North Shore Hospital report - New Zealand Doctor

Opinion 07HDC21742discharge the next day. No concerns about her mobility were detected during her admissionalthough her partner states that she was in pain and had difficulty mobilising when hecollected her. However, a hip fracture was subsequently diagnosed. She was readmitted anddied after her condition deteriorated.My instructions were to comment on the standard of care provided to [Ms A] by North ShoreHospital ECC and explain what standards apply and whether they were complied with. I wasasked [to comment on]:a) the appropriateness of the nursing observationsb) the adequacy of the nursing documentationc) the adequacy of the discharge process.Supporting information assisting in the provision of this reportSt John‘s formRest Home ReferralWaitakere Hospital ECC formWaitakere Hospital clinical notesECC transfer WTK TO NSH formPatient Registration FormAdmission and Discharge Planner pages 1–12Medicines chart pages 1–5Clinical NotesFluid Balance (1 chart)Discharge Summary[Ms A‘s] partner‘s letter of complaint to HDC dated 15 August 2007Interview notes, [ECC RN]Interview notes, [ECC Nurse]Interview notes, [Medical Registrar]Acting Chief Executive Officer, Letter to HDC dated 22 November 2007[Ms A] was admitted to Waitakere Hospital following vomiting coffee grounds. She isreported by her partner to have walked to the St John‘s ambulance from the rest home prior totransfer. She was cared for at Waitakere Hospital where she was monitored until 11.35pmwhen she was transferred to North Shore Hospital. A transfer report was provided fromCharge Nurse to Charge Nurse.The doctors recorded a brief assessment and review of the referral note. The nursing noteswere continued on the ECC transfer form and indicate care delivered, vital signs weremonitored and were stable. The notes report bed-block, and the decision to move to aninpatient area was reviewed and the inpatient bed was cancelled as [Ms A] was beingdischarged the next day. The night staff of the NSH ECC 2 April wrote two entries in theWaitakere notes, at 1.30am the patient was assisted to the commode and at 5.50am the nursereported ―Pt appears scared of mobilising requiring 2 nurses for transfer.‖ [Ms A‘s] partnernoted at interview on 24 January 2008 that [Ms A] had recently been ―walking a bit slow youknow. And not so sure of herself‖. [The medical registrar] at North Shore reported atinterview he was unaware of the ECC nurse entries in the Waitakere progress notes overnight[on] 1 April 2007.It was not possible to know from the notes, what areas of the ECC [Ms A] was nursed in. Thiswas on the computer system. The letter from Acting Chief Executive to HDC dated 22November 2007 reported [Ms A] was moved three times in the time she was in the ECC.North Shore observations were recorded on the Waitakere ECC Assessment form 2 to 4 at1.20am, 5.50am and 11am. The respiratory rate was not recorded. At 7.30am the nursereported there were no complaints and she was waiting for review. At 11am the nurseApril 2009 73