concern. Given that Dr F‘s expectation in this regard appears to have been different from the unit protocol and usual ward practice, clearer instruction was needed. In response to my provisional opinion, Dr F stated that there was no indication from staff that there was confusion about the postoperative neurological orders and it was his experience that if the protocol was to be followed rather than the postoperative orders, staff would be instructed accordingly. 249. I remain of the view that if Dr F did not want Mr A to be moved to two-hourly monitoring until further medical review, he needed to make this clear, preferably noting the rationale. However, I accept that the usual practice was that nursing staff should follow the postoperative neurological orders and that Dr E stated that the orders were in accord with his expectations and wishes. Opinion: RN Ms I Postoperative care — Adverse comment 250. RN Ms I was the nurse allocated to look after Mr A from 2.30pm until 10.30pm on Day 2. She received a handover from the nurse finishing the morning shift, at Mr A‘s bedside. RN Ms I checked and documented Mr A‘s neurological status hourly throughout her shift, but there were some omissions in the checking and recording of his vital signs. Most notably, RN Ms I did not check and record Mr A‘s respiratory rate after 5pm. 251. The generic ―Neurosurgical Postoperative Guidelines‖ allowed for Mr A to be moved to two-hourly observations from 7pm. However, Dr F‘s instructions for Mr A indicated that he should remain on hourly observations. In addition, Mr A was on a PCA, which meant his sedation score, oxygen saturations, and respiratory rate should have been checked hourly for the first 12 hours postoperatively — ie, until 11pm. 252. In these circumstances, RN Ms I should ideally have spoken with Dr F or an on-call doctor to check whether it was reasonable to move to two-hourly observations in 5 September 2012 42 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 accordance with the generic guidelines. Until she had done so, RN Ms I should have adhered to Dr F‘s instructions. I note that although Mr A‘s sedation score was not documented at 9pm or 10pm, it is clear from the notes that Mr A was alert because it was during this time that RN Ms I was attending to Mr A in relation to the difficulty he was having urinating. 253. I note RN Ms I‘s comments that during the evening Mr A was alert and interacting with people. This is consistent with Mrs C‘s recollection that when she left the hospital just before 9pm, her son was awake, conversational, alert, and in good humour. I note also RN Ms I‘s comment that it is not difficult to assess if a patient is having difficulty breathing and at no point was this the case for Mr A. 254. However, as my nursing expert Janet Hewson explains, while sedation scores and the Glasgow Coma Scale were documented regularly, this did not absolve the nurses from deliberately counting respirations. It was important to know whether Mr A‘s respiratory rate was trending up or down — a key aspect of clinical judgement and decision-making. Ms Hewson states that for patients in the SCU, whose condition may change suddenly or slowly over a period of hours, ―the most significant competency the nurse will have is that of surveillance. Regular, purposeful looking at your patient and watching for signs and symptoms of change are the hallmark of nursing practice in a SCU‖. Ms Hewson also notes that while measurement of respiratory rate requires no complex technology, it is the most difficult vital sign to obtain, and it takes deliberate attention and patience on the part of the clinician. 255. There were several CDHB forms relevant to Mr A‘s care that specify respiratory rate as a parameter to be measured and documented. These include the ―Neurosurgery Observation Chart‖ and the ―PCA Chart‖. As outlined in my findings in relation to CDHB, I am concerned that while the ―Neurosurgery Observation Chart‖ showed respiration as one of the vital signs to be recorded, there was no clearly identifiable place to document this (see paragraphs 183–184). Nevertheless, it is evident that nursing staff knew that observations should have included respiratory rate. 256. The fact that Mr A was on a PCA was a further reason for RN Ms I to have checked and recorded this more frequently than she did. 257. Submissions made on behalf of RN Ms I in response to my provisional opinion emphasise that RN Ms I‘s failure to record the respiratory rate had no influence on the outcome. That is not the issue. The issue is whether RN Ms I provided services to Mr A of an appropriate standard. 258. RN Ms I‘s entry in the progress notes at the end of her shift indicated that Mr A was now on two-hourly observations. This was consistent with usual ward practice and the SCU protocol, but not consistent with the specific instructions given by Dr F. My concerns about this issue have been addressed in my findings in relation to CDHB and Dr F. 259. In summary, my primary concern in relation to RN Ms I is her failure to check and record Mr A‘s respiratory rate. In addition, I consider that given the postoperative 43 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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