The Health and Disability Commissioner has recommended a rest home make several changes to current processes, provide additional training, and complete an audit, after the death of a patient who received a poor standard of care.

The patient had deteriorated over the last several months. A nurse noted one night that the patient had become delirious, had a sore red leg, and required regular monitoring. She recorded her concerns.

Despite this, multiple nurses failed to follow up on the patient or complete the necessary assessments. On several occasions observations of the patient’s condition were not recorded or lacked detail.

The patient was transferred to hospital once she became seriously unwell with a high fever. She died the same day of a blood infection.

The Commissioner was critical of the poor communication and care practices of the nurses responsible for the patient’s care.

The Commissioner held that the rest home breached the Code of Health and Disability Services Consumers' Rights by failing to provide the patient with services with reasonable care and skill.

The Commissioner recommended that the rest home:

  • develop policies to assist nurses in relation to when they should seek clinical review and how to manage a deteriorating patient;
  • provide a report to the Commissioner of how it has improved monitoring practices of deteriorating patients and handover procedures between shifts;
  • provide ongoing education to nurses; and
  • to conduct and provide an audit of patients with wound care plans.

The nurse that was responsible for the majority of the patient’s care was also recommended to provide evidence of further training to the Commissioner.

It is important that healthcare providers have effective policies in place to ensure a consistently high standard of care to patients in their care. Failure to implement and enforce these policies may result in poor health outcomes for patients.

If there are concerns about the quality of care being provided, it is wise to speak with a professional experienced in the area.

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Alan Knowsley