UltraTiger3115
SUMMARY 1- Provide a conclusion outlining the main issues/errors…
SUMMARY
1- Provide a conclusion outlining the main issues/errors identified and how these could be prevented from re-occurring in the future.
SUMMARY
1. On 11 January 2013, the respondent was the registered nurse in charge of the afternoon shift at Glen Innes
District Hospital (“the Hospital*).
2. Patient A was an 81 year old patient who had been admitted to the Hospital on 6 January 2013, with shortness
of breath, and a number of other co-morbidities, including diabetes, leg oedema, tachycardia and hypotension.
Patient A’s condition failed to improve over the days subsequent to her admission on 6 January.
3. Over the course of the period -from 1700 hours on 11 January 2013, Patient A’s condition significantly
deteriorated. At approximately 1720 hours, Patient A’s blood pressure was observed to be 89/53, she had a
respiratory rate of 40-44 breaths per minute and she had abdominal pains and diarrhea. The respondent was informed of those observations at approximately 1810 hours. The respondent also made further personal
observations of Patient A after 1810 hours. The respondent did not document these latter observations.
4. Although Patient A’s vital signs remained in the ‘red zone” described in the ‘Between the Flags” policy at all
times after 1720 hours on 11 January 2013, and although hospital policies required that a doctor be notified in
these circumstances, the respondent did not notify a doctor of Patient A’s condition until the locum doctor
arrived at the Hospital at 2200 hours. At this time, Patient A was critically ill. Attempts were made,
unsuccessfully, to have Patient A transferred to Armidale Hospital overnight by ambulance or by air. Patient A’s
condition continued to decline overnight. Patient A died whilst she was being assessed for transport in the
morning of 12 January 2012.
5. The complaint alleged that the respondent was guilty of unsatisfactory conduct in respect of her failure to
recognise and respond to Patient A’s deteriorating condition, and in respect of her failure to document her
assessment and plan of action for Patient A. The respondent admitted all of the particulars in the complaint. She
also admitted that her conduct amounted to unsatisfactory professional conduct. The Professional Standards
Committee (“the Committee”) was satisfied of each of the particulars, and that the particulars amounted to
unsatisfactory professional conduct. Consequential orders were made.
FACTUAL BACKGROUND
6. On 5 January 2013, Patient A, who was 81 years old, presented at the Glen Innes GP clinic complaining of two
nights of breathlessness when lying flat and shortness of breath. On examination, Patient A was found to have
fine creps at the base of both lungs and slightly elevated jugular venous pressure. Her renal function was normal.
She was commenced on oral Lasix and was recommended to have a clinical review two days later.
7. On 6 January 2013, Patient A attended the Hospital again with shortness of breath. Patient A was admitted to
Hospital as the oral Lasix had not improved her symptoms.
8. Over the course of the following days, Patient A’s condition did not improve. On 7 January 2013, the visiting
medical officer, Dr Haron, reviewed Patient A and planned a chest x-ray and blood tests. On 8 January 2013, Dr
Haron reviewed Patient A again and noted diarrhea and right sided tenderness of Patient A’s abdomen. He
organised a ventilation/ perfusion (V/Q) lung scan.
9. On 9 January 2013, Patient A reported dizziness. This coincided with an atrial fibrillation (AF) rate of 120/ min.
Dr Haron was called to review Patient A. He noted that the V/Q scan was “interdeterminate”. Patient A was
refusing food and liquid at this time, and was complaining of feeling very weak and having abdominal pain.
10. At 0830 hours on 10 January 2013, Dr Haron again assessed Patient A He concluded that Patient A was
depressed and anxious. He encouraged nursing staff to mobilise Patient A. The nursing notes that follow Dr
Haron’s attendance refer to discharge planning at 1021 hours, and then, at 1315 hours, comment that Patient A
felt unwell, had refused breakfast and lunch, had no energy and required encouragement to mobilise. Patient A’s
respiratory rate was recorded as 28-30/ minute, but other vital signs were within normal limits.
11. At 1820 hours, the progress notes state that Patient A refused to tolerate her dinner. At 1.910 hours, Patient A
was observed to have a respiratory rate of 40/min and she was tachycardic at 122/min. At 1930 hours, Patient A
was documented as feeling “woozy”, her skin was cold and clammy and she was complaining of severe back
pain. Her SSL was 16.1mmmol/1. An ECG was conducted, which showed a heart rate of 168/min. Dr Haron was
again called. He stated that Patient A should be administered Digoxin and Valium. At 2110 hours, showing Patient
A’s respiratory rate was still at 40/min.
12. At 0530 hours on 11 January 2013, nursing notes state that Patient A was unable to void, was pale and grey,
and had clammy skin and nausea. At 0830 hours on 11 January 2013, Dr Haran assessed Patient A and wrote “?
Significant medical illness*. An abdominal x ray and pathology were ordered. Dr Haran returned at 1330 hours
and noted that Patient A “won’t/ can’t mobilise because of pain in back and abdo” and that her white cell count
had risen to 17.5, despite an absence of fever. A urinary tract infection was subsequently diagnosed and
intravenous antibiotics were commenced at approximately 1430 hours.
13. The respondent commenced her afternoon shift as the nurse in charge at 1430 hours on 11 January 2013. She
read Patient A’s progress notes at approximately 1445 hours. In her evidence before the Committee, the
respondent stated that she was immediately concerned about Patient A’s condition, and explained that she
considered that the Hospital was not equipped to properly care for Patient A. The respondent said that she had
been informed at the handover that Patient A’s treating doctor had “gone away” and “was unable to be
contacted”. The respondent said that as Patient A’s doctor was not available, she intended that to have Patient A
seen by the locum (who usually arrived at around 2100 hours on Friday evenings).
