Assignment 1: Application of Law and Ethics Modules
Objectives: Assignment one: 1
Assignment Brief 2
Assignment Section One: Patient Safety/Nursing Care 2
Assignment Section Two: The Tort of Negligence 3
Assignment Section Three: Ethical Issues 3
Objectives: Assignment one:
After successfully completing this assignment students will:
1. Demonstrate an understanding of law and ethics in 21st Century registered nursing practice in Australia
2. Apply published theory to case situations.
3. Synthesise published material with the student’s own analysis to demonstrate appropriate conclusions.
4. Demonstrate professional communication in the accepted form of an Academic Assignment.
1. Due Date: Monday, August 14, 2017 Extension to Tuesday, Aug 22nd.
2. Word limit is 2000 words – 10% deviation allowed
3. This piece of assessment is an individual submission; it is not group work – it must be your own and will be electronically tracked against other submissions.
4. Submitted via Study Desk, course site (only) – no emailed copies or hard copy accepted
5. Please submit Marking Guide as a separate document (in WORD).
6. APA6 referencing is required as per the USQ Library guide is expected.
7. The teaching team is not in a position to review drafts – but welcomes questions and outlines of your work and questions about areas you may find challenging! These can be in the Communities of Practice if you feel the question would benefit your peers, or emailed to Marie Cleary individually if you feel it is something of an individual nature.
8. Request for extensions are for extenuating circumstances and must be at least three days prior to due date. The examiner will request a ‘work in progress’ at the point of request.
Conduct an analysis of the Case: Findings of the Inquest into the death of Albert Eric Bruce Biffin addressing the three sections as outlined.
In the report of the Inquest into the death of Albert Eric Bruce Biffin1 the Coroner identified the medical cause of death as complications of an incarcerated umbilical hernia. It was known that Mr Biffin had a long medical history however was still relatively independent in his residential care environment. Mr Biffin died on February 27, 2013 at the age of 86.
A number of registered nurses, were involved in Mr Biffin’s care in the period February 24, 2013 to February 27, 2013. The role of the assistant in nursing, the endorsed enrolled nurse and the registered nurse were key within the chain of events that transpired and affected the deterioration and death of Mr Biffin.
In a chapter provided for you on DIRECT readings on the study desk for NUR3020, McDonald and Then (2014) discuss that while individuals can make errors, it also may be difficult to attribute to one person. (McDonald & Then, 2014, p. 134).
Assignment Section One: Patient Safety/Nursing Care
Section 1 – Conduct an analysis of the nursing care (pages 7 – 11) that is outlined by the coroner in the Inquest into the death of Mr Albert Eric Bruce Biffin1 in terms of the involvement of the assistant in nursing, endorsed enrolled nurse and the overarching accountability of the registered nurses for clinical decision making, care delegation and care provision.
a. Use reading and additional references to assist your critique –
MINIMUM of three for passing mark – more are expected
b. It is expected that you will substantiate your points with literature regarding best practice or literature related to nursing care of the older person in residential care settings, the deteriorating patient and patient safety. (Note: practice includes more than psychomotor skills, it is also knowledge, communication, monitoring, reporting, accountability, delegation and responsibility).
Do not provide just a synopsis of the case in itself.
c. Approx. 1100 words for this section (flexible – the overall assign is
Assignment Section Two: The Tort of Negligence
Section 2: Explain how the tort of negligence could be applied to the registered nurse/clinical nurse involved in this case.
Outline the elements which would need to be proved in order to advance a successful claim for negligence.
In the event that the Coroner decided to refer the Doctors and Nurses involved in the case to the regulating authority, what clinical situation may give rise to this situation. There is also the potential that a civil case could be made against the parties involved. Conditions of negligence would need to be met for a court case to be successful. Using the registered or clinical nurses as an example, outline the elements that would need to be demonstrated in order to substantiate a claim of negligence.
a. Use reading and additional references to assist your critique (at least three)
b. Approx. 500 words (flexible – the overall assign is 2000 words)
Assignment Section Three: Ethical Issues
Section 3: Ethical Analysis. In addition to the legal aspects of the case there are a number of ethical issues that could be discussed in relation to the care provided and the testimonies discussed when caring for a resident in a residential care facility.
