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Monitoring of patient with pneumonia; documentation of care (12HDC00548)

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(12HDC00548, 27 June 2014) 

Public hospital ~ District health board ~ Critical care unit ~ Cardiac arrest ~ Finger probe ~ Monitoring ~ Documentation ~ Rights 4(1), 4(2)

A woman was admitted to the critical care unit of a public hospital suffering from lower lobe pneumonia. While in the critical care unit the woman's health was variable. After several weeks, continuous monitoring, including ECG monitoring for heart rate, heart rhythm and respiratory rate, was stopped. It was not clear who made this decision and the decision was not documented in the notes. Only pulse oximetry, which monitored the woman's oxygen saturation via a finger probe, remained in place. At times, the woman removed the finger probe.

Five days later, the woman was found to have suffered a cardiac arrest. She was not wearing her finger probe. The exact time of her arrest is unknown.

When the woman's family arrived at the hospital they agreed that she was not for resuscitation. The day following her arrest she was taken off ventilation and she died the following day.

It was held that the woman should have been subject to continuous monitoring, and the district health board (DHB) should have had in place robust guidelines to ensure that every patient was monitored appropriately while in the critical care unit. It was found therefore that the DHB breached Right 4(1).

Various aspects of the woman's care were not fully documented in the clinical notes, including her having removed her finger probe, decisions around when she was to be discharged to the ward, and, following her cardiac arrest, her treatment plan. Therefore it was found that there was a pattern of suboptimal clinical documentation amongst multiple clinical staff, indicating a lax attitude towards documentation at the DHB. It was found that the DHB breached Right 4(2) for failing to comply with legal standards.

Adverse comment was made in relation to the DHB failing to mitigate the risk presented by the woman removing her finger probe.

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