North Shore Hospital report - New Zealand Doctor

Health and Disability CommissionerMs Wood also noted that Mrs C‘s respiratory rate had triggered a NEWS score of 1on eight occasions when her observations were taken. However, only once did thisresult in her observations being taken two hourly as required by the system. In aninterview, the nurse who cared for Mrs C on the afternoon of 27 September advisedthat NEWS was a guide for when to call a doctor and that four-hourly observationswere appropriate following a score of 1. The nurse stated that this was fairly standardfor her ward. Ms Wood believes this statement demonstrates a systemic problem withthe NEWS system, how it is used and its purpose. She advised that the way the systemwas applied (incorrectly) in relation to Mrs C did not meet Nursing Councilcompetencies. The lack of systematic use of NEWS would meet with severedisapproval. As in Mrs B‘s case, the DHB protocol for patients who regularly triggera high NEWS score was not used for Mrs C.Ms Wood stated that the shift co-ordinator was responsible for overseeing the qualityof Mrs C‘s nursing care. However, the co-ordinator had patients to care for as well assupervising casual staff and new graduates, while working short staffed. The ChargeNurse Manager was responsible for the overall quality of care in the ward, includingthe systems and processes and the adherence to policy. There was no acuity system todetermine if the nursing staffing was adequate for the workload, no audit processes,shared governance or time for quality improvement activities on the ward.On the night Mrs C died, one of the three evening shift nurses had been reassigned toanother ward that was short staffed. This meant Mrs C was not seen soon after theevening handover as she would normally have been. It was not until 12.30am that anurse checked on Mrs C and found that she was not breathing. Waitemata DHBadvised that the nurse caring for Mrs C had been spoken to regarding the lapse inmonitoring and was apologetic for the oversight. I note that although this nurse wascensured, the situation was created by the staffing reassignment.Mrs C‘s son stated, ―It was never my intention to cause a comeback for the nurses. ...I believe that if anyone is to blame at all, it is the NSH [North Shore Hospital] systemand in particular the fact that they do not have enough funds to hire enough nurses ateffective payscales for the work to be properly done.‖ Mrs C‘s other daughter stated,―It is with regret that we have to highlight the NSH nurses‘ plight in such a way.However, there are consequences when procedures and policies are not adhered to.‖Communication issuesTwo communication issues arose between nursing staff and Mrs C‘s family: thenurse‘s ―game‖ when she allegedly informed Mrs C that she was prescribed morphinefor pain relief instead of codeine; and the way in which her daughter was informed oftheir mother‘s death. The nurse has denied the ―game‖ incident and there is noindependent evidence that it occurred. Certainly, if it did happen, it was inappropriate.The way in which the family was told of Mrs C‘s sudden death was also insensitiveand distressing for the family.In relation to the second issue, Ms Wood noted that staff said they had not beenprepared for giving bad news to families. Many hospitals do not provide training inthis area of communication.48April 2009