Using examples from the actions of the of the assistant in nursing, enrolled nurse and registered nurse, critique their behaviour using principles of ethics and considering the resident’s rights whilst in residential care. Utilize published academic texts and literature pertaining to ethical principles to assist your critique.
a. Use reading and additional references to assist your critique
b. Approx. 400 words (flexible – the overall assign is 2000 words)
1. APA6 is the appropriate form of referencing.
2. Achieving correct referencing formatting is just one aspect of referencing. More important is how you use someone else’s published material and correctly synthesise it into your own work – and correctly acknowledge that it is either theirs – or ascribed to someone else within their work (a secondary citation).
3. Each section of the assignment should read smoothly within itself and bring the reader in (introduce the topic) and out (conclude).
4. Three sources from texts or the literature is the MINIMUM expected in sections one and two. Sources should be recent: 8 years old or less.
5. Academic staff assistance is provided to answer questions, look at themes or student outlines or assist with resources. We are not in a position to review drafts – but we will help with specific questions or help with clarifying either the assignment instructions or your plans for your writing!
6. Students ‘tick’ when they turn assignments into STUDY DESK that it is their own work (student declaration statement). Any breach of this is a breach of professional ethics (which is what we are studying) and this will be penalised appropriately. Turning in work that someone else has done for you and stating that it is your own is considered fraud. It does not reflect well on a student who is soon to be a Registered Nurse in Australia. It does not reflect well on the profession.
7. The version that the student submits to STUDY DESK by the due date (or an approved extension) is the ONLY VERSION which will be marked. This is the student’s responsibility to ensure it is correct. Stating later that it was ‘just a draft’ or an assignment for another course will be treated the same as a late assignment with penalties.
1Coroners Court of Queensland (2017) Inquest into the death of Albert Eric Bruce Biffen
McDonald, F., & Then, S. (2014). Ethics, law and health care : a guide for nurses and midwives. Australia: Palgrave Macmillan.
CORONERS COURT OF QUEENSLAND
FINDINGS OF INQUEST
Inquest into the death of Albert Eric Bruce Biffin
TITLE OF COURT:
3 May 2017
3 May 2017
14 June2016, 12-14 September 2016
Christine Clements, Brisbane Coroner
CATCHWORDS: Health care related death, low care nursing home, complications from incarcerated hernia, adequacy of medical assessment, nursing handover and nursing
Counsel Assisting: Ms Donna Callaghan, Ms Holly Ahern
Blue Care, Toowoomba Village
and AIN Grabasch, EN Mathew, RN Suarez,
CN Padget and Ms Hart: Mr D Schneidewin i/b HBM Lawyers
Dr John Lambie: Ms J Rosengren i/b Avant
EEN Watson, RN Suarez, EEN McGowan,
Ms Sally Robb i/b Roberts & Kane
1. Albert Eric Biffin was born on 27 August 1926 in Camden New South Wales. He died suddenly and unexpectedly at his low nursing care residential facility known as Jacaranda Place. He had lived there independently since December 2012. Jacaranda Place was part of the Blue Care Nursing facility at 256 Stenner Street Toowoomba in Queensland.
2. The facility provides 186 beds for residents ranging from low level acuity in Jacaranda Place to high care patients in Wisteria Lodge and dementia patients in Camellia Court.
3. Mr Biffin had been under the care of his general practitioner, Dr John Lambie, for about twenty-five years.
4. Mr Biffin died on 27 February 2013, at the age of 86.
5. Although Mr Biffin was of advanced age, the cause of his death was unclear and therefore the matter was reported to the coroner. Mr Biffin had experienced a recent umbilical hernia requiring medical treatment by his general practitioner and subsequent nursing care. Investigation followed to;
– establish the cause of death, and
– review whether Mr Biffin’s death was health care related as defined in the Coroners Act 2003 (the Act)
6. Section 10 AA of the Act sets out health care related deaths as follows.
(1) A person’s death is a health care related death if, after the commencement, the person dies at any time after receiving health care that-
(i) caused or is likely to have caused the death; or
(ii) contributed to or is likely to have contributed to the death; and
(iii) immediately before receiving the health care, an independent person would not have recent reasonably expected that the health care would cause or contribute to the person’s death.
(2) A person’s death is also a health care related death if, after the commencement, the person dies at any time after health care was sought for the person and the health care, or a particular type of health care, failed to be provided to the person and-
(a) the failure either-
(i) caused or is likely to have caused the death; or
(ii) contributed or is likely to have contributed to the death; and
(b) when health care was sought, an independent person would not have reasonably expected that there would be a failure to provide health care, or the particular type of health care, that would cause or contribute to the person’s death. (3) For this section-
(a) health care contributes to a person’s death if the person would not have died at the time of the person’s death if the health care had not been provided; and
(b) a failure to provide health care contributes to a person’s death if the person would not have died at the time of the person’s death if the health care had been provided.
