A registered nurse and Te Whatu Ora Te Toka Tumai Auckland are being reprimanded after a patient suffered irreversible brain damage due to a morphine overdose.
The Deputy Health and Disability Commissioner found Te Whatu Ora and the nurse breached the Code over the care of the male oncology patient.
The man was receiving treatment for throat cancer and was admitted to Auckland City Hospital with severe inflammation and ulceration of his digestive tract. While being treated for pain, he received an overdose of morphine which resulted in irreversible brain damage.
Deputy Commissioner Dr Vanessa Caldwell found the provider breached Right 4 (1) which ensures people receive services provided with reasonable care and skill. The provider also breached Right 4 (4) which stipulates health and disability services be provided in a way that minimises harm and optimises the quality of life of a person using that service.
A registered nurse was also found to have breached Right 4 (1) which centres on the right of consumers to have services provided with reasonable care and skill. The nurse also breached Right 4 (2) which gives consumers the right to services that comply with legal, professional, ethical and other relevant standards.
Dr Caldwell said policies were not sufficiently clear to support safe practices.
"This is evident in the practices followed by staff that were not in line with the expected standard of care. Opiates are known to suppress breathing and to affect renal function. The risk for this patient was not monitored adequately," she said.
For providing care that fell considerably below the appropriate standard, Dr Caldwell referred Te Whatu Ora Te Toka Tumai Auckland to the Director of Proceedings.
She also criticised the nurse's lack of monitoring and documentation, in particular, failing to record the Code Red event and for leaving the man on his own while getting assistance, instead of undertaking an immediate assessment and raising the alarm.
Dr Caldwell made several recommendations for Te Whatu Ora including education for nursing staff, consideration for a quick reference guide for the management of opioid overdose and providing the man and his family a formal apology.
Dr Caldwell recommended the nurse provide a written apology to the man and undertake further training on emergency procedures, local policy on observations, and documentation.
Since the event, Te Whatu Ora has made numerous changes to improve support for nurses and non-palliative patients, developed appropriate policies and training and expanded access to the Acute Pain Service for oncology ward patients with acute pain.
The Registered nurse has undertaken basic life support training and developed processes to prevent a similar occurrence in future.
