North Shore Hospital report - New Zealand Doctor

Opinion 07HDC21742Dr Henley considered the family‘s comments about not being adequately informedabout the seriousness of Mrs C‘s condition. He stated that the medical records indicatethat Mrs C‘s death was unexpected, and all the documentation suggested a possibledischarge in three days. Dr Henley stated that the communication between the medicalregistrar and the family appears exemplary and is thoroughly documented.Dr Henley advised that sudden death is always possible with an 85-year-old womanwith CHF and chronic heart disease.Nursing careMy expert advisor, Ms Wood, noted that Mrs C was initially prescribed Panadol forpain. It was to be given four hourly as required, and was given irregularly to Mrs C.Ms Wood considered the way the prescription was expressed to be confusing. Shewould have expected the nurses to clarify this. She also considered that becauseosteoarthritis causes persistent pain and the other medication was being withdrawn,the nurses should have given the Panadol more regularly.The DHB has a pain management practice that was followed by the medical staff inprescribing the Panadol, but it was not followed by the nurses in their administrationof the analgesia. Ms Wood stated, ―Appropriate pain management is a fundamentalhuman right and under-management is a worldwide problem.‖Ms Wood criticised the approach to assessment and documentation by nurses andindicated it did not comply with the systematic approach required of nurses by theirprofessional bodies and promoted by the DHB‘s own workbook. As with Ms A andMrs B, there was no nursing care plan. There was no list of patient needs and nursingproblems to indicate what the nurses were observing, managing and monitoring.Nowhere in Mrs C‘s progress notes did the nurses record the data they collectedrelating to her heart failure symptoms, to make it explicit that they were monitoringthe impact of therapy.While the progress notes adequately described the care given to Mrs C on26 September and the following morning, this was not the case for the afternoon of27 September. Ms Wood stated that it is extremely difficult to assess Mrs C‘scondition at that time given the lack of physical findings and observations in thenotes.Mrs C‘s family are particularly concerned that she was not adequately monitored bynursing staff on the day she died. Ms Wood noted that when the family reported theirconcerns that their mother was deteriorating, the nurse did not document anassessment of Mrs C‘s level of consciousness, the presence of or any improvement inthe oedema in her legs, her lung sounds or her JVP (jugular venous pressure). Routineobservations were not made after 4pm. She was reported as ―comfortable‖ at 8pm.Waitemata DHB acknowledged that standard nursing protocols regarding monitoringwere not followed on the evening of 27 September. It advised that the registered nurseresponsible for Mrs C‘s care that evening has been spoken to about these omissions.April 2009 47