(4) For this section, a reference to an independent person is a reference to an independent person appropriately qualified in the relevant area or areas of health care who has had regard to all relevant matters including, for example, the following-
(a) the deceased person’s state of health as it was thought to be when the health care started or was sought;
(b) the clinically accepted range of risk associated with the health care; (c) the circumstances in which the health care was provided or sought. (5) In this section-
Commencement means the commencement of this section.
Health care means-
(a) any health procedures; or
(b) any care, treatment, and advice, service or goods provided for or purportedly for the benefit of human health. Cause of death
7. With consent of Mr Biffin’s family, a full internal autopsy order was made and examination was undertaken by forensic pathologist Dr Terry. It was noted Mr Biffin was well nourished. The major findings at autopsy were:
(i) Incarcerated umbilical hernia containing ischaemic small bowel;
(iii) Cardiomegaly (meaning with concentric left ventricular hypertrophy and dilated ventricular chambers);
(iv) Mild-to-moderate to severe coronary artery disease, requiring pacemaker;
(v) Benign nodular hyperplasia of the thyroid gland and benign cortical adenoma; and
(vi) Fibrosis of liver (early cirrhosis).
8. Dr Terry’s report recorded there was an incarcerated umbilical hernia which contained an ischaemic appearing loop of small bowel 120mm long with adjacent haemorrhagic mesentery. The segment of bowel was purple in colour and had a slightly thickened wall. The small bowel proximal to the hernia was slightly dilated. Fibrin was not identified over the serosal surface of the small bowel.
9. There was no ascites. There was a small Meckel’s diverticulum 30mm long which was non-inflamed. The large bowel was normal and contained solid faecal material.
10. Dr Terry concluded Mr Biffin died due to complications of incarcerated umbilical hernia. He considered death most likely followed cardiac arrhythmia induced by electrolyte imbalance in conjunction with sepsis due to the effects of necrotic and poorly functioning small bowel.
11. He also noted there was concurrent bronchopneumonia which most likely made Mr Biffin more susceptible to the effects of electrolyte imbalance and septicaemia. Moderately severe coronary artery disease was identified. The pathologist noted the presence of a pacemaker as well as benign prostatic, adrenal and thyroid disease.
Events leading to Mr Biffin’s death
12. Mr Biffin’s death on 27 February 2013 was unexpected and raised questions about the adequacy of both the medical care and nursing home care provided, particularly in the last few days prior to his death. These findings are however prefaced by the circumstances that Mr Biffin lived independently in a low care facility. He was not residing in a high dependency unit nor was he in a hospital. He did however have extensive medical history and was becoming more vulnerable and dependent. As recently as 21 February 2013 he was assessed as having profound hearing loss requiring new hearing aids as well as difficulties with his vision. His wife was living separately in a higher care facility and he visited her as often as he could.
13. A registered nurse was available to attend residents in Wisteria Lodge and
Jacaranda Place if called upon by staff caring for the residents. On Sunday 24 February 2013 at 11:30 a registered nurse reviewed Mr Biffin at the request of an enrolled or assistant in nursing because of vomiting. The registered nurse was told it was not a large vomit but more dry retching. She did not know how long the vomiting or dry retching had been going on.
14. The registered nurse’s entry in the progress note was:
‘Called to see Mr Biffin re: complaining of lower abdo pain and episodes of vomiting and dizziness. Physical obs checked by staff. BP under 102/79, P 48, T 36.8, states he feels tired. Staff reported not a large amount of vomit noticed but only dry retching and he is up and down to the toilet. O/E (on examination) noticed a? Hernia (large lump to his abdomen). Advised staff to give Bruce a Movicol to rule out constipation and give his regular paracetamol for possible pain and discomfort. Staff also advised him to rest, sit down today. Staff to continue to monitor.’
15. When assessed by the registered nurse Mr Biffin was sitting in his chair with his wheelie walker nearby. He complained of feeling unwell and told her he had a ‘tummy ache’. He was able to speak with the nurse without any difficulty. He denied pain and did not appear to be in distress. The registered nurse saw a large lump about the size of a $0.50 piece which she described as being pink and inflamed. Mr Biffin told her it was a hernia and it was not painful. He did not seem to be concerned about the hernia. The nurse did not recall touching or examining the hernia. She did not know how long the hernia had been present as this was the first time she had met Mr Biffin. The nurse thought he might be constipated and therefore authorised as required Movicol.
