HEALTH PRACTITIONER REGULATION NATIONAL LAW (NSW) No 86a
NURSING AND MIDWIFERY PROFESSIONAL STANDARDS
COMMITTEE OF NSW
INQUIRY UNDER SECTION 171
SANDRA CHRISTENE MCGARRITY
REGISTRATION NUMBER: NMW0001253440 (NSW)
DAVID ROBERT KING
REGISTRATION NUMBER: NMW0001226322 (NSW)
STEVEN CYRIL CAMPBELL
REGISTRATION NUMBER: NMW0001187242 (NSW)
STATEMENT OF DECISION
SUPPRESSION ORDER APPLIES
________________________________________________________________
CITATION:
HCCC v McGarrity and Ors [2016] NSWNMPSC
PARTIES:
NSW Health Care Complaints Commission represented
by Scott Maybury instructed by Fabian Flintoff of the
Health Care Complaints Commission.
Sandra McGarrity and David King represented by Linda
Alexander, Solicitor, NSW Nurses and Midwives’
Association.
Steven Campbell represented by Katherine Doust,
Solicitor, NSW Nurses and Midwives’ Association.
TRIBUNAL:
Mark Paul
Karen Sherwood
Leigh Schalk
Robert Kelly
(Chairperson)
(Nurse Member)
(Nurse Member)
(Lay Member)
HEARING:
27, 28, 29 and 30 June 2016
DECISION:
29 July 2016
DATE OF ORDERS:
29 July 2016
ORDERS (in summary):
Sandra McGarrity is reprimanded. Her registration is
subject to a condition for indirect supervision
ORDERS (in summary):
David King is reprimanded. His registration is subject to a
condition for mentoring
ORDERS (in summary):
Steven Campbell is reprimanded. His registration is
subject to a condition for indirect supervision
CATCHWORDS:
Professional responsibilities, decision-making, polices and
practices.
LEGISLATION CITED:
Health Practitioner Regulation National Law (NSW)
No86a (National Law) – s139B(1)(a), s170, clause 7 of
Schedule 5D.
Overview of our decision
1.
Early in the morning of 16 May 2012 a residential client of Casurina Grove
Aged Care and Disability Facility, had vomited. RN Campbell arranged for him
to see the visiting medical officer a few hours later that morning. Treatment
was given and the patient was observed. On the following shift he vomited,
2
and the ‘same appeared to have blood/faecal matter in it’1. When
RN McGarrity saw the vomit, she decided it was of no concern. RN Campbell
returned for the next shift. When the patient again vomited he spoke to
RN King to discuss calling an ambulance. RN King expressed a different
opinion, and no ambulance was called.
2.
Next morning, just before 7:00am, the patient was found dead on the floor of
his room in a pool of what was described as vomit and faecal matter. He was
55 years old. Whether his death could have been averted by some particular
action taken by any of the registered nurses is unknown, and that is not the
immediate focus of this inquiry.
3.
The task of this Professional Standards Committee is to determine whether
the conduct of Sandra McGarrity, David King and Stephen Campbell, all
involved in his care in the 24 hours before his death, demonstrated that the
knowledge, skill or judgment that they each possessed or the care they each
exercised was significantly below the standard reasonably expected of a
registered nurse of their levels of training or experience. In our view the
conduct of each, in different aspects, and to different degrees, was
significantly below the standard to be expected.
4.
Aspects of the conduct of each of them amounted to unsatisfactory
professional conduct, and in the protection of the public we have decided to
reprimand each registered nurse and to impose conditions on their practices
as registered nurses.
Direction for suppression of patient’s name
5.
At the commencement of the hearing, and pursuant to clause 7 of Schedule
5D of the Health Practitioner Regulation National Law (NSW) (National Law),
the Chairperson directed that the name of the patient not be published. The
patient is referred to in our Decision as Patient A or the patient. His name is
1
Client Progress Notes, HCCC-1, Tab 48, and Unit Report – 24 Hour Cycle, HCCC-
1, Tab 49.
3
recorded in an Annexure to the original of this decision, which is not to be
copied and is to be removed before publication.
The hearing
6.
Our inquiry proceeded over four days from Monday, 27 June to Thursday,
30 June 2016. By s170 of the National Law we were able to conduct the three
inquiries at the same time.
7.
The Health Care Complaints Commission, the complainant in each matter,
was represented by Scott Maybury, instructed by Fabian Flintoff a solicitor
from the Commission. Katherine Doust of the NSW Nurses and Midwives’
Association represented Stephen Campbell, and Ms Linda Alexander also of
the Association represented Sandra McGarrity and David King.
8.
The Commission tendered two volumes of tabbed material and a third volume
containing the medical records of the patient. All of that material was accepted
into evidence without objection. Each of the registered nurses tendered a
folder containing their statement supported by a number of documents
including curriculum vitae, records of courses and training undertaken,
references in support and some additional statements. All were accepted as
evidence in the inquiry.
9.
Also in evidence was a document called Accommodation and Nursing
Services Hunter Residences tendered by Ms Alexander on behalf of RN King
and RN McGarrity on the question of their responsibilities on their shifts. A
document called Role of Registered Nurses as OIC was marked for
identification but was not admitted into evidence.