14. At approximately 1720 hours, Patient A reported to nursing staff that she was feeling dizzy and had
abdominal pain (8/10). She was observed to have a respiratory rate of 40 -.44/min, very low blood pressure of
89/53 and a heart rate of 88.
15. Shortly before 1810 hours, the respondent was advised of Patient A’s condition by an enrolled nurse. The
respondent said that she would have Patient A reviewed once the locum arrived. At around 1810 hours, the
respondent was informed that Patient A had continual diarrhea. The respondent again said that she would have
Patient A reviewed when the locum arrived. After this conversation, the respondent personally reviewed Patient
A. The respondent did not document her observations. However, in her evidence before this Committee, the
respondent acknowledged that Patient A’s vital signs had not improved at this time.
16. At approximately 1910 hours, the respondent arranged for a further ECG to be undertaken for Patient A.
17. At approximately 2020 hours, the respondent telephoned the Clinical Nurse Manager, Ms Catherine Jones, to
arrange for medication to be obtained from the drug safe (for a patient other than Patient A). At approximately
2030 hours, Ms Jones attended the Hospital and signed for the medication. The respondent did not raise any
issues concerning Patient A with Ms Jones at this time.
18. At approximately 2100 hours, the respondent and another registered nurse completed an ISBAR (Introduction
Situation Background Assessment Recommendation) form. In that form, the respondent described Patient A as
“deteriorating”, and recommended that Patient A’s condition be reviewed “ASAP”. She also stated that Patient
A’s family had been contacted.
19. The locum, Dr Valentine, arrived at 2200 hours. By this time, Patient A was critically unwell. The emergency
on-call doctor, Dr Corey, arrived at approximately 2300 hours and inserted a large bore IV cannula to treat
Patient A’s severe dehydration. Over the course of the night, attempts were made to transport Patient A to a
rural referral hospital. The ability to transfer Patient A was significantly complicated by Patient A’s critical
condition. Tragically, Patient A died whilst she was being assessed by the air evacuation team the following
morning. The primary cause of death was stated to be septicaemia.
44. Whilst accepting that she was guilty of unsatisfactory professional conduct, the respondent also pointed to a
number of matters in mitigation, which, it was said, provided some context to her conduct on the day in
question.
45. As these mitigating factors are of relevance to the appropriateness of imposing protective orders, it is
convenient to set them out briefly at this time. Specifically, the respondent explained that:
1. The afternoon shift was a very busy shift. The respondent was in charge of the emergency department, as well
as the being the nurse in charge of the hospital;
2. At the time that the respondent was first notified of Patient A’s deteriorating state by an enrolled nurse, she
was administering Diazepam, a Schedule 4 medicine drug to a patient in the emergency department, which was
a task that required her undivided attention;
100. Patient A had been seen by her treating doctor, Dr Haran, at 1330 hours. Dr Haron had prescribed
antibiotics. The administration of those antibiotics did not commence until the respondent started her shift, at
1430 hours. The respondent said that she thought that Patient A’s deteriorating vital signs would be improved by
the continuation of antibiotics:
4. The respondent understood from the handover that Patient A’s regular doctor, Dr Haran, was not available
(this turned out to be incorrect), and she also understood that the locum was not available until 2100 hours:
5. Apart from the locum, the only other doctor available was Dr Correy, who was rostered as the on-call
emergency department physician. The respondent acknowledged that Dr Corey was in fact physically present in
the Hospital until approximately 1800 hours on 11 January 2013. However, the respondent stated that, at the time
of the incident, there was a lack of clarity in the policies and practice of the Hospital as to whether the
emergency department doctor could be prevailed upon to examine a patient who was not in the emergency
department where the patient’s doctor was not available. The respondent said that on previous occasions when
she had attempted to ask the emergency doctor to see a patient in a ward where the patient had not been
admitted by the “on call/emergency doctor”, she had been told to wait for the locum, The respondent gave
evidence that this informal stance was maintained rather rigidly by some Visiting Medical Officers, to the point
where nursing staff (including the respondent as nurse-in-charge) were reticent about calling them because of
the “ear-full” they would receive. The respondent gave evidence that subsequent to this complaint policies
around calling the on-call doctor had been clarified for both nursing staff and clinicians; 6. Whilst the respondent had received training in respect of the “Between the Flags” policy at the time of the
incident, she said that she had not been made aware of the aspect of the policy that required a doctor to be
called when the patient was in the “red zone”
46. The Committee acknowledges that there are stresses and pressures that are placed on rural nurses that do
not exist for nurses in hospitals outside of a .rural context. In particular, the Committee accepts the respondent’s
evidence that it was difficult to arrange for a doctor to attend to a patient at the Hospital, particularly when the
patient’s treating doctor was unavailable. The Committee also acknowledges the particular stresses and
demands that were placed on the respondent by reason of her performing in charge roles in the emergency
department and in the Hospital as a whole.
47. Whilst raising these matters in mitigation, the respondent appropriately accepted the particulars of the
complaint and also accepted that she was guilty of unsatisfactory professional conduct. In her evidence before
the Committee, the respondent stated that she has learnt a great deal from this tragic event. She said that she
would now call a doctor whenever a patient was in the “red zone”. She said that she insists on doctor
attendance, even if it means being subjected to verbal abuse by a doctor. The respondent said that other staff in
the hospital will often ask her to contact doctors to insist on attendance, as she is known as a person who is
prepared to insist upon doctor attendance. The respondent said that she is still placed in the position of being
required to be in charge of the emergency department and the Hospital, although it is something that she tries to
avoid. The respondent said that she also now understands the importance of complete documentation, and that
she always documents her observations, to protect herself as well as her patients.
