Nurse failed ailing man, says report

Resident, 70, died within hours of check

A registered nurse of a privately owned rest home who was busy attending a meeting failed to adequately assess that an elderly man was ‘‘seriously unwell’’ just hours before he died, the health and disability commissioner says.

Deputy commissioner Theo Baker’s report does not name the 70-year-old man, the nurse, the rest home or its location.

The man, referred to as Mr A in the report, was suffering abdominal pain after three to four days of no bowel movement in mid-july 2009.

He was being looked after by a caregiver who reported his condition to the clinical co-ordinator, Ms C, a registered nurse.

Enema treatment failed and the co-ordinator asked the caregiver to call the man’s doctor.

The doctor asked the caregiver to check the man’s vital signs and report back. But he was unable to assess Mr A’s blood pressure and pulse and again advised Ms C of his concerns.

Ms C assessed Mr A, reported his vital recordings to the doctor and made an appointment for him to be seen by the doctor at 4.15pm – she then left for a meeting at 2pm.

When Mr A was escorted to the doctor’s office about 4pm, the doctor found he was ‘‘seriously unwell’’ and had a weak pulse.

Mr A collapsed and died before an ambulance could be called. He was pronounced dead at 4.35pm. He died of myocarditis, an inflammation of the heart muscle.

Hypertension and small bowel obstruction were also contributing factors to his death.

The health and disability commissioner began looking into the circumstances surrounding Mr A’s death after the coroner filed a complaint in November 2009.

Ms Baker said Ms C did not provide the man with ‘‘reasonable care and skill’’ and her documentation did not meet profession standards, Ms Baker said.

‘‘Ms C performed only a cursory examination of Mr A and failed either to arrange for another senior staff member to check on him or to provide Mr D [a nurse] with clinical instructions should Mr A deteriorate.

‘‘This was unacceptable regardless of any time constraints Ms C felt she was under.’’

The nurse had explained she was overworked as she had just returned after four days off when Mr A became seriously ill, but Ms Baker said there was ‘‘insufficient evidence’’ to establish that the level of support for the nurse was so deficient that she was unable to properly assess him.

The nurse resigned in October 2009 and later sent an apology letter to the man’s family.

Ms Baker did not find the rest home liable for the nurse’s performance.