16. Staff in Jacaranda Place were directed to keep an eye on Mr Biffin and to hand over information regarding his condition to the registered nurse coming onto the night shift that evening. She did not think he was in distress or sufficiently unwell to warrant calling a doctor or family members. She said that his physical observations were within normal limits. The nurse was reassured that Mr Biffin was able to respond to her questions and mobilise.
17. On the afternoon of Sunday 24 February another registered nurse who was one of three registered nurses rostered on the afternoon shift, reviewed Mr Biffin. He was based in the Wisteria lodge, the high care area with 32 beds on the floor above Jacaranda Place. The registered nurse had a patient load in Wisteria and would only attend Jacaranda if specifically called. At 16:00, the nurse recorded giving Mr Biffin further Movicol as he had not moved his bowels for two days.
18. At 21:00 that evening the same registered nurse made the following entry:
‘Given further Movicol as Bruce states bowels not open for the past 2 days. Reported copious amount of vomit at 20:48 hours; complaining of pain at central and lower left abdominal area. Noted prominent bulging of umbilical hernia. Warm to touch. Given ordine as above. Head of bed elevated, given vomit bag, Bruce advised to notify staff. Obs: BP 158/71, P 48, T 36.7 C. To monitor overnight. Dr Lambie notified and follow-up tomorrow. Also noted offensive wound D/C discharge (L) lower leg.” The registered nurse notified Dr Lambie by means of a facsimile sent to his practice premises at 21:45 on 24 February 2013. The message stated:
Re-: Bruce was given Movicol for reported constipation, a nurse initiated medication. At 21:00 hours tonight, Bruce had big vomit. Obs: BP–158/71, P–48, T–36.7C.
C/O (complained of) pain of his umbilical hernia which is warm to touch. Also noted offensive exudate of his chronic ulcer at the L lower leg.
Could you please make arrangements for assessment visit. Attached is medication chart. Thanking you.”
19. Dr Lambie became aware of Mr Biffin’s hernia for the first time on the morning of Monday, 25 February 2013 when nursing home staff rang the surgery at about 10:30. He had not seen or been informed of the facsimile sent to the surgery on the preceding evening at 21:45 hours by RN Suarez. Dr Lambie recalled being told by his reception staff that nursing home staff reported Mr Biffin had a lump in his abdomen and was in pain and had vomited once. Dr Lambie was seeing other patients at the time and considered the circumstances were not urgent and decided he would visit Mr Biffin during his lunch period. This was usually between 12:30 and 14:00 when he performed house calls.
20. In the interim period from 21:00 on the Sunday evening, until Dr Lambie attended on the early afternoon of Monday 25 February, the following interactions between staff and Mr Biffin occurred.
21. There was a nursing direction to monitor overnight which meant that if there was a recurrence of pain or vomiting, formal observations should be repeated.
Dr Lambie’s attendance on Mr Biffin on 25 February 2013.
22. On arrival at the nursing home Dr Lambie approached the nursing station and asked one of the nurses to accompany him to see Mr Biffin. He did not review the progress notes prior to seeing Mr Biffin nor obtain any history from the nursing staff. He could not recall the name or the professional position of the female staff member. He knew that staff ranged from personal carers to registered nurses but he could not differentiate the roles by the uniforms. He expressed general faith in their capacity to care for residents.
23. Dr Lambie asked Mr Biffin how long the lump had been there. He said Mr Biffin was vague in his response. Dr Lambie asked if he was experiencing significant pain, and he asked him whether he had vomited. Mr Biffin said he had vomited once. Mr Biffin told him the pain started a couple of days ago and was around his umbilicus. Dr Lambie agreed Mr Biffin told a nurse in Dr
Lambie’s presence that he felt sick and unwell, as was expected by Dr Lambie given the presence of the hernia. Dr Lambie disagreed that Mr Biffin expressed any concern. He said Mr Biffin expressed his experience of pain by slight restlessness.
24. Dr Lambie stated he did not ask any questions about his bowels, whether he was eating or drinking or still felt nauseous. Dr Lambie acknowledged his conversation with Mr Biffin was very brief. Later in his evidence Dr Lambie stated Mr Biffin had told him he had not opened his bowels for 3 days. He recalled Mr Biffin was lying in bed. He then examined Mr Biffin noting the acute hernia was a significant size, recorded as 2–2 5 cm. He said ‘it may have been slightly larger than that’.
