Failure to Recognise Fluid Draining from Abdomen

Failure to Recognise Fluid Draining from Abdomen 77. Mr Treacy told me that had he been aware there had been 400 millilitres in the drain overnight he would have taken Mrs Magriplis back to the theatre for reoperation immediately. If he had done so, the reoperation would have occurred 18 hours earlier. The failure to recognise that the drain had been changed is therefore of crucial importance. 10 Pain para 56 15 78. At that point in the evidence I asked Dr Treacy the following question: “So am I to take it, if it was on the chart and you didn’t look at the chart – you’ve made a crucial error – or if it wasn’t on the chart the nurse has made a crucial error? Is that right? 79. Mr Treacy answered, “Yes”.11 80. He said he did not see the notation of 400 millilitres in the Fluid Balance Sheet on his review that morning. That may have been the case. The nurse told me that it would have been written along with the other observations at the end of the hour. That was 8.00am. It is therefore possible that she wrote it shortly after Mr Treacy had reviewed Mrs Magriplis and left for the operating theatre. 81. That raises a significant issue: If a nurse writing on the Fluid Balance Sheet is the only system ensuring that the deteriorating condition of Mrs Magriplis was recognised and treated appropriately, the system is unsafe. 82. Of course part of the system is the hourly updates to the Fluid Balance Sheet. If they had been done there would have been hourly amounts in the drain, more easily seen and detected. 83. The nurses told me there was another system. They said that the drain couldn’t be changed without a direction from the treating doctor. The nurse that came on shift at 7.00am told me that she would have phoned Mr Treacy. With the intervening period neither she nor Mr Treacy could recall that specific phone call. If the call was made, one might have expected Mr Treacy to recall it thirty or so minutes later when he saw Mrs Magriplis. 84. However, also on the Fluid Balance Sheet from the night before was 280 millilitres in the “drain” column made up of a number of entries recorded prior to midnight.12 One might think a doctor looking at the Sheet and seeing.

******CLICK ORDER NOW BELOW AND OUR WRITERS WILL WRITE AN ANSWER TO THIS ASSIGNMENT OR ANY OTHER ASSIGNMENT, DISCUSSION, ESSAY, HOMEWORK OR QUESTION YOU MAY HAVE. OUR PAPERS ARE PLAGIARISM FREE*******."