For report and Essay Canthopexy case Sequence of events

Mrs P a 76 year old lady was initially referred to the Ocular Plastics service in 2014. Since this time she had undergone four previous procedures, the latest being in December 2017. Mrs PS had attended regular follow up appointments prior to this time. On the 13 October 2019 she attended a further follow up appointment, during which it was identified that she required a right, lower lid tightening procedure (Canthopexy) and a biopsy of a small lesion to the side of her right eye. The decision was made to operate and she was consented for both procedures. At this point the Consultant who saw Mrs P in clinic completed a waiting list slip indicating what procedure she required, on which eye, the type of anaesthetic and how long they anticipated Mrs P surgery would take and obtained written consent for the procedure which correctly described the site and side of the surgery.

A date was then booked for Mrs P surgery and she was invited to attend her pre-assessment appointment on the 18 December 2019.  The necessary documentation and clinical investigations were completed at this time in preparation for her surgery.

On the 28 March 2019 Mrs P, was admitted to an Ophthalmology day ward at the local hospital in the late morning. Mrs P was the second patient for surgery on the afternoon theatre list.

On arrival at the day ward Mrs P was seen by a Doctor, who was not to be the operating surgeon, and signed another consent form for the planned right Canthopexy and excision of the lesion on the side of her right eye. A marking arrow was put onto the right side of her forehead in preparation for surgery at this time; the Doctor intended this arrow to mark laterality rather than site. Mrs P also expressed concern to the Doctor about a second lesion lateral to her left eye. At this time there was a lack of clarity regarding the nature of the lesion on the left side and whether this should be excised as well and the Consultant was asked to review Mrs P with a view to confirming that a biopsy on this lesion would be performed at the same time.

The team brief was then carried out. As is usual on a combined team brief was held with staff from theatres and the ophthalmology clean room as patients are booked into either venue and can be interchanged in the interests of efficiency.  Four patients were discussed during the team brief, two whose procedures were to go ahead in the clean room and two for theatre. The Doctor who had reviewed Mrs P earlier led the team brief in which she was discussed; during the team brief the Consultant informed the team that she would be reviewing Mrs P as she had another lesion which may require excision at the same time. The Surgeon operating on Mrs P was not present for the entire team brief as he had been delayed in his morning clinic which had overrun. He did not hear the discussion around Mrs P.

Following the team brief, and before the first case the Consultant responsible for Mrs P attended the ward to review her personally. The Consultant examined the lesion on the left side that Mrs P had mentioned to the Doctor earlier and made the decision that this lesion should also be biopsied during the operation. The consent form was amended by the Consultant to reflect this additional procedure and  both patient and the Consultant countersigned the amendment on the consent form.

Mrs P was again marked in preparation for her surgery by the Consultant with a marking arrow pointing to each of the two lesions for biopsy (one on the right and one on the left) in addition to the existing arrow on her right forehead. The change to Mrs P’s procedure was clearly personally communicated to the surgeon by the consultant after the team brief and before she left for her lunch after the first case.

The first case of the afternoon then went ahead successfully; it was described by the Consultant as a challenging, intense case which took a considerable length of time. An atmosphere of pressure around time and ensuring the list finished on time was felt to be evident by the team. This patient was then taken back to ward and the Surgeon who was later to operate on Mrs P proceeded to write up the operation notes.

After the first case the Consultant agreed with the Surgeon that he would carry out the second case unsupervised and reminded him about the addition of an excision biopsy on the left temple.

