Mr B was an 86-year-old male who had been living in a low-level care facility in Northern Queensland for about one year.

One Sunday, Mr B notified staff he was unwell and had vomited. The RN on shift at that time reviewed him and noted the presence of a small hernia that was not painful.

The RN advised staff to give Movicol to rule out constipation as Mr B had not moved his bowels for two days, and to give his regular paracetamol for possible pain and discomfort.

The staff were asked to monitor and handover to the night shift RN. However, Mr B continued to vomit and complain about abdominal pain.

He was administered oral morphine, and a fax was sent to his GP’s office requesting a review. The very next day Mr B was examined by his GP, the same RN and later an enrolled nurse who had never met him before.

On Tuesday, only two days after initially complaining of not feeling well, Mr B stayed in bed and did not eat or shower. Mr B died later that day.

It turned out Mr B had died from complications of an incarcerated umbilical hernia which contained part of his small bowel.

The death most likely followed a cardiac arrhythmia induced by an electrolyte imbalance in conjunction with sepsis due to the effects of his poorly functioning small bowel.

So could Mr B’s death have been prevented?

When the coroner reviewed the case, as seen in the Victorian Institute of Forensic Medicine’s (VIFM) Residential Aged Care Communique, he found that the GP’s assessment of Mr B was limited because the GP did not seek information from the nursing staff who had requested the review, did not read the nursing home progress notes and had not seen the fax that was sent.

Therefore, he remained unaware that oral morphine had been administered. The coroner also found that the effectiveness of the GP’s direction to nursing staff about what matters should be communicated to him was questionable.

In Mr B’s case, the history taking was inadequate and the GP made no note in the record about this and did not know the level of qualifications of the staff member he passed his verbal instructions on to.

The coroner concluded that Mr B’s death was a healthcare related death. Nursing staff should have been monitoring Mr B and recognised the signs of deterioration. Especially since there was a drop in his blood pressure, his increased confusion, inability to self-care which was out of character, his disinterest in food and remaining in bed.

The coroner noted the ‘handovers’ had a narrow focus on whether or not Mr B’s bowel function had returned rather than looking at his overall condition.

Coroner’s Recommendations

So what can aged care providers learn from Mr B’s death? From the case, the coroner made three main recommendations, not just to the facility but the industry as a whole.

Firstly, that aged care providers introduce “a requirement for personal carers and assistants in nursing to enter any variation in a resident’s condition in the progress notes”.

The second recommendation was that providers should “encourage visiting medical officers to document the diagnosis and management plan, including any planned review and indications for earlier escalation.”

The coroner also said that this would be an opportunity for introducing procedures and training for nurses “to assist them in requesting visiting medical officers to state and preferably record their diagnosis and treatment plan”.

It is crucial that there is enough information to inform nursing staff on every shift what was required and when medical staff or emergency services be contacted.

And the third and final recommendation was that aged care providers consider implementing further training for personal carers, in order for them to make entries in the resident’s records where appropriate.

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