25. Dr Lambie said the hernia appeared to be the normal colour of stretched abdominal skin, described by him as ivory. Mr Biffin was a large man and Dr Lambie observed him as he lay in bed. His abdomen was not distended. He palpated the abdomen for tenderness and some tenderness was evident as expected around the hernia. Mr Biffin did not exhibit any signs of tenderness or discomfort of the abdomen outside 2 or 3cm from the umbilicus.
26. Dr Lambie described Mr Biffin as very slightly tender over the hernia, which was of normal temperature compared to the rest of the skin. He then checked for the presence of any other hernias. There were none. No mass was detected in the abdomen which might have caused the hernia. Dr Lambie did not have his stethoscope with him and did not therefore listen for bowel sounds in the abdomen. No other examination was performed including a rectal examination. Dr Lambie then informed Mr Biffin he had a hernia and he would attempt to reduce it to relieve his discomfort. Dr Lambie considered this was appropriate as there was no evidence of any sign of overt bowel obstruction or overt strangulation.
27. The orifice through which the hernia had protruded was observed after reduction to be 1.5cm. Dr Lambie stated in his evidence that if an orifice is smaller than 1.5cm an obstruction or strangulation is more likely to occur.
28. To reduce the hernia Dr Lambie applied gentle pressure over the apex of the hernia as it was lying above the skin. By doing this he was able to reduce the volume by pushing some of the bowel contents back into the intestine inside the abdomen. He continued the pressure using both hands; ‘It tended to want to come out the sides where I did not have my fingers, so I used both hands,’ he said.
29. After there was no visible hernia above the surface of the skin Dr Lambie said he was able to put his index finger in up to the second joint, ‘about an inch’. He could not feel any bowel and he ‘palpated around the circumference of the hernial orifice, which was smooth with nothing–no other tissue attachment to it’.
30. Dr Lambie then packed the orifice with Jelonet (paraffin impregnated gauze) which was provided by nursing staff at his request. He then placed ordinary surgical gauze on top to a 3cm thickness. A combine cotton dressing was placed over this and strapped firmly in place with a good length of Elastoplast adhesive bandage strapping. This was to ensure it was firm enough not to loosen. The strapping was placed horizontally, vertically and diagonally, and caused some compression of the bandage.
31. Dr Lambie could not recall any further conversation with Mr Biffin. He recalled there were two nursing staff present when he examined Mr Biffin. He was then accompanied by nursing staff back to the nursing station. He told the female staff member that ‘hopefully the hernia will remain in place’. He instructed her to contact him directly or via the surgery if there was any increased pain, increased amount of vomiting or general decline in his condition. He said he communicated to the staff member that he wanted to know if there was any vomiting or increased pain especially.
32. Dr Lambie had no recollection of any conversation at the nursing station involving a staff member expressing the view that Mr Biffin was more unwell than simple constipation. Dr Lambie considered the hernia was the explanation for his reduced eating, dry retching, vomiting and abdominal pain.
33. Dr Lambie did not request nursing staff to perform vital signs observations or to keep an eye on fluid or oral intake. He said that although Mr Biffin was constipated, this was a usual situation for him and it was of little significance on 25 February 2013 when he reviewed Mr Biffin.
34. Dr Lambie’s note in the nursing home record was as follows:
‘Umbilical hernia, reduced and strapped.
35. Dr Lambie believed Movicol may help him relieve the incomplete small-bowel obstruction. He diagnosed incomplete small-bowel obstruction due to the prolapsed hernia, which he had examined and considered was full of bowel. There was some oedema.
36. Dr Lambie estimated the visit was between 10 and 15 minutes duration. He instructed nursing staff to leave the dressing until he reviewed it in 48 hours. He agreed in hindsight that it would have been better to include in the nursing home record the instructions given to the nurse to contact him if there was an increase in abdominal pain, continuing vomiting or general deterioration.
37. After his return to the surgery Dr Lambie entered in his own records; ‘local hernia reduced-some improvement. Strapped.’
Nursing staff involvement with Mr Biffin after Dr Lambie’s visit
38. There was no review by a registered nurse recording observations until the same registered nurse who reviewed Mr Biffin on the Sunday evening returned and saw Mr Biffin the following afternoon on Monday 25 February at 16:30. This was after Dr Lambie had visited Mr Biffin around lunchtime.