Mrs P was brought into the anaesthetic room whilst the Surgeon was still writing up the notes from the previous case. The initial patient safety checks which are usually completed in the anaesthetic room in ophthalmology as there is no reception area within the ophthalmology theatres were completed with the ward nurse present, who then left.  The safer surgery sign then commenced with the Anaesthetist and the Operating Department Practitioner (ODP) confirming Mrs P’s details and the planned procedure against the consent form. The ODP also confirmed with Mrs P what procedure she was expecting to have and checked that she had been marked ready for her surgery. The safer surgery sign in had already been completed by the time the Surgeon entered the anaesthetic room. In keeping with his understanding of the procedure’s he was to perform he administered the local anaesthetic as he would do to perform bilateral Canthopexy’s and bilateral excision biopsies, The Anaethetist left after this as is usual in cases requiring local anaesthetic only.

As the Scrub Nurse was preparing to scrub for Mrs P the Consultant informed her that a second lesion on the left was to be excised, and she left theatre to fetch the extra equipment required for the additional procedure. As the Scrub Nurse was completing her preparation the Surgeon entered the scrub area from the anaesthetic room and began to scrub whilst the ODP brought Mrs P into the theatre. The ODP asked if the team were happy to start the time out section of the safer surgery checklist, the Scrub Nurse, the Theatre Assistant and the Surgeon were present for the time out. The Surgeon confirmed that he was happy listening to the time out from the scrub room whilst he was washing his hands and preparing for surgery. The ODP read out Mrs P details whilst the Scrub Nurse confirmed them against the consent form. The Scrub Nurse then read out the procedure as per the consent form and confirmed that Mrs P had bilateral markings. The theatre team have confirmed that the correct procedures were read out; in spite of this the Surgeon believed that both the Canthopexy and the excision of lesions were to be undertaken bi-laterally.

During the time out the Scrub Nurse checked the white board and realised that it had not been completed to show the intended procedure. She asked the Theatre Assistant to write the procedure on the white board, the procedure was written as a left Canthopexy. The Surgeon would usually write the procedure on the board however he was already scrubbed in preparation for the case.

The ODP completed the anaesthetic element of the care plan at this point, without checking if the rest of the care plan had been completed.

The remainder of the time out checklist was completed and the procedure commenced with the Surgeon responding to a question from the scrub room. It is unclear at what point the Surgeon joined the team around Mrs P. The right Canthopexy was completed first followed by the right, temple excision biopsy. These two procedures were undertaken uneventfully and took approximately forty minutes. The Surgeon then moved to the left side of the patient and started to perform a left Canthopexy. It is not usual practice within Ophthalmology theatres for another time out moment to be repeated at this time. At the point that the Surgeon made the initial incision the Scrub Nurse immediately “stopped the line” and alerted the team of her concerns, questioning if the Canthopexy procedure should be bilateral.

The Surgeon immediately stopped and checked the white board in theatre which, he and the scrub nurse recall, said only left Canthopexy. The team then checked the consent form which correctly stated a right Canthopexy and bi-lateral excisions of lesions. On realising the error he closed the 1cm skin incision with dissolvable suture, before continuing to successfully perform the required left, temple excision biopsy.

 An incident report form was completed on the day of the incident by the Surgeon. The theatre team informed the Deputy Team Leader of the incident who tried to contact the floor control to inform them of the situation, they were unable to do this as it was after 17:30hrs.

