Deputy Health and Disability Commissioner Rose Wall today released a report finding a registered nurse in breach of the
Code of Health and Disability Services Consumers’ Rights (the Code) for failures in the care of a rest home resident who
deteriorated overnight.
The elderly woman became unwell one evening, with vomiting and shortness of breath. The nurse who provided care to the
woman overnight twice administered Asthalin (a respiratory solution) and oxygen via a nebuliser. Neither of these
medications had been prescribed for the woman. The nurse did not contact the woman’s general practitioner (GP) or family
overnight, or call an ambulance. The woman was seen by her GP in the morning and admitted to hospital, but she continued
to deteriorate and sadly died the following day.
Deputy Commissioner Rose Wall was critical that the nurse acted outside her scope of practice by administering
medications that had not been prescribed for the woman, and failed to escalate the woman’s care overnight. She also
found that the nurse did not communicate with the woman’s family in a timely or appropriate manner, and did not document
the care she provided adequately.
Ms Wall was critical that rest home staff did not document their 30-minute observations of the woman overnight, and
considered that this contributed to the failure to recognise the woman’s deterioration.
"I acknowledge that when administering the oxygen and Asthalin, [the nurse] was trying to alleviate [the woman’s]
symptoms," said Ms Wall. "However, this does not mitigate the seriousness of her acting outside her scope of practice,
or of the other issues identified. In my view, the above concerns amount to a failure to provide services to [the woman]
with reasonable care and skill."
The Deputy Commissioner recommended that the nurse review her practice in light of HQSC’s NZ Frailty Care Guides and
report back to HDC; report back to HDC on her learnings from the further training she has attended; and provide a
written apology to the woman’s family. She also recommended that the Nursing Council consider whether a review of the
nurse’s competency is warranted.
Ms Wall recommended that the rest home owner provide training to staff on documentation; consider amending its Emergency
Policy; and provide a written apology to the woman’s family.
The full report for case 18HDC02271 is available on the HDC website.