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Management of rest home resident’s fall; follow-up of PSA test (08HDC17309)
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(08HDC17309, 26 May
2010)
General practitioner ~ Rest home ~ Falls ~ Standard of care
~ Communication and co-operation ~ Rights 4(1), 4(5)
A family complained about the care provided to their father by a
GP and rest home staff following two falls. Prior to his admission
to the rest home, the man had been diagnosed with prostate cancer
and received treatment. Two months after admission, the GP
requested that the man's PSA level be checked and noted that he
should continue to have monthly PSA tests. It was also noted that
if the man's PSA level rose above 10µg/L, treatment should be
restarted. The man's PSA was checked two months later, but his
records were misfiled and it was then six months before his next
check. By that time, the man's PSA level had risen to 38.8µg/L.
Treatment was prescribed and given.
A fortnight later, the man had a fall. He was checked by nursing
staff, who found no evidence of injury. The man's son was informed,
and he advised rest home staff that previously the same prostate
treatment had affected his father's balance. Early the next
morning, the man was found by a caregiver on the floor of his
bathroom. He was checked by nursing staff. The man did not want to
go to hospital, and it was agreed he should be seen by a doctor.
The GP was contacted two hours later, by which time there was
swelling and bruising around the man's left eye, and bruising to
his right elbow and sides. The GP reviewed the man early that
afternoon. No significant injury was identified.
The following morning the man's condition deteriorated. The GP
had arrived at the home that morning for a scheduled round but was
not alerted to the man's deterioration and did not see him until
four hours later. It was agreed that the man should be admitted to
hospital. The GP made a routine request for ambulance transport,
and the ambulance arrived about two hours later. The man was found
to have a fractured left eye socket, an odontoid peg fracture (part
of the cervical spine), and a possible fracture of the fusion
between his 2nd and 3rd vertebrae, although
this may have been an old fracture. He was dehydrated. The man died
the following day.
It was held that there were problems with the GP's systems for
the storage and retrieval of patient records, and with the
arrangement with the home to ensure diagnostic testing was carried
out as required. This resulted in a failure to monitor the man's
PSA appropriately. The man's care was also compromised by a lack of
co-operation between the GP and the rest home staff at the time of
the falls. The GP was found in breach of Rights 4(1) and 4(5).
It was also held that following the man's second fall, nursing
staff did not act in accordance with the falls policy. They should
have sought medical assistance more promptly and monitored his
condition more closely. Staff failed to communicate effectively
with one another and with the GP to ensure quality and continuity
of services. The home was found in breach of Rights 4(1) and
4(5).