Timeline of Events

Time	What  happened	What should  happened	What did happen
13/10/18	Mrs P seen in clinic and listed for a Right Lateral Canthopexy with excision of cystic lesion on the right lateral orbital rim.	Consent form completed   Patient Information leaflets should be given	Good practice with the consent form being completed in clinic.   Patient information leaflet for Canthopexy not available other general leaflets given
18/12/18	Mrs P attends pre op clinic	All documentation and investigations completed	No issues noted with pre op clinic
28/3/19	Operating Surgeon working in the Orbital Clinic for the morning session and in theatre for the afternoon session.	Surgeon should have the opportunity to take a break between settings.	Orbital Clinic over ran on the day   No time for the operating Surgeon to take a break before commencing afternoon theatre list
28/3/19 11:23	Mrs P admitted to Day ward	All required documentation completed appropriately.	No issues identified with admission to Day ward
	Mrs P consented  by Doctor in Training for right Canthopexy and excision of lesion on right side   Lesion noted to left temple by Doctor in Training	Consent process should start at pre assessment or the initial clinic appointment   Consultant  made aware of second lesion to left temple	Mrs P consented on the day of surgery (duplicate)
	Mrs P marked by the Doctor in Training with an arrow on the right forehead intended to indicate laterality.	Surgical site marking should indicate the intended surgical site	No consistent practice with marking patients.  The Consultant marks the  intended site whilst Junior team mark laterality
13:30	Theatre Team brief commenced. This was a joint team brief for 2 theatres and the clean room.   During the team brief the Consultant informed the team that they would be reviewing Mrs P in regard to second lesion being identified by Doctor in Training	Team brief should be recorded on template	Team brief checklist not completed.
13:45- 13:50	The Operating Surgeon arrived at theatre from morning clinic	The team brief should involve all team members	Team brief had already commenced. The Operating Surgeon did not hear Mrs P being discussed.
	Consultant reviewed Mrs P decision made to undertake excision of lesion on left side and  written consent form was amended	Consent form should be signed by both the Clinician and patient when amendments are made	Consent form was appropriately amended. The intended procedures changed after the team briefing had taken place.
	Mrs P was marked with arrows pointing to each intended surgical site by the Consultant	Site Marking arrows did indicate the intended surgical sites as per policy	No consistent practice with marking patients. Operating surgeon thought arrows marked laterality.
	The change in procedure was communicated to the Operating Surgeon by the Consultant
This case took 1 – 1.5 hrs	Consultant and Surgeon completed first case on the list	The procedure was carried out as intended	This was a difficult case with challenges around clinical care of the patient.
	The Consultant left the theatre after agreeing with surgeon that he could carry out second procedure unsupervised and reminding him about the change in procedure.		The Surgeon was suitably experienced to carry out procedure unsupervised
16:07	The Theatre reception checks were undertaken in the Anaesthetic room	This is usual practice in this area due to having no reception area within the Ophthalmic suite.	This is usual practice and considered appropriate in the environment.
16:07	The Safer Surgery sign in was completed in the Anaesthetic room with Anaethetist and ODP	Safer Surgery sign in should  be completed with the Operating surgeon present	The Operating Surgeon was not present, as they were writing up notes from previous case
	Local anaesthetic injected in the anaesthetic room by the Operating Surgeon	A Bi –lateral block would have been required for both procedures. Surgeon should have been present for the sign in before administering the local anaesthetic	Surgeon arrived to administer local anaesthetic after sign in was completed.
	The Anaesthetist left at this point	This is usual practice in cases requiring local Anaesthetic
	Mrs P was  taken into the operating theatre
16:26	Safer Surgery “Time out” completed	The entire theatre team should be engaged and in site of the consent form	The Surgeon was listening from scrub room with the taps running
	The intended procedure was written on white board by the theatre support assistant	The Surgeon usually writes procedure on board	The procedure was written on the board as left Canthopexy.
	Anaesthetic element of care plan completed		No check was made to see if the rest of the care plan had been completed
	Surgery commenced
	Right Lateral Canthopexy completed	This took approximately 40 mins. No issues identified with this procedure.
	Right Temple Excision Biopsy completed	No issues identified with this procedure.
	Surgeon moved to other side of patient
	Left Lower lid Canthopexy commenced – incision made		Patient was not consented for left Canthopexy
	Nurse stopped the line
	Consent form and white board checked by the theatre team	The Consent form was found to be correct	When it was realised that the white board stated the wrong side the team checked the consent form to confirm the intended procedure.
	The incision made to commence the left Canthopexy was closed
17:23	Left excision biopsy completed	The procedure was completed without incident
17:37	Theatre staff attempted to contact floor control	Any issues in theatre should be notified to the senior team immediately	Floor control finish at 17:30 The team did not realise that the team leader in the Emergency theatre holds the floor control bleep and could of been contacted.
17:34	Mrs PS left theatre and was taken to recovery
17:51	Discharge letter to GP completed		No mention of wrong side surgery in the discharge letter.
	Explanation and apology offered to Mrs P by the Consultant and Surgeon	Full apology as per Duty of Candour
	Extended team brief to discuss incident	Team brief, support offered to team
18:00	Observations noted to be stable
18:20	Mrs P discharged home with routing post op care.
	Incident form  Completed
	Patient Safety Team made aware