10.
Each of the registered nurses gave evidence. In addition the Committee heard
evidence from Ms Dawes and Ms Pinner, both assistants in nursing (AIN) who
worked on the shift with RN Campbell. The Committee also heard from
Ms Kathie Terrens who was the Residential Nurse Manager at Casurina Grove
at the time.
11.
Dr Schmidt the visiting medical officer, gave evidence by telephone of her
consultation with Patient A on the morning of 16 May 2012. Roydon Cannon,
4
also a registered nurse, gave evidence of the handover on the morning of
17 May and then attending Patient A’s room to discover he was dead. Ms
Thuia, another AIN, gave evidence of her observations during the night.
RN Hemley told of her recollection of conversations she said she had with
Ms Dawes and Ms Pinner and her subsequent discussion with RN McGarrity.
12.
Ms Jamieson also gave evidence. She was the registered nurse who took the
vomit that appeared to have blood/faecal matter to show RN McGarrity, and
which RN McGarrity later ‘noted to be blood/faecal matter’2. Ms Jamieson’s
conduct is not the subject of this inquiry.
13.
Ms Deborah Armitage, engaged by the Commission, attended and gave
evidence as an expert, in addition to the reports she had prepared concerning
her assessment of the conduct of each of the registered nurses. Her
attendance at the hearing assisted the Committee as she was able to express
her opinion of the conduct of each nurse taking into account additional
information provided during the hearing, in particular by RN Campbell.
14.
The Committee was greatly assisted by the approaches taken by Mr Maybury,
Ms Doust and Ms Alexander during the hearing. From the many documents
and detailed evidence they were able to distil the important issues, and each
made appropriate concessions.
15.
In his written outline of submissions Mr Maybury helpfully summarised the
applicable law: applying the civil standard and considering Briginshaw; what is
to be reasonably expected of a professional such as a registered nurse; the
importance of proper medical records as an essential aspect of good patient
care; the protective rather than punitive function of this Committee; the
significant trust placed by patients in health professionals; and the importance
of protecting the public. These principles were not contested by Ms Doust or
Ms Alexander and are accepted by this Committee.
2
RNR Shift Report, HCCC-1, Tab 50
5
16.
Overall there was little dispute about the events at least with respect to
matters that immediately touched on the Complaints made and as
particularised by the Commission. Our task was to determine if the practice of
the nurses amounted to unsatisfactory professional conduct. Dealing with the
events chronologically, and then considering the particulars of the Complaints
as each event arises best elucidates our consideration.
Arrangements at Casuarina Grove and the knowledge of the nurses
17.
Casurina Grove is a 100 bed facility which is divided into ten houses each of
ten beds. There are three shifts of registered nurses. One nurse usually has
responsibility for two of the houses, with the help of the assistants in nursing,
the AINs.
18.
RN Campbell worked Shift A from 7:00am to 3:00pm on 16 May 2012 assisted
by AIN Dawes and AIN Pinner. RN McGarrity worked Shift B from 3:00pm to
11:00pm but not as the nurse in charge of two houses. Instead she was what
was called a Registered Nurse Rover (RN Rover) a role having a supervisory
function over all the ten houses. RN Campbell returned at 11:00pm on
16 May to work Shift C through to 7:00am on the morning of 17 May 2012.
RN King was the RN Rover on Shift C.
19.
RN Campbell, RN McGarrity and RN King are each practitioners of long
standing with extensive experience in their areas of practice.
20.
Patient A’s medical history was well known to each of them, particularly his
history of bowel problems, and as Patient A often said, he had a ‘crook gut’.
They each knew he had a limited ability to communicate and each accepted
that it was important to be careful in providing him care to make sure that
nothing was missed.
21.
RN McGarrity, RN King and RN Campbell each acknowledged that the
presence or apparent presence of faecal matter in vomit is a medical
emergency requiring escalation to a medical practitioner or an ambulance to
hospital.
6
22.
A significant issue in our inquiry was whether there was any relevant division
of responsibility to respond to that medical emergency as between the nurses
in charge on Shifts B and C and the Registered Nurse Rovers during those
shifts.
23.
In our opinion the failures of each of the registered nurses, in different ways, to
treat the apparent presence of faecal matter in Patient A’s vomit as a medical
emergency arose from confusion in the roles of the registered nurse and the
Registered Nurse Rover, and uncertainty about who it was that had the
capability and the responsibility to escalate care.
24.
Our concern is that each of the registered nurses allowed policy and practice
to override their professional obligations as registered nurses.
The events on Shift A and RN Campbell’s role
25.
Shortly after commencing Shift A RN Campbell was told that when AIN Pinner
had taken Patient A to be showered and toileted AIN Dawes had reported
what she thought were two small vomits in his bed. One was on the pillow and
other was on the Kylie (a protective covering of the centre of the bed).
AIN Pinner thought what she saw contained faeces although she also knew
that Patient A was faeces incontinent and so she was not sure if what she saw
was vomit.
26.
After a discussion with AIN Pinner she took the vomit to RN Campbell on a
face washer, but apparently without any particular comment. RN Campbell
said that what he saw was mucus and undigested food, no suggestion of
faecal matter. After an assessment RN Campbell arranged for Patient A to be
seen by the medical officer later that morning. He did so because of the two
small vomits but also because he was concerned about Patient A’s unusual
lethargy, and his lack of appetite.
