Page Section: Centre Content Column
Assessment and documentation of deteriorating condition of rest home resident (03HDC13895)
Download Assessment and documentation of deteriorating condition of rest home resident (03HDC13895) (PDF 140Kb)
(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
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
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).