Highlights
CASE STUDY
Peter Sutcliffe, 59 years old and a marathon runner, was admitted to Sunny Days Private Hospital for elective surgery for repair of a rotator cuff injury.
Peter was on no regular medication and was otherwise healthy. Peter underwent his surgery at 2pm and the procedure was uneventful. Peter was transferred to the Recovery area at 3.30 pm. On arrival, Peter's oxygen saturation was 64%. The nurse did not notify the anesthetist of this low reading. Peter was transferred to the ward and a handover was given to the ward nurses. No mention was made of Peter's low oxygen reading in the handover. The ward nurse looking after Peter completed his observations, noted his oxygen saturation was 80%, administered facial oxygen and did not check his oxygen saturation again. During the evening Peter remained sleepy and difficult to rouse.
The two night duty nurses (one Registered Nurse and one Enrolled nurse) came on shift at 1030 pm and checked the patients in the ward. The Enrolled Nurse completed Peter's observations and noted that his oxygen saturation was 82% and he was difficult to rouse. She documented these findings in Peter's medical record but did not notify the Registered Nurse. Shortly after coming on shift, the Registered Nurse told the Enrolled Nurse that he was going to sleep in a spare patient bed and did not want to be interrupted.
The Enrolled Nurse was left with monitoring and caring for all 40 patients in the ward. As she could not complete all the patient care including the observations, she made some up (including Peters) and wrote them in the patients' medical records without actually assessing each patient. At 4 am when she went into Peters' room she could not hear him breathing and he was not rousable. She rang the emergency call bell and the Registered Nurse came to the room, commenced CPR and called for additional staff to assist.
Peter was transferred to a nearby public hospital for continued care but was pronounced dead on arrival. The case was referred to the coroner.
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