27.
RN Campbell took all of the relevant records to Dr Schmidt, and stayed with
the patient throughout the examination. Dr Schmidt had seen the patient
before and was familiar with his medical history.
7
28.
There is some uncertainty about the history RN Campbell communicated to
Dr Schmidt. Patient A had limited verbal ability and was unable to
communicate on his own behalf. It was obviously important that RN Campbell
be particularly careful to ensure that all potentially relevant information was
conveyed to the Medical Officer. RN Campbell accepted that responsibility.
29.
RN Campbell was sure that he had mentioned the two small vomits to
Dr Schmidt, although he was more concerned about Patient A’s lethargy and
apparent lack of appetite. Dr Schmidt could not recall RN Campbell
mentioning the two small vomits, perhaps because her main concern was that
of faecal impaction.
30.
Dr Schmidt prescribed a ‘rescue dose’ of Movicol. Dr Schmidt thought she
would not have prescribed Movicol if she was concerned about the vomits.
Ms Armitage gave evidence that in her experience as a nurse, small vomits
would necessarily not exclude Movicol, though that was dependant on the
nature of the vomits. Based on his knowledge and experience RN Campbell
thought Dr Schmidt’s prescription for Movicol was appropriate.
31.
On their return from the visit to Dr Schmidt RN Campbell arranged for the
patient to receive the Movicol and he then observed him over the balance of
the shift. However RN Campbell did not make records of his observations and
attendances.
The Shift A Complaint against RN Campbell
32.
33.
The complaint against RN Campbell is, in summary, that he:
1.
failed to make an adequate nursing assessment of Patient A,
2.
failed to adequately communicate information to the medical officer,
3.
subsequently failed to monitor Patient A’s condition, and
4.
failed to record the prescription of Movicol for Patient A in the mediation
chart.
The particulars of the complaint were based on the information and records
available to the Commission at the time and as then assessed by
Ms Armitage. In his statement and during the hearing RN Campbell gave
8
further evidence of what he did by way of his assessment and monitoring
Patient A during Shift A. When those matters were put to Ms Armitage she
agreed that he had conducted an adequate assessment of Patient A and had
adequately monitored Patient A’s condition during the shift. We agree.
34.
Although not a particular of the Complaint, RN Campbell did not make entries
in the records of his original assessment of Patient A, the attendance with the
medical officer or his later observations throughout the shift. RN Campbell
readily acknowledged his failure to make proper notes.
35.
We are of the view that RN Campbell’s readiness to acknowledge deficiencies
in his conduct even though no allegation was made against him is a
demonstration of his understanding of his professional obligations as a
registered nurse. It is a valuable trait to identify flaws in your own conduct
without them first having being pointed out by others, or there being a formal
complaint. In doing so RN Campbell demonstrated insight.
36.
We are of the view that RN Campbell could have and should have been more
definite in communicating what he thought might have been the significance of
the vomits. But in his failing to do so we do not consider that he fell
significantly below the standard reasonably expected.
37.
RN Campbell did fail to record the administration of Movicol in Patient A’s
medication chart. Apparently Dr Schmidt had not recorded the order for
Movicol on the medication chart.
38.
Ms Armitage was of the view that it was not for RN Campbell to record the
administration or transcribe the medical order from Dr Schmidt’s notes.
Although he should have asked Dr Schmidt to correct the record, his failing to
do so, was not conduct significantly below that expected of him.
39.
Movicol had been prescribed and was administered as requested. That
RN Campbell did not take steps to have Dr Schmidt properly record the
medication was an oversight.
40.
The deficiencies in RN Campbell’s conduct during Shift A did not amount to
unsatisfactory professional conduct.
9
Were there other vomits on Shift A?
41.
Ms Hemley gave evidence that shortly after the death of Patient A she was
talking with AIN Dawes and AIN Pinner about what had happened. She said
both of them told her that Patient A had vomited when being showered on that
morning and also vomited on the dining table at lunch time. She said they had
reported both events to RN Campbell and he had brushed them off.
Ms Hemley said she told that to RN McGarrity but otherwise did nothing even
though two such vomits would have been surprising and alarming events. It
was not until she was asked, much later, did she put in writing what had been
said to her some considerable time earlier.
42.
RN McGarrity said that a few days later she informed Ms Terrens what she
had been told by Ms Hemley, and she did so to assist Ms Terrens finalise her
report. Ms Terrens had finalised that report some days earlier, within four
hours of Patient A’s death as was required. Ms Terrens said she had hardly
spoken to RN McGarrity about the incident. Ms Terrens gave evidence she
was happy with the performance of both AIN Dawes and AIN Pinner, a
comment unlikely to be made if she had been aware that each of them had
seen the vomits but had made no report. When Ms Terrnes gave her
evidence, nothing was put to her about the report RN McGarrity apparently
had made by to her.
43.
There is nothing in any of the documents or records to support vomits in the
shower or on the dining table. In oral evidence both AIN Dawes and
AIN Pinner, who were said to be present on both occasions, deny those
events ever happened. They denied saying anything of the sort to
Ms Hemley.
