Tribunal reprimands enrolled nurse for failing to advocate for her patient

04 Nov 2016

A tribunal has found that an enrolled nurse engaged in unprofessional conduct after she failed to advocate for her patient and failed to make adequate notes in the patient record.

The Victorian Civil and Administrative Tribunal (VCAT) found that Ms Catherine George engaged in unprofessional conduct in relation to two allegations. The tribunal reprimanded Ms George and imposed conditions on her registration, requiring her to undertake and complete further education in the form of a law and ethics course, which includes a component on documentation requirements.

The conditions imposed by the tribunal require Ms George to:

1. submit the details of a proposed course to the Nursing and Midwifery Board of Australia (NMBA) for approval prior to commencement
2. complete the course within eight months of the tribunal’s findings and determinations
3. provide to the compliance department at AHPRA, within one month of the date of completion of the course, evidence of completion of the education by way of a copy of a certificate of attainment in relation to the approved course, and
4. provide to the compliance department at AHPRA, within one month of the date of completion of the course, a written report which covers the following:
   1. her reflection on the issues raised by the notification
   2. a written summary of the outcomes/lessons learnt from the education, and
   3. a written summary of how she intends to apply this knowledge to her practice.

Both of the allegations relate to Ms George’s care of a patient on or about 18 August 2011. The first allegation of failing to advocate for the patient, referred to:

• circumstances where she had observed the patient to be drowsy but responsive, she had an obligation to query the anaesthetist as to whether it was appropriate to continue with the proposed procedure without anaesthesia, but failed to meet this obligation, and
• circumstances where she was of the view that the patient was drowsy but responsive, she had an obligation to alert medical practitioners in the room as to her observations to that effect, but failed to meet this obligation.

The tribunal also found that Ms George had failed to make adequate notes in the patient record by failing to make concise, clear records, either during the procedure or immediately thereafter or, at the latest, prior to the transfer of the patient to a hospital setting, including:

• her observations and/or view regarding the state of consciousness of the patient, namely, that the patient was drowsy but responsive
• that the results of blood tests undertaken the previous day were abnormal
• that the procedure on the patient was carried out without anaesthesia; and
• her understanding that the procedure on the patient was carried out under a medical emergency because of the assessment of the medical practitioners present that the patient had a possible septic uterus.

The reasons for the tribunal’s decision are published on AustLIi website.

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