Responding and communicating appropriately to patient deterioration

In May 2016, the Professional Standards Committee (PSC) held an inquiry into the conduct of two Registered Nurses (RNs). 

A six-month old baby was taken to the Emergency Department of a rural hospital and was under the care of both the nurses. On arrival at the hospital, an initial diagnosis of gastroenteritis was made. It was later determined by medical staff that the baby had been suffering from a bowel obstruction, at which point a decision was made to transfer the baby by ambulance to a tertiary hospital where sadly the infant later died. 

The complaint alleged that the nurses failed to appropriately manage or communicate with the Paediatrician changes and responses to the patients' condition or maintain appropriate clinical records of observation

A finding of unsatisfactory professional conduct against both practitioners was made, in response to allegations arising from the circumstances surrounding the death of the infant. A Paediatrician was also charged with unsatisfactory professional conduct during a separate PSC hearing.  

The hearing found that the practitioners' conduct did not demonstrate the knowledge, skill, judgement or care expected in the practice of nursing. This was significantly below the standard reasonably expected of practitioners' of an equivalent level of training or experience  and it also raised serious questions regarding clinical reasoning ability. 

Specific findings included;

• Observations around urinary output were poorly made and inadequately documented; there was a failure to maintain appropriate clinical records.

• Poor understanding of the importance of nursing care for this particular patient or assessing the adequacy of urinary outputs in infants

• Failure to adequately recognise and assess the patient's hydration status with little importance placed on fluid balance data

• Poor situational awareness and a lack of understanding of the potential consequences of dehydration 

• Inappropriate oral feeds not approved or known by the Paediatrician 

• Failure to communicate with the Paediatrician deterioration in the patient's condition 

• Lack of clarification around the urgency of patient's departure from hospital or when the patient had left the hospital

• Inadequate communications to the ambulance service

The inquiry and a subsequent hearing found that a reprimand should be issued to both nurses. Conditions were imposed on both registrations however, as one of the nurses did not hold valid registration at the time, these would be applied should she seek registration in future. 


To ensure the safety of patient's it is essential to; - identify a deteriorating patient, escalating and responding appropriately - communicate changes and urgency in a patient condition to relevant parties - make observations and accurately document these - ensure continued professional learning or ask questions if there is an area of practice you are unsure about.