44.
Following Patient A’s death there was a coronial inquest and subsequently an
investigation by the Ombudsman’s Office. Those who gave evidence to the
Committee had already been interviewed and questioned, at different times
and in different contexts, about the events leading to Patient A’s death. The
written records of those earlier interviews and answer to questions revealed,
unsurprisingly, differences and inconsistencies in the various versions,
10
45.
Had there been a vomit in the shower and had RN Campbell been told it is
hard to accept that he would not have mentioned the event to Dr Schmidt.
And had he done so Dr Schmidt could be expected to have recorded the event
in her notes or remembered it. And given that Dr Schmidt asked RN Campbell
to observe Patient A, and RN Campbell’s evidence is that he did observe
Patient A, it is also hard to accept that had Patient A vomited onto the dining
room table at lunch time that RN Campbell, along with AIN Pinner and
AIN Dawes would have then acted as if the event had never happened.
46.
Although quite some time was taken up on the point Ms Alexander submitted
that the evidence was only relevant to explaining Ms McGarrity’s belief about
what had happened rather than being evidence that the vomits in the shower
and on the dining room table had actually happened.
47.
The complaint made by the Commission against RN Campbell does not
include as a particular that there were any vomits in the shower or at
lunchtime. We find that the two vomits as reported by Ms Hemley did not
occur.
RN McGarrity’s conduct during Shift B
48.
Relevantly, whilst RN McGarrity may have believed what she heard from
Ms Hemley, her belief can have no impact on her conduct on 16 May because
it was only later that she had heard the relaying of events from Ms Hemley.
49.
RN McGarrity worked Shift B as the RN Rover commencing at about 3:00pm
and finishing at 11:00pm. Shortly after 10:00pm RN Jamieson came to
RN McGarrity and said that Patient A had a small vomit. She showed
RN McGarrity a face washer with a small amount of dark fluid on it.
RN Jamieson took the vomit to RN McGarrity because it appeared to contain
blood/faecal matter. RN Jamieson was aware that Patient A had seen the
medical officer in the morning, had been prescribed Movicol, and was to be
kept under observation. RN McGarrity was aware of those matters from her
reading of the pertinent records when she commenced her shift.
11
50.
RN Jamieson was concerned enough about the vomit to take it to
RN McGarrity. Between the two of them they concluded that the vomit could
not contain the blood/faecal matter that had initially concerned RN Jamieson
but was reflux from a Milo drink taken some hours beforehand. They reached
that conclusion without checking whether Patient A had in fact taken any Milo
at the 8:00pm supper. They both appeared to have assumed that he did on
the basis that Milo was normally given at that time. The notes show that
during the day the patient had been eating and drinking very little, and that
fluids needed to be forced. Neither of them thought to ask the AIN on duty if
Patient A had taken any Milo at supper.
51.
RN McGarrity was insistent in her evidence that the vomit “smelled sweet, like
Milo”. RN McGarrity gave no evidence that from her knowledge or experience
that had Milo been taken at 8:00pm and then been regurgitated by way of
reflux at a little after 10:00pm that the result would be dark brown in colour,
and would have smelled sweet like Milo.
52.
A particular of the Complaint against RN McGarrity was that she failed to
recognise Patient A’s deteriorating condition in light of the information she had.
RN McGarrity agreed that a vomit containing faecal matter was a medical
emergency requiring immediate escalation of care to a medical officer or
transfer by ambulance to hospital.
53.
Additionally RN McGarrity was said to have made no notation at that time or
later about her discussion with RN Jamieson, nor of the conclusion that she
reached that what appeared to be blood/faecal matter to RN Jamieson did not
contain any faecal matter but was only Milo reflux.
54.
In the client progress notes, HCCC-1, Tab 48, RN Jamieson had recorded:
2200hr client vomited same appeared to have blood/faecal matter
Discussed with RNR, client to be reviewed by MO in AM
55.
In the Unit Report – 24 Hour Cycle document, HCCC-1, Tab 49, RN Jamieson
recorded:
12
2200 [Patient A] - Vomited small amount same appeared to have
blood/faecal matter in it. RNR notified, client to be reviewed by MO in
AM.
56.
Both of those entries record the discussion with RN McGarrity but neither
makes any mention of the vomit that appeared to contain blood/faecal matter
now being treated only as Milo.
57.
There must have been something that concerned RN McGarrity as she
expressed the opinion to RN Jamieson (and later recorded by RN Jamieson)
that Patient A should be seen by the medical officer in the morning. If the
event was truly of no concern why was there any necessity to have Patient A
see the medical officer in the morning? Both nurses knew Patient A was to be
observed and that any deterioration was to be reported to the medical officer.
If the vomit of Milo was a sign of deterioration why delay reporting the event to
the medical officer? If the Milo was not a sign of deterioration, why was there
a need for review by the medical officer in the morning?
Contact with the medical officers overnight
58.
It appears there was a practice within Casurina Grove about contacting the
medical officers after 10:00pm. Up until 10:00pm the telephone numbers for
the medical officers were kept within the records area of each house and were
accessible to the staff on duty. But shortly after the RN Rover came on duty
each evening that contact information and other notes were taken away from
the houses to be held in the RN Rover office overnight. If anybody, including a
registered nurse, wanted to contact a medical officer they would first have to
contact the RN Rover and ask for the telephone details.