Points to address

• What information do you need to gather for this type of investigation and why?

• What is the procedure that should have happened? – think A&P

• Looking at the summary and the timeline what do you think went wrong?

• What were the route causes / most basic cause/s of this incident?

• Why did these things go wrong?

• Think personal/ environmental/ educational – so human factors

• You will need to see if there were policies/ guidance that should have been followed, if there was what did the guidance say?

• What could be done to prevent this happening again?

• What needs to be done to care for the patient and thcae staff involved?

Write a report from above case.

Report on Assignment plan Words 1500 (10%+/-) 

Introduction: (100-150) 

brief and accurate what reports contains,  

Include background and scenario and key point of the investigation 

State that reports will make recommendation and which healthcare professional(s) the recommend will be aimed at 

Includes areas of improvement of care or service delivery identify and rationale 

Adding summary of scenario in appendix 

Main Body: (900) 

Identify three Themes from investigation and develop arguments on the contribution of each theme to care delivery and improvement 

Theme 1. Identify the theme, what went wrong, why did it go wrong/fail? what were the factors?  

Repeat in Theme2 and 3 

Conclusion: (100-150) 

Synthesise the information in the report, provide a summary that brings all together which discus and identifies  

Recommendation (250-300) 

In this section you need to provide a list of recommendation to improve serves 

In addition Appendix  its not in word count

Include a summary of the scenario at the end of the assignment (150 to 200 words do not include in word count) 

Scholarly References  15 minimum scholar (recent mostly last 5 to 8 years and UK references)

Part B 2^nd Assignment (1500 words) Team working and collaborative Practice 

Academic work complements the report 

Title Based on the recommendations in the report, critically evaluate team working and collaborative practice in the relation to the incident investigated. 

Introduction 

Set the scene (100-150) 

A lead  

in which should identify the importance of the teamwork and collaborative practice using evidence discussed within module (200) 

Main  

Where should critically evaluate teamwork and collaborative practice. Specifically related to 1-2 themes identified in your report, provide a rationale as to shy these themes are of importance in relation to the Nursing Associate role (1000-1100) 

Conclusion: Summaries your work 

Scholarly References  15 minimum scholar (recent mostly last 5 to 8 years and UK references)

3^rd Assignment

Learning Outcomes:

1)         Accurately determine the result of a number of numerical calculations across a range of care situations (100% pass numeracy exam)

2)         Critically apply knowledge of body systems and homeostasis, human anatomy and physiology, biology, genomics, pharmacology, social and behavioural sciences to care delivery within the role of the nursing associate

3)         Critically reflect on the complexities of providing mental, cognitive, behavioural and physical care needs across a wide range of integrated care settings

4)         Critically discuss the effects of medicines, allergies, drug sensitivity, side effects, contraindications and adverse reactions and administer medications safely within the role of the nursing associate

5)         Evaluate and monitor the effectiveness of care in partnership with people, families and carers. Document progress and report outcomes

6)         Critically explore the challenges of providing safe nursing care for people with complex co-morbidities and complex care needs

VIVA Scenario

This is a seen exam you can approach panel and discuss overall approach to the scenario is appropriate/ relevant in terms of the issues you have identified and the resources you plan on accessing. This would need to be a face to face/ virtual meeting.

