The importance of applying a patient-centred approach to
care, and involving family members when warranted was
highlighted in a decision published by Deputy Commissioner,
Rose Wall.
In her decision, Ms Wall found a Clinical
Nurse Manager in breach of the Code of Disability Services
Consumers’ Rights (the Code), for failing to provide
services that minimised potential harm to an elderly woman,
and for not optimising her quality of life.
This case
involves an elderly woman who had recently suffered a stroke
and was confused and unsettled. She was separated from
family, being cared for in a busy hospital environment by
people she was unfamiliar with.
“Given her
vulnerabilities, the onus was on the health professionals
involved in this woman’s care to ensure any intervention
was carried out with respect, with reasonable care and
skill, and with due consideration to her dignity,” said Ms
Wall.
“The actions of the Clinical Nurse Manager and
the manner in which she bandaged this elderly woman’s
hands and arms to stop her from moving them was
unacceptable. The use of this kind of restraint, and the way
in which it was implemented, clearly does not align with
current best practice,” said Ms Wall.
During the
woman’s stay in the neurology ward, the Clinical Nurse
Manager applied bandaging to her hands and arms, to stop the
woman from hurting herself. Unfortunately the Clinical Nurse
Manager overlooked the risks and harm that could be caused,
and failed to exercise reasonable care and skill in the
bandaging process. The way in which the woman’s hands were
restrained caused bruising and discolouration to her hands,
and also resulted in her right thumb being found in an
abnormal position.
After the bandaging was applied,
the Clinical Nurse Manager failed to monitor or review the
woman, or organise someone else to monitor and review her.
This meant the woman suffered unnecessarily over an extended
period. The Clinical Nurse Manager also did not document the
care provided. Other nursing staff did not monitor the
woman, and the harm was not identified until the following
morning.
The Clinical Nurse Manager also did not
communicate with the woman’s family in order to
de-escalate her unsettled behaviour.
“Communication
with the woman’s family should have occurred to facilitate
the provision of health services that respected her social
needs, values, and beliefs,” said Ms Wall.
Ms Wall
noted that while the DHB has a duty of care to patients, and
a responsibility to keep them safe whilst in hospital, she
did not find them to be in breach of the Code.
She
made educative comments about a proactive strategy for
behaviour of concern, and the ability of junior staff to
raise concerns about care provided by senior staff.
Ms
Wall recommended the Clinical Nurse Manager provide a
written apology to the woman’s family, and provide
evidence of having completed training on the use of
restraints and the management of actual or potential
aggression.
She also recommended the DHB provide an
apology to the woman’s family and provide evidence that
changes made and training provided to nursing staff have
been effective, and consider implementation of the
recommendations made by HDC’s independent nursing
advisor.
Following the events, the DHB conducted an
internal review with the nursing staff involved, and as a
result of this complaint, it has implemented a number of
changes to its processes and procedures and ensured its
staff undergo further training. The Clinical Nurse Manager
has undergone further training and implemented changes to
her practice.
“Complaints offer a significant learning
opportunity, to reflect on how care could be improved. I am
pleased to see the nurse has made changes to her practice
and undergone further training,” said Ms
Wall.
Editors notes
This case relates to a
complaint made to HDC in 2019. We aim to investigate
complaints as promptly as possible, ensuring natural justice
and the interests of all the parties involved to provide
information, is considered.
The full
report of this case will be available on HDC’s
website. Names have been removed from the report to protect
privacy of the individuals involved in this case. The DHB
(now Te Whatu Ora), has not been named in this case as they
were not found to be in breach of the Code.
The
Commissioner will name providers and public hospitals found
in breach of the Code unless it is not in the public
interest, or would unfairly compromise the privacy interests
of an individual provider or a consumer.
More
information for the media and HDC’s naming policy can be
found on our website here.
HDC
promotes and protects the rights of people using health and
disability services as set out in the
Code of Health and Disability Services Consumers’ Rights
(the Code).
While HDC acknowledges the significant
pressure the health and disability system is currently
under, we must also remain focused on ensuring peoples’
rights under the Code are
protected.
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