59.
Given that both RN Jamieson and RN McGarrity had noticed something with
respect to Patient A sufficient to warrant Patient A being reviewed by the
medical officer in the morning why did not RN Jamieson ask for the telephone
number so she could call the medical officer then and there. And why did
RN McGarrity not do so herself?
13
Responsibility for calling a medical officer or an ambulance
60.
Much evidence was given and many questions were asked about whether it
was the responsibility of the registered nurse or the RN Rover to call the
medical officer or an ambulance. The registered nurses said the call was the
responsibility of the RN Rover. The RN Rovers said it was the responsibility of
the registered nurses. Those conflicting statements both relied on the same
policies and practices for justification.
61.
It is not the function of this inquiry to review the policies and practices of
Casurina Grove in place at that time. But it would appear there must be some
flaw in those policies and practices if it can be that registered nurses on a shift
believe they are unable to contact a medical officer or call an ambulance
without the approval of the RN Rover, and at the same time the RN Rovers
think it is not their responsibility to contact a medical officer or call an
ambulance, but that the responsibility resides only with the registered nurses.
RN McGarrity’s completion of her RNR Report
62.
It is the task of the RN Rover to prepare the RN Rover Shift Report, a report
drawn from the completed Unit Report – 24 Hour Cycles from the houses.
RN McGarrity said that the RNR Shift Reports were to be prepared by way of
simple transcription or copy and paste of the Unit Report – 24 Hour Cycle
reports.
63.
The RNR Shift Report prepared by RN McGarrity for that shift was not a
simple transcription or copy and paste of the Unit Reports. RN McGarrity’s
entry in the RNR Shift Report concerning Patient A recorded that the small
amount of emesis (vomit) at 21:45 was ‘noted to be blood/faecal stained. For
follow up with GP in the morning’. She used the word ‘noted’ rather in place of
‘appeared’. There were other differences between the Unit Reports and the
RNR Shift Report completed by RN McGarrity, though not concerning Patient
A. When questioned about the differences RN McGarrity said the RNR Shift
Report did not just repeat everything in the Unit Reports but did record the
‘stand outs’. It was open to RN McGarrity to have added the reference to Milo,
but she did not do so.
14
64.
Whilst it might not have been RN McGarrity’s responsibility to make an entry in
the clinical notes or in the Unit Report, it was her responsibility to make a
record in her RNR Shift Report and in this regard she failed. She had
participated in a discussion with a colleague that resulted in a decision that no
action would be taken other than to observe the patient with a referral to be
seen by the medical officer in perhaps 12 hours time. Such a significant
conclusion, one that overrode what otherwise presented as a medical
emergency requiring a call to a medical officer or an ambulance, clearly
warranted the making of a record of the reasons for the decision.
Was it RN McGarrity’s responsibility to make a call?
65.
RN McGarrity says it was not her responsibility to make the call; it was for
RN Jamieson. There was no discussion between them that night about whose
responsibility it was. RN McGarrity said her role as RN Rover was not to
make the decisions but to assist and provide support to the registered nurses.
Even if that is assumed to be an accurate description of the role of the
RN Rover it would still have been incumbent on RN McGarrity as a registered
nurse to make explicit to RN Jamieson that it was for RN Jamieson to decide
whether to make a call, and that RN McGarrity was doing no more than
providing her opinion.
66.
RN McGarrity agreed that when she was talking to RN Jamieson she was
giving her best opinion of the vomit in light of Patient A’s medical history. That
being so, it was important that RN McGarrity tell RN Jamieson that
RN McGarrity was not making a decision but instead leaving that to
RN Jamieson. Given the seriousness of a possible faecal vomit RN McGarrity
should have been explicit with RN Jamieson. In this regard RN McGarrity
failed to take appropriate action.
67.
Having reached the conclusion the vomit was Milo RN McGarrity gave
evidence she would not herself have called an ambulance even if she thought
it was within her area of responsibility to do so. That is a surprising conclusion
given her understanding of Patient A’s medical history, his visit to the medical
officer, the administration of Movicol, the need for observation, and that a
15
colleague was informing her of a vomit that appeared to contain blood/faecal
matter. The conclusion that the vomit was only some reflux of Milo was
reached too easily and without care.
68.
This committee does not accept that the policies and practices of Casurina
Grove, or at least how they were understood by RN McGarrity, relieved her of
her professional responsibility to give consideration to what was in the best
interests of Patient A.
69.
Ms Armitage was of the view that RN McGarrity’s conduct with regard to her
discussion with RN Jamieson and her subsequent decisions fell significantly
below the standard reasonably expected of a practitioner of her level of
training and experience. We agree.
70.
Ms Armitage also expressed the opinion that RN McGarrity’s failure to
adequately document her decision with respect to the decisions she made
about Patient A was significantly below the standard reasonably expected.
We agree.
71.
