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Monitoring of patient with pneumonia; documentation of care (12HDC00548)
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(12HDC00548, 27 June
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