401021 Assessment 2 – Nursing Case Study - 2019

On 5 January 2013, Patient A, who was 81 years old, presented to a GP clinic complaining of two nights
of breathlessness when lying flat and shortness of breath. On examination, Patient A was found to have
fine creps at the base of both lungs and slightly elevated jugular venous pressure. Her renal function was
normal. She was commenced on oral Lasix and was recommended to have a clinical review two days
later.

On 6 January 2013, Patient A attended a local hospital again with shortness of breath. Patient A was
admitted to hospital as the oral Lasix had not improved her symptoms.

Over the course of the following days, Patient A's condition did not improve. On 7 January 2013, the
Visiting Medical Officer (VMO) reviewed Patient A and planned a chest x-ray and blood tests. On 8
January 2013, the VMO reviewed Patient A again and noted diarrhoea and right sided tenderness of
Patient A's abdomen. He organised a ventilation/ perfusion (V/Q) lung scan.

On 9 January 2013, Patient A reported dizziness. This coincided with an atrial fibrillation (AF) rate of
120/ min. The VMO was called to review Patient A. He noted that the V/Q scan was "interdeterminate".
Patient A was refusing food and liquid at this time, and was complaining of feeling very weak and having
abdominal pain.

At 0830 hours on 10 January 2013, the VMO again assessed Patient A. He concluded that Patient A was
depressed and anxious. He encouraged nursing staff to mobilise Patient A. The nursing notes that follow
Dr Haron's attendance refer to discharge planning at 1021 hours, and then, at 1315 hours, comment that
Patient A felt unwell, had refused breakfast and lunch, had no energy and required encouragement to
mobilise. Patient A's respiratory rate was recorded as 28-30/ minute, but other vital signs were within
normal limits.

At 1820 hours, the progress notes state that Patient A refused to tolerate her dinner. At 1910 hours, Patient
A was observed to have a respiratory rate of 40/min and she was tachycardic at 122/min. At 1930 hours,
Patient A was documented as feeling "woozy", her skin was cold and clammy and she was complaining
of severe back pain. Her BSL was 16.1mmmol/I. An ECG was conducted, which showed a heart rate of
168/min. The VMO was again called. He stated that Patient A should be administered Digoxin and
Valium. At 2110 hours, showing Patient A's respiratory rate was still at 40/min.

At 0530 hours on 11 January 2013, nursing notes state that Patient A was unable to void, was pale and
grey, and had clammy skin and nausea. At 0830 hours on 11 January 2013, the VMO assessed Patient A
and wrote "?Significant medical illness". An abdominal x ray and pathology were ordered. The VMO
returned at 1330 hours and noted that Patient A "won't/ can't mobilise [because of] pain in back and abdo"
and that her white cell count had risen to 17.5, despite an absence of fever. A urinary tract infection was
subsequently diagnosed and intravenous antibiotics were commenced at approximately 1430 hours.

Registered Nurse (RN) John commenced her afternoon shift as the nurse in charge at 1430 hours on 11
January 2013. She read Patient A's progress notes at approximately 1445 hours. In her evidence before
the Committee, the respondent stated that she was immediately concerned about Patient A's condition,
and explained that she considered that the Hospital was not equipped to properly care for Patient A. The
respondent said that she had been informed at the handover that Patient A's treating doctor had "gone
away" and "was unable to be contacted'. The respondent said that as Patient A's doctor was not available,
she intended that to have Patient A seen by the locum (who usually arrived at around 2100 hours on
Friday evenings).

*All names have been changed in this case study to provide confidentiality
Citation: HCCC v Heather Conyard [2015] NSWNMPSC 3
 401021 Assessment 2 – Nursing Case Study - 2019

At approximately 1720 hours, Patient A reported to nursing staff that she was feeling dizzy and had
abdominal pain (8/10). She was observed to have a respiratory rate of 40 -.44/min, very low blood
pressure of 89/53 and a heart rate of 88.

Shortly before 1810 hours, the respondent was advised of Patient A's condition by an enrolled nurse. The
respondent said that she would have Patient A reviewed once the locum arrived. At around 1810 hours,
the respondent was informed that Patient A had continual diarrhoea. The respondent again said that she
would have Patient A reviewed when the locum arrived. After this conversation, the respondent
personally reviewed Patient A. The respondent did not document her observations. However, in her
evidence before this Committee, the respondent acknowledged that Patient A's vital signs had not
improved at this time.

At approximately 1910 hours, the respondent arranged for a further ECG to be undertaken for Patient A.

At approximately 2020 hours, the respondent telephoned the Clinical Nurse Manager, Ms Catherine
Jones, to arrange for medication to be obtained from the drug safe (for a patient other than Patient A). At
approximately 2030 hours, Ms Jones attended the Hospital and signed for the medication. The respondent
did not raise any issues concerning Patient A with Ms Jones at this time.

At approximately 2100 hours, the respondent and another registered nurse completed an ISBAR
(Introduction Situation Background Assessment Recommendation) form. In that form, the respondent
described Patient A as "deteriorating", and recommended that Patient A's condition be reviewed "ASAP''.
She also stated that Patient A's family had been contacted.

The locum, Dr Vallentine, arrived at 2200 hours. By this time, Patient A was critically unwell. The
emergency on-call doctor, Dr Correy, arrived at approximately 2300 hours and inserted a large bore IV
cannula to treat Patient A's severe dehydration. Over the course of the night, attempts were made to
transport Patient A to a rural referral hospital. The ability to transfer Patient A was significantly
complicated by Patient A's critical condition. Tragically, Patient A died whilst she was being assessed by
the air evacuation team the following morning. The primary cause of death was stated to be septicaemia

*All names have been changed in this case study to provide confidentiality
Citation: HCCC v Heather Conyard [2015] NSWNMPSC 3