Of concern to us was that during her evidence RN McGarrity continued to
maintain that she did nothing wrong that night, and she was entitled to do what
she did in reliance upon her assumption about Milo, and also that her role as
RN Rover meant that she did not have any responsibility for Patient A in the
situation that was presented to her. Her attitude suggests to us that
RN McGarrity does not understand the professional obligations that she has a
registered nurse. We are concerned that RN McGarrity showed no insight into
her conduct.
RN Campbell’s return to duty on Shift C
72.
During Shift A RN Campbell had been asked to return for Shift C to cover a
staff shortage, and he did so as the registered nurse in charge of two of the
houses.
73.
When he arrived and received a handover he says he was told by
RN Jamieson that Patient A would need to go to hospital during the night and
it was up to him or organise it. Apparently she pointed to clinical notes on top
16
of a cupboard. When RN Campbell asked her why Patient A not been
transported already she left without giving an answer. He thought he should
call an ambulance but did not do so. RN Campbell had read the patient notes
and was aware of the vomit that appeared to be blood/faecal matter. Patient A
was sleeping soundly and RN Jamieson had recorded that she had spoken
RN McGarrity, there was no decision to call an ambulance and RN McGarrity
had decided to wait until the morning to consult the medical officer. So he
took no action other than to observe Patient A. Looking back he regrets his
decision not to call the ambulance then and there.
74.
RN Jamieson gave a somewhat different version of events but we accept
RN Campbell’s evidence. His statement of what he says he was told by
RN Jamieson is against interest, as is his expression of regret in not having
acted the moment he arrived on shift.
75.
Whilst we believe that RN Campbell could have made a better decision we do
not believe his conduct at the time was significantly below that expected. He
was concerned about the issue and had tried to speak to RN Jamieson. He
was also relying on the decision that she and RN McGarrity had made. He
went to observe Patient A and found him asleep and apparently calm.
RN Campbell agreed that a patient may sleep as much from exhaustion as
well as being calm and relaxed. RN Campbell made a poor decision but not
so as to amount to unsatisfactory professional conduct
76.
During the night Patient A’s condition deteriorated. About 1:30am he was
seen by RN Campbell wandering through the house with small vomits on his
pyjama top and signs of faecal incontinence on his pyjama pants.
RN Campbell escorted Patient A back to his room to calm him and observe
him, and then he called RN King who was in the RN Rover role for that C Shift.
RN Campbell and RN King discuss whether to call an ambulance
77.
RN King attended a short time later and both of them sat on the bed with
Patient A. RN Campbell told RN King that he wanted to call an ambulance.
When giving evidence, RN King agreed that RN Campbell had said that he
wanted to call an ambulance.
17
78.
RN Campbell said he had mentioned calling the ambulance by way of a
question to RN King as he believed the decision to call an ambulance was a
decision for RN King to make.
79.
It was RN King’s belief that the decision was for RN Campbell to make.
80.
RN King gave oral evidence that in response to RN Campbell comment, he
had said, “Let’s wait, and assess”.
81.
RN Campbell said nothing as he was taken aback by RN King’s response,
which he interpreted as a refusal to call an ambulance.
82.
By default neither of them took any action other than to observe Patient A,
calm him down and then leave the room when he appeared to be asleep.
That position continued throughout the night with neither of them at any stage
calling a medical officer or an ambulance.
83.
Neither made any record of their discussion or the resultant decision to not call
an ambulance. Both could easily have made a note in the clinical records or
elsewhere.
84.
RN King acknowledged that there had been a disagreement between him and
RN Campbell about calling an ambulance. The fact of the disagreement was
confirmed by what happened at the handover the following morning just before
7:00am. RN King said to RN Cannon, as he came on duty, that RN Campbell
would want to see RN Cannon to talk about a difference of views - by
implication a reference to the discussion about calling an ambulance.
85.
A few moments later RN Campbell tried to speak to RN Cannon about then
calling an ambulance for Patient A. It seems that RN Campbell believed that
once RN King had not agreed to call an ambulance that he would have to wait
until the next shift to ask RN Cannon to call an ambulance. RN Campbell took
RN Cannon to the patient’s room. They found him dead on the floor.
86.
There was further evidence about what happened that morning, but the
evidence did not deal in a direct or useful way with the Complaints before us.
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87.
It is unfortunate that the same confusion as to policies and practice which so
adversely affected the discussion between RN Jamieson and RN McGarrity,
had a similar impact on the discussions between RN Campbell and RN King.
There was a failure by all of them to call an ambulance, a decision that they all
acknowledged should have been made in a case of a possible faecal vomit.
88.
As previously discussed it is our view that policies and practices cannot be
allowed to prevail over the professional obligation of a registered nurse to
provide care to a patient. For a registered nurse to seek to pass the decision
to the RN Rover, and for the RN Rover to suggest that the patient is not within
their care, are each an abrogation of professional responsibility.
Assessment of the conduct of RN Campbell
89.
In our view RN Campbell’s conduct, as particularised in the Complaint, with
respect to the treatment he afforded to Patient A from about 1:30am on
17 May 2012 through to the morning fell significantly below the standard
reasonably expected, as also did his failure to adequately document the care
that he did provide and the basis of those care decisions.
Assessment of the conduct of RN King
90.
