MEDICAL NEGLIGENCE PATIENT SAFETY
A Notifiable Medical Incident involving Failure to monitor a deteriorating Patient.
John Whelan with Specialist expertise in Medical Negligence and Patient Safety gives an example of a case which falls outside of the definition of a Notifiable Incident as envisaged by the Patient Safety Act 2023. This example involves similar mistakes to that envisaged by the Act but yet it is not a Notifiable Incident as defined. This example is one of many cases which should fall within the ambit of the Patient Safety Act and can be introduced by a Ministerial regulation under Section 8.
A notifiable medical incident involving the failure to monitor a deteriorating Patient can lead to significant harm or death if the Patient’s condition worsens without timely recognition or intervention. This type of incident highlights gaps in Patient monitoring, communication, or clinical judgment, making it a critical concern for healthcare safety.
Example: Failure to Monitor a Post Surgical Patient Leading to Cardiac Arrest
A Patient undergoes an abdominal surgery to remove their appendix due to a severe appendicitis case. The surgery is successful, and the Patient is transferred to the post operative recovery ward for monitoring. Initially, the Patient’s vital signs are stable, but during the next few hours, the Patient begins to show signs of deterioration. The Patient experiences increasing pain, rapid breathing, and a decrease in blood pressure, but these signs are not acted upon in a timely manner by the attending nursing staff.
The nursing staff, busy with other Patients and tasks, attribute the Patient’s symptoms to normal post surgical pain and fail to escalate the issue to the surgical team or conduct more frequent monitoring. Despite the Patient’s repeated complaints of severe pain and difficulty breathing, the Patient’s vital signs are only checked intermittently, and no action is taken to investigate or treat the underlying issue.
A few hours later, the Patient suffers a cardiac arrest caused by internal bleeding (post operative haemorrhage) that had gone undetected. Resuscitation efforts are initiated, but the Patient does not survive. Upon investigation, it is determined that had the Patient been more closely monitored and the symptoms properly evaluated, the internal bleeding could have been identified earlier, and life saving treatment could have been provided.
What went wrong:
a) Failure to recognise early warning signs.
b) Delayed escalation.
c) Infrequent monitoring.
d) Lack of critical thinking.
Consequences:
Patient death: The most tragic outcome is the avoidable death of the Patient, which likely could have been prevented with proper monitoring and timely intervention.
For more detailed insights into how the Patient Safety Act 2023 impacts you and how Whelan Law can support you, please visit our Patient Safety Rights Legal Advice https://www.whelanlaw.ie/news/medical-negligence-and-patient-safety/