Expectations for the viva

• Present the patient to the panel and at the conclusion of the presentation identify the key issues/ care concerns within the case scenario – this should take no more than 10 minutes
• You will be expected to be able to discuss rationale for the nursing care
• You will be expected to demonstrate knowledge and understanding of the medical care being provided and how this impacts the nursing care
• You will be expected demonstrate an understanding of the anatomy/ physiology relating to the patients condition and be able to present/ discuss this with the panel on the level of a registered practitioner
• In relation to the key issues you identify you should be able to discuss how these would be addressed and within this how the relevant guidelines/ legislation etc might impact care provision and your role within that care provision.
• You will be expected to be able to identify and discuss apparent omissions in care.
• In relation to all of the above you will be expected to discuss the patients care moving beyond the few days in the scenario.
• You are expected to demonstrate knowledge of the medications within the scenario – but should assume that the prescribed medication regimen is broadly correct and avoid becoming sidetracked by discussions as the  appropriateness or otherwise of the prescribing decisions

Scenario

1. Initial admission information/ overview

James Smith is a 72 year old gentleman with a diagnosis of Paranoid Schizophrenia, Type 2 diabetes and chronic leg ulcers.  James has been living in a residential rehabilitation unit in the community for service users with long standing mental health conditions for the past five years.  James often presents with ideas of grandeur and fixed beliefs that he is a recently retired Major General.  Historically he has been a high risk of assault on others and neglect.  He has a long standing treatment plan of Flupentixol Decanoate depot every four weeks (last administered on 22/12/22), and oral risperidone, which James is ordinarily compliant with.

Four days ago, staff observed James to be walking awkwardly and complaining of pain in his legs.  When questioned, he allowed staff to assess his legs and it was found that he had an area of skin breakdown on a previous ulcer site.   The area was red and inflamed and was also noted to be oozing clear fluid.

Staff have also reported that James has become less settled and has started refusing his medication.

James has been assessed by the medical staff and started on oral antibiotics and is to remain within the residential unit.

Social History

James lives in a residential unit, which accommodates four other male service users.  Ordinarily he is sociable and enjoys the company of one or two of the other residents.  He is confident with collecting his benefits, walking to the local shops with members of staff and either makes his own meals or eats with the other residence.  He had previously been detained under the Mental Health Act (1983) however the Community Treatment Order (Section 117 of the MHA 1983) has lapsed.

• Re-Assessment due to change in behaviour/physical condition

	Usual  (information taken from carer)	Current
Maintaining a safe environment	Lives in a fully staffed unit, with support in meeting his ADL’s.	Reluctant to spend time in the communal areas, says his leg is painful and a 6cm x3cm lesion is noted and has been covered with an NA dressing. Discharge/oozing from the wound is making his trouser leg damp.
Communicating	Communicates well, however can become distracted by thoughts of grandeur that will result in “knights move” thinking. Deemed to have capacity over his physical, social and financial needs.	Reluctant to engage in conversation.  Ideas of grandeur more evident. Capacity over health needs of concern.
Breathing	Gave up smoking many years ago, but does still get slightly breathless if he walks too quickly.	Respiratory rate 16 breaths per minute.
Eating food and drinking fluids	Has food prepared by carers or prepares own food.  Does not comply with a Diabetes appropriate diet.	Diet reduced due to not going out to buy food and reluctant to spend time in the communal areas.
Eliminating body wastes	No concerns	No concerns
Personal cleansing and dressing	No support required. Usually very smartly/ formally attired as per his belief that he is a retired senior military officer	No support required – however staff have noted that he is looking a little unkempt and has not shaved for the last couple of days which is out of character.
Controlling body temperature	No Issues	No issues
Mobilizing	Usually walks with a stick, does not require any further assistance. Usually goes for accompanied walk to local shops with member of staff.	James has a marked limp favouring his right leg and states his left leg is really very painful
Working and playing	Enjoys socialising with other residents and going out to local pub with carers	Isolating self, and not carrying out usual routine
Expressing sexuality	Has previously shown inappropriate sexual behaviour to females	Historical risk noted. Carer advises female staff should not care for James in his room alone
Sleeping	Usually sleeps for about 6 hours.	Staff have noted that he is sleeping less, and moving around his room at night.
Dying	No issues	No issues.  Appears to lack to capacity to understand his physical health needs and the consequences of mismanagement.

