09HDC01565 - Health and Disability Commissioner

Health and Disability Commissioner
it was noted the patient could be heard snoring and that his condition did not
significantly change. In my opinion the nurses would incur a mild to moderate
disapproval from professional peers.
2. Were there any systemic factors impacting on the ability of nursing staff to
provide appropriate care?
I note that recommendation 8.2 calls for a rename of the SCU to the Progressive Care
Unit with upgraded equipment and specially trained nurses. While this is a positive
proposal, there are issues that need to be addressed regardless of the where the unit is
located, how it is equipped and the level of staffing.
Handover report should be given in the unit. This ensures that the time gap between
handover is minimal and that the patients are still under surveillance. In this case not
only was handover given outside the unit, the nurses did not directly return to the
SCU after report. Nurse [Ms K] stated she chatted for a few minutes.. . . clinical
records and drug charts, checked when medications were due. . proceeded to the SCU.
Nurse [Ms J] states that after report she read his notes and checked medications with
colleagues. This paints a picture of delays in ―seeing‖ the patients first thing. Patients
who are in the SCU are there for a reason. It is the responsibility of the nursing staff to
avoid being away from the bedside area as much as possible. Once handover is
completed, the first priority should be to see the patient, preferably with the ongoing
and off-going nurses going to the bedside together. Then notes can be read and
medications sorted. It is not clear if the SCU has its own supply of medications but
this would be an expected standard for the new Progressive Care Unit.
3. Do I have any concerns about the individual practice of any of the nursing
staff involved in [Mr A’s] care?
Following on the theme of prioritizing, I believe Nurse [Ms K‘s] actions on entering
the SCU the morning of [Day 3] were unreasonable. [Mr A] was behind a curtain and
[another patient, Mr X] had returned from recovery around 0130 hours; however she
chose to attend to the ambulatory patient first. [Mr A] and [Mr X] were a higher
priority. As I stated previously all patients must be looked at first thing, then the nurse
can plan her care, In [Mr A‘s] case, about an hour had passed before he was seen and
he was behind a curtain.
Nurse [Ms K] should have looked at him on entering the room, I also note that it had
been passed on in report [Mr A] was snoring, I wonder if Nurse [Ms K] heard him
snoring when she entered the room. If not, this should have raised suspicion.
Nurse [Ms K] is very experienced in neuroscience nursing (clinical, education,
research and management). I would expect she is considered a proficient to expert
practitioner by her peers. However her nursing actions in this case did not meet the
competencies of a nurse with her experience and education (NCNZ competency 1.4 &
2.2) or the purposes and objectives of the CDHB Special Care Unit. In my opinion she
would incur moderate to severe disapproval from professional peers.
5 September 2012 58
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.