HCCC v Drinkwater; HCCC v Lilly; HCCC v Davies; HCCC v Chan  NSWCATOD 39
The above case concerned the death of a patient, who took her own life, at the Psychiatric Intensive Care Unit (PICU) at Mater Mental Health Centre in Newcastle in March 2015. The patient was an involuntary patient who had been placed in the PICU because of a high risk of suicide.
The patient used a bedsheet as a noose and hung herself by her bedroom door, between 6:30 am and 7:30 am on 19 March 2015, even though she was meant to have been closely observed every 15 minutes by the PICU staff at the Mental Health centre. The patient’s door was slightly ajar and she was in full view of the nurses’ station when this event occurred. The nursing staff had presumed that from 6:45 am onwards, the patient was standing behind the door watching them, when in fact she was dying or already dead.
There were as many as six nurses present at the nursing station at the time of the patient’s death and they had assumed that she was still alive and that someone else had checked on her wellbeing. Another patient found her and raised the alarm.
A Root Cause Analysis (RCA) and a Coronial Inquest in 2017 identified a number of systemic failings within the PICU. A number of measures were undertaken to combat the systemic failings. These included:
- Painting the PICU bedroom doors a different colour from the white bed sheets.
- Replacing the door handles with handles that could not be used as ligature points.
- Improving the corridor lighting.
- Observation policy revisions, which require staff to engage with a patient who needs to be closely observed.
- Allocation of a patient to a particular nurse.
- Protected handover time, where nurses are paid extra to stay for the handover period.
This case concerned allegations of unsatisfactory professional conduct in terms of the failure of four nurses involved in the care of the patient to conduct observations. There were additional allegations of professional misconduct, in relation to supervision failures of three of the nurses.
The nurses argued that ‘sighting’ a patient every 15 minutes met the requirement of a close observation. A ‘sighting’ could be accomplished by walking past a patient’s open door, walking past the patient in the corridor, or observing a patient who was visible from the nurses’ station.
The HCCC argued that an observation of a patient in an acute mental health setting involved an exercise of professional judgement which was both qualitative and quantitative. It was argued that an assessment, regardless of how many times it was undertaken, required an assessment of the patient’s state of health in order to determine whether the patient was deteriorating or was at increased risk. The tribunal agreed with the HCCC’s position.
The four cases were heard concurrently, and all four respondents attended the hearing and gave oral evidence.
The tribunal heard evidence about previous suicide attempts made by the patient while she was a mental health patient being treated by HNELHD. The day before her suicide, a nurse had found her trying to construct a noose out of her bed sheet. An assessment by a psychiatrist at 6:21 pm on 18 March 2015 had found that she was at a high risk of suicide with the intent and a plan. The patient was transferred to PICU because of this high risk.
The nurse allocation on PICU was one nurse to two patients, but this could be increased if a patient required one-on-one supervision.
The usual PICU practice was to assign specific patients with specific nurses, on day shifts but not on night shifts. A team nursing model was used during the night shifts. This was not in accordance with the HNELHD procedure relevant to observations in a mental health unit.
When the patient was admitted into PICU the admitting nurse mistakenly recorded her as being of a medium suicide risk rather than a high suicide risk in the computer system. This mistake was carried over into the night shift.
On 18 March 2015 the patient was visited by her mother, who expressed her concerns for her daughter to the nursing staff.
The nurse in charge of the night shift said that during the oral handover from the afternoon shift to the night shift, the night staff were told that the patient was a high risk of suicide and had attempted suicide on another ward.
The night shift nurses’ accounts of when they had observed the patient during the crucial period were at times vague and inconsistent.
At least eight members of staff observed the patient at a distance, in a standing position partially obscured by her door between 6:45 to 7:25 am. The behaviour was perceived as odd, and it was discussed by the staff. Importantly, no-one went to investigate why the patient was behind the door.
The HNELHD Mental Health: Levels of Observations MH_LP_1.137.94 (2015) was the mandatory procedure the nurses were required to follow when carrying out observations.
The nurses argued that it was sufficient to merely sight a patient every 15 minutes to fulfil the mandatory requirement to ‘sight the patient every 15 minutes’.
The expert witness Ms Muller, while not critical of staff taking a literal interpretation of the procedure, noted that the ‘spirit’ of the procedure was to keep patients safe and that observations are to ensure that a patient is safe, alive and well. She considered that mere sightings needed to be interspersed with more engaged interactions which would allow a fuller assessment of a patient.
The HCCC noted the systemic failures but submitted that the systemic failures were not causal factors in the death of the patient. Nothing prevented any of the respondents walking less than 10 metres to check that the patient was alive and well. The failure to do this should be regarded as conduct which fell significantly below the standard of any registered nurse. It was submitted that to interpret an observation as simply a sighting demonstrated a lack of skill and judgement.
The nurses submitted that the failures to observe the patient were borne out of systemic failures such as the lack of a protected handover period and wide-spread established practices of merely sighting a patient being counted as an observation. It was additionally submitted that the patient could have been allocated a higher risk status by the medical staff.
Findings and Reasons
The tribunal found as follows:
- A submission that the patient should have been allocated a higher suicide risk is no answer to the charge of a failure to properly undertake the observations relevant to the risk that had been determined.
- An observation is a qualitative assessment. Just because staff have to conduct that assessment every 15 minutes does not mean that the professional obligations are satisfied by merely sighting a patient.
- A sighting cannot be said to have occurred in circumstances where a patient is only partially visible and where their facial expression cannot be seen. Such a sighting is not an observation as it does not allow the nurse to make the necessary clinical assessment.
- The night nurses involved in the care of the patient had not read her file.
- Due to a combination of factors, which included the fact that no particular nurse was allocated to the patient during the night shift; nurses signed for observations they had not personally undertaken; observations were conducted from a distance and the sparsity of clinical notes, no-one on either the night shift or the morning shift could accurately say who had last seen the patient or what state she was in after 5 am.
- The day shift staff were misled into thinking that the patient had been awake for a shorter period than she had been, and she had been observed more recently than she had been. Additionally, the crucial information about the recent suicide attempt was not passed onto the day shift.
The tribunal made findings of unsatisfactory professional conduct against two of the nurses from the night shift and the day shift. They also made findings of professional misconduct against the nurse in charge of the night shift and the nursing unit manager.
This tragic case serves as a reminder that box-ticking procedural exercises are, as the tribunal pointed out, not ends in themselves but rather, they are records of actual assessments of clinical judgement. The case also highlights that patients can slip through the net when no particular nurse is assigned the responsibility of caring for a particular patient. It is far too easy for one nurse to think that another nurse has attended to a task and for mistakes to be compounded with further mistakes. The clarification of what is meant by an observation by the tribunal will hopefully mean that in the future patients who have been deemed to be of a high suicide risk will be safer in psychiatric units.