Inquest into the death of MA

Contributing factors

• Routine non-compliance with patient observation protocols
• Falsification of observation records - 'phantom entries' where observations recorded without being performed
• Inappropriate staffing mix - trainee nurse without supervision assigned high-risk patient
• Absence of formal training in observation procedures for nursing staff
• Lack of auditing program to detect non-compliance
• Inadequate supervision of trainee enrolled nurse
• Poor communication between medical and nursing staff regarding risk assessment and observation levels
• Absence of documented rationale for changes in observation levels
• Cadet trainee treated as supernumerary staff and allocated patient loads inappropriately
• Nurse-in-charge assigned multiple competing responsibilities limiting availability for supervision

Coroner's recommendations

1. Develop policies to ensure appropriate skill mix in nursing staff within mental health units to enable proper patient engagement and observations
2. Develop practices and procedures to ensure identification and communication by all mental health clinical staff of the rationale for setting and/or changing patient observation status and levels
3. Develop policies clearly identifying the nurse assigned responsibility for conduct and recording of patient engagement and observations, with clear identification in patient health care record
4. Develop policies to ensure responsible nurse documents observations when they occur, avoiding 'block recording' practice
5. Develop and maintain regular ongoing education programs for development and maintenance of procedural knowledge and nursing skill sets relevant to mental health patient engagements and observations
6. Develop and maintain auditing program designed to test compliance with NSW Health Policy Directive on Engagement and Observation in Mental Health Inpatient Units and local procedures
7. Develop and maintain policies to ensure results of auditing process inform ongoing education programs related to compliance with observation policies