39. At 13:55 on Monday 25 after Dr Lambie’s visit, an Assistant in Nursing documented Mr Biffin’s observations as follows: BP 157/70, pulse 45 and temperature 36.9.
40. Subsequently at 14:30 that afternoon an enrolled endorsed nurse recorded that Mr Biffin complained of nausea that morning and had refused some of his medications. She described him as looking generally unwell and complaining of being nauseated and sick before and after Dr Lambie’s visit.
41. At 16:30 that afternoon a registered nurse recorded issuing two more sachets of Movicol with no result for constipation.
42. The next entry in the medical record is dated Tuesday 26 February at 09:00 when the clinical nurse made the first of two identical entries in the chart, both recording two doses of Movicol for constipation. The second dose was recorded at 14:00. No other information was recorded by the clinical nurse in the record.
43. An enrolled nurse then recorded an entry relating back to the time of 13:00 earlier that afternoon. The note recorded Mr Biffin was tired and had stayed in bed the whole day. It confirmed he had been given Movicol x2 at 09:00 and 14:00 and was awaiting the result. It was noted he had a small amount of lunch and due medications were administered.
44. At 18:00 that evening the clinical nurse again recorded authorisation of Movicol. The entry is followed by the clinical nurse stating:
‘Nil reported vomiting today.’
45. The clinical nurse confirmed at the time her duties were to oversee the enrolled nurses and the assistants in nursing from Wisteria and Jacaranda units, as well as other duties including, rostering and clinical issues and problems. The clinical nurse did not have direct resident care responsibility, rather the responsibility to oversee all residents including keeping an eye on those with a change in their health status or who had been unwell. She agreed it was expected that she would review and assess such residents.
46. Many of the staff who interacted with Mr Biffin in the last few days of his life did not know Mr Biffin, but the clinical nurse did. She had performed numerous assessments upon his admission. She knew him to be a quiet, gentle person who did not complain. As recently as 20 February 2013, she had performed a cognitive assessment for Mr Biffin. The result was some short term memory loss but minimal cognitive loss.
47. She acknowledged at the inquest her memory of events was scant given the passage of time. Her entry in the records was also very brief. She agreed that by the end of her shift at 18:00 on the evening of 26 February Mr Biffin had taken 10 doses of Movicol to address his constipation over two days without result. She agreed this was a high dose. She could not recall but stated she would have asked staff caring for him whether he had vomited and therefore recorded the entry ‘Nil reported vomiting today.’
48. She said she did recall at the end of her shift Mr Biffin was sitting in his chair, just not looking very well. She instructed the enrolled nurse to ‘take his observations and act accordingly’. This was not documented. She explained she expected if the observations were abnormal then the enrolled nurse would report to the registered nurse who was working in the other unit or ring Dr Lambie. She could not be certain she had told the enrolled nurse to ring Dr Lambie if observations were abnormal. Her only certain recall of events was at the 18:00 entry at the end of her shift. She did not hand over to the other registered nurse working in the other unit, she spoke with the enrolled nurse who was to continue until later that evening. She said it was not the practice to hand over to someone at the level of registered or clinical nurse.
49. She recalled she would have been alert to any signs of pain or vomiting which could indicate obstruction. She was unaware of any ongoing pain or vomiting since Dr Lambie had visited. She stated she would have arranged Mr Biffin’s transfer straight to hospital if she had been concerned.
50. She said variously that she was not very familiar with obstructed bowel but agreed with a proposition put to her that Mr Biffin’s situation was not a classical presentation. She did not perceive there to be a relationship between the reduced hernia and the ongoing constipation. She considered the hernia had been resolved.
51. The clinical nurse was quite clear she would have sent Mr Biffin straight to hospital had there been vomiting in the context of ongoing unresolved constipation.
52. Her only recalled observation of Mr Biffin’s physical appearance was that he appeared quite pale. She confirmed it would be at the instigation of a doctor, clinical/registered nurse that regular observations were commenced. She also acknowledged it was the first shift for the enrolled nurse in that unit who was working that evening shift alone.
The clinical nurse held a more senior position and responsibility than any of the other staff involved with Mr Biffin. Even though the clinical nurse did not have direct nursing involvement with Mr Biffin the position necessarily involved most responsibility for overview of a resident who had recently been reviewed by a doctor and had a procedure to reduce