• Medical and Nursing Updates

02/01/23	James attended promptly to breakfast and morning medication, although required encouragement to take his medication.  Noted to be limping.  James reported discomforted in his lower L leg.  Left leg assessed. James has chronic venous eczema with occasional tissue breakdown resulting in venous ulceration. Wound is 6cm x 3cm and appears clean with only minimal inflammation at the wound margin. Duty doctor informed and advised to commence oral antibiotics (prescribed).  All physical observations done and recorded on chart.  James has been noted to be pacing about the unit, however will sit down and elevate his leg when encouraged. PM Visual observations to confirm James is present in the unit continue 3 times daily at handover. Leg redressed as leaking through dressing
03/01/23	James has again declined leave, and chosen to eat his meals from the communal trolley. Compliant with all medication and physical observations.  Wound has been redressed as per TV advice, but margins look more red and wound continues to ooze heavily. Redressed with  NA dressing and dressing pad, has sat down with staff and residents in the TV lounge when prompted.
04/01/23	James has been reluctantly compliant with all medication and complaining of pain in his left leg. Dressing removed and area of inflammation much extended, and observations taken – has pyrexia of 38.5. Duty doctor has reviewed James and determined he needs to be admitted to the acute trust for urgent IV Antibiotic therapy. Referral to Acute trust has been made and they will inform us when a bed is available but hoping to transfer him later today. Visual observations to confirm James is present increased to hourly due to change in behaviour and physical health.   He has been self-isolating for the majority of the day.  Noted to be talking quietly under his breath whilst in communal areas and becoming agitated when approached by staff, especially when checking his leg.
05/01/23	09.00 Initial review by FY2 Acute trust Admission unit (AU) James Smith arrived on AU at 06.30 this morning. Transferred from RRU with a 2 day history of venous leg ulceration with signs that the wound has become infected. Have been advised IVABx will be required. James is accompanied by staff from RRU. Discussion with RRU staff, James would probably be better in a side room as the noise of the ward may make him more agitated IVABx prescribed to commence as soon as access established. Patient is reluctant to have cannula inserted. Reviewed by Tissue viability who recommend Tielle or Allevyn foam dressing with changes every 3 to 4 days dependent on level of exudate. Allevyn 10 x10 in situ wound swab taken prior to dressing. PM – RRU staff have advised James has agreed to have a cannula inserted. IVABX administered
06/01/23	AM – night staff report that James has become more agitated overnight. James has been more agitated and had removed his cannula, but RRU staff have managed to de-escalate the situation and encouraged James to comply with treatment. They have accompanied James when he went for a walk to the hospital shop as he wanted to purchase some Pepsi-Max. Appeared much calmer on return to the ward. RRU staff did mention that James had indicated that he would need to leave the ward tomorrow as he has regimental duties. PM – call from manager at RRU, the night staff member to special James has called in sick – they are trying to identify cover, but at this point can not assure the ward James will have a staff member overnight.

