Case study: Two deaths when standards not upheld

From Annmaree Nicholls, Professional Officer

This is one of the saddest cases I’ve ever witnessed. A nurse had been occasionally showing up to work clearly under the influence of alcohol. She had a turbulent home life and abusive marriage. 

She was beloved by her nursing colleagues who often looked out for her in regard to picking up her slack at work, covering for her mistakes, and sometimes even putting her to sleep in a spare hospital bed or quietly sending her home when she was too drunk to complete her shift. 

This went on for an extended number of years and the intoxicated presentations to work increased. The cover up continued. 

One day she came to work intoxicated and made a significant medication administration error that caused a patient’s death. 

Her impaired condition and alcohol problem could no longer be hidden and came to light in the worst of circumstances. 

Her employer reported a complaint for the medication error, impairment and patient death. 

A number of organisations were involved, including the Nursing & Midwifery Council, who quickly called an urgent hearing to determine the risk to public, herself and her colleagues and what would be required to manage that risk. The Council determined that she could not safely practice in her current state and they placed restrictions on her registration to protect the public and the practitioner. 

At the Council hearing she appeared jaundiced, was clearly unwell and this was likely due to years of alcohol abuse. Sadly, she passed away shortly after from her illness.

Could her untimely death have been prevented? Could she have recovered and lead a healthy life, possibly to return to practice? Could the patient’s death have been prevented?

We cannot know whether any individual’s or organisation’s earlier intervention could have saved this nurse and her patient. However we can imagine that this case may have turned out differently with interventions, such as if her health concerns had been reported much earlier as required of her nurse colleagues. 

All registered nurses, midwives and enrolled nurses are mandatory reporters under mandatory notification law, and must make a report any time they reasonably believe that a registered colleague is under the influence of drugs or alcohol. It isn’t enough to just make a report to the employer or HR department; the notifier must ensure that the report reaches the regulator.

And as registered health practitioners, we all commit to upholding the standards:

  • The registered nurse or midwife considers and responds in a timely manner to the health and wellbeing of self and others in relation to the capability for practice. [3.1/3.8]
  • The enrolled nurse "promotes the safety of self and others in all aspects of nursing practice." [3.9]

In this sad case, the standards weren’t upheld when the nurse failed to consider her own health and wellbeing as part of her capability to practice, when her colleagues failed to respond to her diminished health and wellbeing, and when this lead to a collective failure to consider the dangers to the patient’s health and wellbeing.

Good nursing practice isn’t only about how we look after ourselves and our own fitness to practice, or how we look after our patients. It is also about how we look after our colleagues. Sometimes this means taking the difficult but important step of intervening early and making a mandatory notification for the sake of all involved. 

Learning note: The Council manages such cases in a non-disciplinary fashion by ensuring the practitioner has appropriate treatment, monitoring this as necessary and ensuring the 
practitioner is supported and safe. In some serious cases, a period of not working is 
recommended to allow time for healing before a graded return to work. These conditions allow colleagues and health organisations to continue to support practitioners with an impairment.