09HDC01565 - Health and Disability Commissioner

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Health and Disability Commissioner 272. All three patients in SCU were due to be checked at 7am. RN Ms K states that the patient with the highest priority was the patient who had most recently returned from surgery — the patient in bed space three. When RN Ms K first entered, she observed that this patient was sleeping and she noted that his pulse and oxygen saturations were well within acceptable levels. 273. The curtain had been pulled around Mr A‘s bedspace to prevent the night light shining in his face. RN Ms J states that throughout her duty, the curtain was drawn but with a gap such that she was able to see Mr A when she was sitting at the nurses‘ station. RN Ms K states that when she entered SCU for the first time, the curtain around Mr A was closed if not fully, then at least to the point that she was unable to see Mr A from where she was standing. She states further that although it was not her practice to allow patients in SCU to have the curtains closed for any length of time, it was not unusual for this to occur for short periods of time when patients wanted a degree of privacy. 274. Ms Hewson states that RN Ms K‘s actions on entering SCU were unreasonable. One patient was ambulatory. One patient was visible, as was his monitor. The third patient, Mr A, was not visible. Ms Hewson considers RN Ms K should have verified Mr A‘s condition in the first instance. CDHB also notes that RN Ms K had no reason to be concerned about Mr A, but acknowledges that she should have sighted all of the patients in the room before becoming involved in the provision of care. Ms Pirret, the nursing expert consulted by RN Ms K‘s legal representative, submits that RN Ms K‘s actions at this time were reasonable on the basis that the information provided at handover gave no reason to be concerned about Mr A. 275. I appreciate that having been given no information at handover to suggest any cause for concern about any of the three patients, the highest priority for RN Ms K was the patient who had most recently returned from surgery. However, I agree with Ms Hewson and CDHB, that RN Ms K should have visually observed all of the patients in the room before becoming involved in their care. The curtain had been pulled around Mr A‘s bedspace to prevent him being disturbed by the light. It had apparently not prevented Mr A from being observed by RN Ms J during her shift, because she was seated at the nurses‘ desk. RN Ms K was in a different position, and the curtain did prevent her from sighting Mr A. I agree that RN Ms K‘s judgement in this regard was poor, but in my view, this must be seen in the context of the concerns I have previously outlined in relation to the functioning of the SCU at this time, and the handover advice that Mr A was stable. 276. I note also RN Ms K‘s actions on finding Mr A unresponsive. She explains that her first instinct was to go back to what she had been taught for years, namely the ABC resuscitation process. She states that she is fully aware that the new guidelines emphasise cardiac compressions over artificial respirations. I accept RN Hewson‘s advice that it is understandable that RN Ms K reverted to previous practice in this stressful situation. Once she saw Mr A, RN Ms K raised the alarm immediately and help arrived promptly. 5 September 2012 46 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 277. In its responses to my provisional opinion, RN Ms K‘s legal counsel, Mr P, and CDHB submitted that it is unreasonable to comment adversely on RN Ms K, given the context of her involvement with Mr A, including the indications that he had died prior to the start of her shift. RN Ms N states that when she entered the SCU, she thought Mr A looked as though he had already died. However, RN Ms M, states that when she arrived, Mr A was deeply unconscious but not cold. Given this conflict, there remains a degree of uncertainty with regard to Mr A‘s condition at the time resuscitation commenced. 278. In addition, Mr P states that it is difficult to comprehend how RN Ms K‘s care could be said to be suboptimal when she was attending to a patient in pain. In fact, RN Ms K attended first to the ambulant patient, who she states was keen to be discharged and had some questions about this. CDHB states that RN Ms K ―quite rightly‖ attended first to the patient who sought nursing help. However, it previously acknowledged that RN Ms K should have sighted all patients before becoming involved in the provision of care. 279. Mr P submitted that it was arguable that, had RN Ms J sighted Mr A at the start of her shift, ―the outcome would have been any different‖ (sic). It is accepted that had RN Ms K checked Mr A when she first entered the SCU and initiated the emergency response sooner, the outcome for Mr A may have been no different. However, as stated above, that is not the issue. The issue is whether the failure to sight all patients was a departure from the expected standards of a registered nurse. I remain of the view that RN Ms K should have sighted Mr A when she first entered the room. 280. In summary, the care provided to Mr A by RN Ms K was, in the respects identified above, suboptimal. Her failure to check her patient on entry to the room reflects a poor choice within a pattern of prior decisions by others (as to monitoring), reassuring information that his condition was stable, and a culture that had subtly eroded the acuity with which patients were regarded. It forms part of, and was informed by, a pattern of suboptimal performance in the SCU, and in these circumstances is appropriately seen as part of an overall failure by the service to provide the care that Mr A needed. Recommendations 281. As previously noted, CDHB‘s efforts to identify the factors that may have contributed to Mr A‘s death, and the changes it has initiated to reduce the likelihood of a similar event occurring again, are to be commended. I recommend that CDHB: provide to HDC by 19 September 2012 a written apology for forwarding to Mr A‘s family. 47 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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