In our view RN King’s conduct, as particularised in the Complaint, with respect
to the treatment he afforded to Patient A from about 2:30am on 17 May 2012
through to the morning fell significantly below the standard reasonably
expected, as also did his failure to adequately document the care that he did
provide and the basis of those care decisions.
91.
RN King was reluctant to accept responsibility for his role during Shift C even
though he acknowledged that vomiting faecal matter was a medical
emergency. His response to questions about his role suggested that he found
it onerous and that the responsibility was too great. He spoke of having fewer
registered nurse responsibilities when in the role of an RN Rover. He held that
view because when rostered as an RN Rover he had additional organisational
responsibilities and could not be expected to retain his responsibilities as a
registered nurse as if he were an RN on shift.
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92.
Whilst his attitude may have come about in the context of the policies and
practices at Casurina Grove the public rightly expects of registered nurses that
they do not allow policies and practices, in and of themselves, to take
precedence over their professional obligations towards the patients for whom
they have a responsibility.
93.
RN King’s conduct with respect to his conduct on behalf of Patient A when
called by RN Campbell was significantly below the standard expected. By his
conduct and comment he had the effect of inhibiting RN Campbell from calling
an ambulance. He had the same information about Patient A as RN Campbell
had.
94.
Apparently he believed it was not his responsibility to call an ambulance but
only assist RN Campbell to do so if RN Campbell wanted to do so. If that was
his belief then his statement “Let’s wait, and assess” was ill judged and wrong.
RN King ought to have escalated care just as much as RN Campbell should
have done so. RN King also failed to make any record in the progress notes
or elsewhere about the actions he took and the decisions made, as he should
have done.
The importance of records
95.
A failure to document events or decisions is often thought to be of a lesser
seriousness than substantive failures in affording treatment. Making accurate
and complete records of treatment provided to a patient and the decisions
taken is vital. Doing so not only provides a crucial tool in the future treatment
of a patient by others but the making of notes and the recording of decisions
may also prompt practitioners to reconsider and re-evaluate what it is that they
have done so far.
96.
These proceedings are a case in point. It would have been preferable if there
were a better record of Patient A’s vomits on the morning and what was told to
the medical officer. When it comes to the discussion between RN Jamieson
and RN McGarrity it would have been valuable had they made a record of why
it was that what first appeared to be blood/faecal matter could after
consideration and discussion be considered as no more than the regurgitation
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of Milo by reflux. Had they made notes they each may have realised that they
were expecting the other to make the decision, and each may have then taken
a different path. Similarly the abbreviated discussion between RN Campbell
and RN King on Patient A’s bed fell away to inaction partly because neither of
them took the time to make a note of their decision, an action that may well
have prompted at least one of them to make a different, and better, decision.
Findings
RN McGarrity
97.
We find that the conduct of RN McGarrity in failing to recognise Patient A’s
deteriorating condition, the failure to take appropriate action and the failure to
adequately document the care that she did provide to Patient A was
unsatisfactory professional conduct.
98.
In order to protect and maintain the confidence of the public in the standards
expected of registered nurses we consider it necessary that RN McGarrity be
reprimanded so as to record our disapproval of her conduct in her interaction
with RN Jamieson and her decision-making.
99.
We are concerned that RN McGarrity does not appear to have gained any
insight into her conduct. Even allowing for possible confusion about roles and
responsibilities, RN McGarrity should have appreciated the importance of her
position when RN Jamieson approached her with the vomit. Without some
further professional development we do not believe RN McGarrity should
practise without some supervision.
RN Campbell
100. We find that the conduct of RN Campbell in failing to take appropriate action in
not escalating the care of Patient A to a medical officer or arranging transfer to
a hospital, and in failing to adequately document the care that he did provide
was unsatisfactory professional conduct.
101. RN Campbell impressed the committee with his understanding and
assessment of the errors in his conduct. He has reflected on what he did, and
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has learned from his mistakes. He has been prepared to criticise himself
where appropriate and acknowledge his failings. He has taken significant
steps at further education and now understands where his learning was
lacking. He presented as a practitioner showing thoughtful insight and deeply
concerned about the consequences of his failures. He was clearly committed
to improvement so that he could better discharge his professional obligations
as a registered nurse, and now understands where his professional
development was lacking.
102. Nevertheless he did allow policies and practices to override his desire to look
after the patient. In order to protect and maintain the confidence of the public
in the standards expected of registered nurses we consider it necessary that
RN Campbell be reprimanded for his conduct.
103. Given the position RN Campbell found himself in – caught between calling or
not calling an ambulance - we believe RN Campbell would benefit from some
mentoring, and he would then better serve the public.
RN KIng
104. We find that the conduct of RN King in failing to take appropriate action in not
escalating the care of Patient A to a medical officer or arranging transfer to a
hospital, and in failing to adequately document the care that he did provide
was unsatisfactory professional conduct.
105. In order to protect and maintain the confidence of the public in the standards
expected of registered nurses we consider it necessary that RN King be
reprimanded so as to record our disapproval of his conduct towards RN
Campbell in suggesting and a course of action without taking responsibility for
his decision.
106. RN King found the responsibilities of being the RNR onerous. When
undertaking that role he felt he was unable to also discharge his
responsibilities as a registered nurse. Without some further professional
development we do not believe RN King should practice without some
supervision.
