Lessons from the sad case of Joshua Plumb

Who's my patient? Who am I responsible for? When should I request help? Sound familiar? 

Nurses often work in very stressful, dynamically changing environments. They have to be flexible, committed and able to work under pressure. Often they work with less than optimal levels of staffing and adjust working arrangements to cope. As the findings of the Joshua Plumb inquest highlight, this can be fraught with danger for patients and staff. In an attempt to cope, nurses need to ensure they are not making assumptions which expose them to liability and/or criticism.

Background

Joshua Plumb was born in 2003 with aspirated meconium and diagnosed with epilepsy and spastic quadriplegia. He was hospitalised 122 times in his seven years of life. He was unable to walk, talk or crawl and unable to control his head or sit up, although in bed he was mobile.

In December 2010, he presented at the hospital with blood in his bowel motions and a generalised deterioration in his condition; his mother proffered a flare-up of colitis. Blood tests confirmed a diagnosis of gastroenteritis with mild dehydration. The admitting doctor informed the ward staff that Joshua's urine output should be checked every two hours, but did not comment on the frequency of 'general' observation; this was to be at the discretion of nursing staff.

The ward Joshua was admitted to was particularly busy and arguably became somewhat chaotic. The sequence of events was that RN A went to Joshua's room about 7.40pm to administer his medication. He was crying and upset. Padded bed 'bumpers' were attached to the bed rails by RN B. While firmly in place, they could be pushed, and hence there was a possibility for Joshua to protrude though the vertical bed rails.

On the last occasion that Joshua was seen alive, at 9.35pm, his PEG tube was entangled; RN B attended to correct the situation. That was the last time observations were made on Joshua before he was found dead. At the time, the nurses were trying to cope in a highly fluid, increasingly stressful and ever-demanding environment. There were 10 patients in the ward, including two children with cystic fibrosis, two in isolation and three post-operative patients for two nurses. In response to the 'heavy' workload and falling behind in their scheduled tasks, the two nurses decided to work as a team and share all the duties rather than have assigned patients.

Due to a series of interruptions and escalating workload from 9.35pm to 11.15pm, Joshua's scheduled observation at 10pm was missed. At 11pm, RN B left the ward, passing on that Joshua's scheduled nappy check and observations had not been done. Between 11.10pm and 11.15pm, RN C entered Joshua's room and saw he was lying cross-wise on the bed wedged between the padded vertical bed rail and the mattress, and obviously compromised. He was cyanotic and not breathing.

The coroner made findings in relation to a number of issues.

Issue 1: Nursing care plan

There was no written nursing care plan - a written and carefully considered nursing care plan was neither realistic nor feasible in light of the level of staff and demands of delivering nursing care.

Consequently, the nurses created a verbal plan (an 'understanding'). It was agreed as part of the plan that two-hourly observations were sufficient. Clearly, the admitting nurse should have completed a written nursing care plan.

Issue 2: Nursing care agreement/arrangement

The coroner found that the nurses' agreement - to cope with the workload - to share all the nursing tasks of the ward, failed to deliver sufficient observational regularity for Joshua. It was found that the agreement was not patient-specific and failed to stipulate which nurse was responsible for which task.

The vagueness of responsibility pursuant to the agreement contributed to the failure of checking Joshua.

Issue 3: Team leader responsibilities/ A request for staff - a challenge to training institutions

The team leader assessed that the ward was understaffed but was reticent to 'argue' for or ask the nurse manager for more staff.

The coroner recommended that nurse training be reviewed to highlight and educate nurses concerning their responsibility as a team leader, to continually consider the need for additional staff, the responsibility of the team leader to actively enquire and respond to a ward's capacity to deliver adequate care and the need to continually assess risk and prioritise competing demands on staff. This potentially has consequences for nursing education.

Nurses are the front-line workforce which tends to simply cope. While coping with the pressures of the clinical situation, careful consideration should be made to match resources to demands. This inquest highlighted the need for nurses not to be afraid or timid in requesting assistance/more staff when they feel they are understaffed. This is the primary responsibility of the team leader.

This inquest highlighted the tension between nurse's assuming a 'cope at all costs' mentality (knowingly or not) and thereby exposing themselves to questioning of their professional conduct (in the eventuality of an adverse event) and their ethical duty of beneficence to do good and provide care.

It is arguable that the invidious position thrust upon nurses on occasions due to unrealistic demands dictates that they must pause, caution themselves and consider their potential liability and own exposure to censure.

Scott Trueman is a lecturer in the School of Nursing, Midwifery and Nutrition at James Cook University.

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