4.0 Medication administration Chart

James Smith RRU AU	Hospital No U456789	Weight 65kg
		Time dose due	02/01	03/01	04/01	05/01	06/01
Respiridone (oral)	1mg	08.00	rf	rf	rf	No stock	Df
		18.00	rf	rf	rf	ld	ld
Flupentixol Decanoate IM	500mg 4 weekly
		12.00	——-	——–	——-	——–	——
Insulin Levemir (SC)	28 units	08.00	rf	rf	rf	jhy	df
Insulin Novorapid (pre meal)	11 units	08.00	rf	rf	rf	jhy	jhy
		12.00	rf	rf	Rf	ld	Ld
		18.00	rf	rf	rf	ld	ld
Doxcycline (oral)   Start 02/01 Stopped 05/01	200mg	08.00	X	No stock	rf	——–	——-
Flucloxacillin (IV) Start 05/01/23	2gm	06.00	——	——-	——-		Df
		12.00	——	——-	———–	No IV access	No IV access
		18.00	——-	——-	——–	pkl	No IV access
		22.00	——-	——-	——–	jhy	df

Medication as Required

Medication

Dose

Paracetamol (Oral) pain

1gm upto QDS 4 hourly

1gm

1gm

05/02

05/01

08.00

12.00

jhk

jhk

Novorapid if CBG above 12

4 units

Hourly Visual Observation Chart

NAME:          James Smith           DATE: 02.01.2023

TIME	LOCATION	BEHAVIOUR
07.00
08.00
09.00
10.00
11.00	Bedroom	Awake
12.00	Dining room	Eating
13.00	Bedroom	Awake
14.00	Corridor	Pacing
15.00	Lounge	Stood watching TV
16.00	Bedroom	Awake
17.00	Dining room	Eating
18.00	Bedroom	Awake
19.00	Bedroom	Awake
20.00	Kitchen	Making Drink
21.00	Bedroom	Awake
22.00	Bedroom	In bed – Appears asleep
23.00	Bedroom	In bed – Appears asleep
00.00	Kitchen	Making Drink
01.00	Bedroom	Awake
02.00	Bedroom	Awake
03.00	Bedroom	In bed – Appears asleep
04.00	Bedroom	In bed – Appears asleep
05.00	Bedroom	Awake
06.00	Kitchen	Making drink

NAME:          James Smith                     DATE: 03.01.2023

TIME	LOCATION	BEHAVIOUR
07.00	Kitchen	Making Breakfast
08.00	Clinic Room	Physical obs and meds
09.00	TV Lounge	Stood watching TV
10.00	Corridor	Pacing
11.00	Bedroom	In bed – appears asleep
12.00	Dining room	Eating
13.00	Bedroom	Awake
14.00	Bedroom	Awake
15.00	Lounge	Stood watching TV
16.00	Bedroom	Awake
17.00	Dining room	Eating
18.00	Bedroom	Awake
19.00	Bedroom	Awake
20.00	Kitchen	Making Drink
21.00	Bedroom	Awake
22.00	Corridor	Pacing
23.00	Bedroom	Awake
00.00	Kitchen	Making Drink
01.00	Bedroom	Awake
02.00	Bedroom	Awake
03.00	Bedroom	In bed – Appears asleep
04.00	Bedroom	In bed – Appears asleep
05.00	Bedroom	In bed – Appears asleep
06.00	Kitchen	Making drink

NAME:          James Smith                     DATE:04/01/23

TIME	LOCATION	BEHAVIOUR
07.00	Kitchen	Making Breakfast
08.00	Clinic Room	Physical obs and meds
09.00	Corridor	Pacing
10.00	Corridor	Pacing
11.00	Bedroom	In bed – appears asleep
12.00	Dining room	Eating
13.00	Bedroom	Awake
14.00	Bedroom	Awake
15.00	Corridor	Pacing
16.00	Bedroom	Awake
17.00	Dining room	Eating
18.00	Bedroom	Awake
19.00	Bedroom	Awake
20.00	Kitchen	Making Drink
21.00	Bedroom	Awake
22.00	Corridor	Pacing
23.00	Bedroom	Awake

Capillary blood Glucose Readings

	Pre-Breakfast	Pre-dinner	Pre-tea	Pre-Bed
01/01	7	9	10	10
02/01	6	8	7	9
03/01	9	8	7	9
04/01	10	7	18	10
05/01	7	10	11	12
06/01	13	14	17	28