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Decision
107. This Statement of Decision is to be given to the Commission, RN McGarrity,
RN King and RN Campbell, and the Nursing and Midwifery Council of New
South Wales.
Reprimands, directions and orders
With respect to RN McGarrity:
108. We reprimand RN McGarrity
109. We direct RN McGarrity may only practise as a registered nurse under the
supervision of a registered nurse (Division 1) who does not have any
conditions on their practice. Supervision may be remote, that is, where the
supervisor is:
1.
on site, but not working in close proximity to RN McGarrity’s workplace;
or
2.
off site or working remotely from RN McGarrity. At all times the
supervisor must be accessible to RN McGarrity to provide advice either
in person or by telephone.
110. RN McGarrity must:
1.
inform all current nursing employers of the conditions immediately and
provide the Nursing and Midwifery Council of New South Wales with
each employer’s name and contact details;
2.
inform all future nursing employers of the conditions, and provide the
Nursing and Midwifery Council of New South Wales with the name and
contact details of each employer, before commencing work/employment
as a registered nurse.
111. RN McGarrity must only be employed/work as a nurse in circumstances where
the employer has agreed to notify the Nursing and Midwifery Council of New
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South Wales of any breach of the conditions, and exchange information with
the Council related to compliance with the conditions.
112. Sections 125 to 127 of the Health Practitioner Regulation National Law 2009
are to apply should RN McGarrity’s principal place of practice be anywhere in
Australia other than in New South Wales, so that the appropriate review body
in those circumstances is the Nursing and Midwifery Board of Australia.
113. The Nursing and Midwifery Council of New South Wales is the appropriate
review body for the purposes of Division 8 of the Health Practitioner
Regulation National Law (NSW).
With respect to RN Campbell:
114. We reprimand RN Campbell
115. We order that RN Campbell must engage in a mentoring relationship in
relation to his practice and concerning his approaches towards and methods
of dealing with any conflicts in decision making. The mentoring relationship
must occur when RN Campbell is practising as a nurse, for a minimum
cumulative period of six months full time equivalent, commencing from the
date the mentor is approved by the Nursing and Midwifery Council of New
South Wales. The mentor must be:
1.
a registered nurse (division 1) who meets the criteria specified in the
Nursing and Midwifery Council of New South Wales Mentor Policy; and
2.
approved by the Nursing and Midwifery Council of New South Wales.
116. RN Campbell must:
1.
provide, within three months of the date of this decision, the Nursing
and Midwifery Council of New South Wales with the name, contact
details and résumé of the registered nurse who has agreed to: act as
mentor; and act as specified in the conditions; and notify the Council of
any breach of the conditions including repeated failure to attend
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mentoring meetings; and exchange information with the Council in
relation to the registrant’s compliance with the conditions.
2.
provide to the Council a copy of the conditions signed by the registrant
and by the mentor indicating their awareness of the conditions and
authorisation.
3.
submit within four weeks of the mentor being approved, a mentoring
plan that is developed in consultation with the mentor which meets the
standards required by the Council’s mentoring policy.
4.
submit a mentoring report to the Council every two months for a period
of at least six months, and until the Council advised the registrant in
writing. The mentoring report to: be co-signed by the approved mentor
and meet the standards required by the Council’s mentor policy.
117. Sections 125 to 127 of the Health Practitioner Regulation National Law 2009
are to apply should the registrant’s principal place of practice be anywhere in
Australia other than in New South Wales, so that the appropriate review body
in those circumstances is the Nursing and Midwifery Board of Australia.
118. The Nursing and Midwifery Council of New South Wales is the appropriate
review body for the purposes of Division 8 of the Health Practitioner
Regulation National Law (NSW).
With respect to RN King;
119. We reprimand RN King
120. We direct RN King may only practise as a registered nurse under the
supervision of a registered nurse (Division 1) who does not have any
conditions on their practice. Supervision may be remote, that is, where the
supervisor is:
1.
on site, but not working in close proximity to RN King’s workplace; or
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2.
off site or working remotely from RN King. At all times the supervisor
must be accessible to RN King to provide advice either in person or by
telephone.
121. RN King must:
1.
inform all current nursing employers of the conditions immediately and
provide the Nursing and Midwifery Council of New South Wales with
each employer’s name and contact details;
2.
inform all future nursing employers of the conditions, and provide the
Nursing and Midwifery Council of New South Wales with the name and
contact details of each employer, before commencing work/employment
as a registered nurse.
122. RN King must only be employed/work as a nurse in circumstances where the
employer has agreed to notify the Nursing and Midwifery Council of New
South Wales of any breach of the conditions, and exchange information with
the Council related to compliance with the conditions.
123. Sections 125 to 127 of the Health Practitioner Regulation National Law 2009
are to apply should RN King’s principal place of practice be anywhere in
Australia other than in New South Wales, so that the appropriate review body
in those circumstances is the Nursing and Midwifery Board of Australia.
124. The Nursing and Midwifery Council of New South Wales is the appropriate
review body for the purposes of Division 8 of the Health Practitioner
Regulation National Law (NSW).
Mark Paul
Chairperson
Date
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