Criticality of Observations - Mental Health Settings

The Council has recently been managing a number of cases from mental health settings where nurses did not undertake observations of patients at the required level, and documentation of observations had been falsely recorded.

This particular case resulted in tragic circumstances and highlights the critical nature of observations being completed as prescribed within an acute mental health setting. It also demonstrates the importance of both accurate observation and documentation.

A Professional Standards Committee (PSC) hearing was held after the investigation of a complaint by the Health Care Complaints Commission. The Committee considers matters of a serious nature where a finding of unsatisfactory professional conduct may be made and professional reprimands and/or conditions on registration may need to be imposed.

The complaint was related to the death of a young patient who had taken his life whilst admitted as a voluntary patient at a Mental Health Inpatient Unit at a hospital.

The patient had presented to the hospital, following three months of worsening depressive symptoms, the development of suicidal thoughts and had a history of hospitalisation. The consulting psychiatrist had prescribed close observation due to the high suicide risk.

Specifically, the complaint alleged that three nursing staff had not attended observations at the 15-minute intervals prescribed by the psychiatrist. The morning nurse implemented an incorrect observation regime throughout the day. Furthermore, it was claimed that the nurses each falsified medical records to indicate the completion of observations which did not occur.

Findings from the hearing concluded that;

  • The nurses each failed to observe the patient every 15 minutes as prescribed by the psychiatrist
  • Each failed to clarify the care level of the patient with other staff or review the patient’s file
  • The morning shift nurse-in-charge did not review any care level requirements or communicate these with the nursing team.
  • The nurses signed the observation sheet although they had not completed the observation.
  • Inaccurate and misleading entries and incorrect signatures of all nurses were on the patient's record

The Committee determined that all three nurses were guilty of unsatisfactory professional conduct under sections 139B(1)(a) and 139B(1)(l) of the National Law. The nurses were reprimanded, conditions were imposed and educative orders made. These were published on the public register.

The hearing report stated that 'the strict regime imposed by the treating doctor seems to have been regarded as a negotiable suggestion rather than a strict protocol for rigid observance' and the determination and orders applied strict penalties accordingly.

By extension, it also revealed endemic failures of clinical practice, procedure and culture within the hospital at that time.

Practice points

  • Observations must be conducted as ordered by the consulting practitioner. If you think a differing level of observation care is appropriate, discuss this with your manager and the consulting practitioner and make a note in the patient records that this has occurred and the outcome of the consultation. Do not make any alterations unless the consultant has altered the care plan.
  • If there are concerns about staffing resources available for carrying out the observations these should be notified in writing and discussed with the appropriate nursing supervisor. Record sheets must be completed accurately. Do not sign entries you are uncertain to have been completed. Do not back sign earlier observations that have not occurred.
  • If observations are missed because of nursing care priorities, ensure you consider the risks and provide an explanation for the missed observation and record the correct time the next observation was made.
  • If you notice entries are missing and the level of care is below the standard prescribed, discuss with your manager immediately.
  • If the patient is asleep and on frequent observations you must continue to conduct the observations as prescribed and according to protocol. Mental health intensive care, similar to other forms of intensive care nursing, requires vigilance to protect the safety of patients

    Please note: The NSW Health July 2017 Policy Engagement and Observation in Mental Health Inpatient Units is the Policy which should be upheld and practitioners should familiarise themselves with this.