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Assessment and documentation of deteriorating condition of rest home resident (03HDC13895)

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(03HDC13895, 28 February 2005)

General practitioner ~ Rest home ~ Deteriorating condition ~ Documentation ~ Rights 4(1), 4(2)

A rest home resident was admitted to a public hospital suffering from expressive dysphasia, right-sided weakness, and confusion. The discharge letter requested that her general practitioner (GP) monitor the woman's urinary tract infections and blood pressure.

On her return to the rest home, the woman's health appeared satisfactory until a few days later, when her speech and walking were noted to be very slow. Five days later she was assessed by the house doctor, because of deterioration in her general health. The house doctor took blood tests, which showed that she was anaemic. The following day, because her condition had not improved, she was seen by her GP. The GP ordered a urine test, which showed no infection.

The GP telephoned the rest home four days later to check on the woman's condition. On being told that she was confused and drowsy, the GP instructed staff by telephone to withhold some of her medication. He telephoned again the following day and, as he was told the woman was still drowsy, he stopped more medication. Over the next few days, the rest home nursing staff documented that the woman was experiencing increasing unsteadiness and confusion, resulting in falls.

The GP assessed the woman three days later and recorded that she was still very confused, and referred her to a geriatrician at the public hospital for assessment. She was diagnosed with pneumonia and admitted to hospital. Hospital nursing staff recorded that the woman's heels appeared red and she had a large fluid-filled blister on the sole of her right foot and a small blister on her left foot. She was treated for pneumonia and a urinary tract infection prior to discharge to another hospital.

It was held that the GP failed to fully discharge his duty of care because he did not adequately and appropriately assess, monitor and treat the woman's deteriorating condition. He also failed to make a clear and accurate record of his final examination, and breached Rights 4(1) and 4(2).

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