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Analyse the case and answer the following questions; Case Study- Introduction 1. This is an inquest into the death of Mr Sam Cain who died whilst he was an involuntary patient at the High Dependency Unit at the Royal North Shore Hospital (RNSH). 2. Mr Cain was 23 years of age when he died at the RNSH on 5 February 2019. 3. In NSW, the Coroners Act 2009, invests coroners with special jurisdiction to investigate the cause and manner of death of a patient in a psychiatric hospital. All such deaths are required to be reported to the coroner. 4. It has long been accepted that the “rationale for singling out the deaths of psychiatrically unwell people who die while involuntary patients is that they constitute an especially vulnerable group within the community who are deprived of many of their rights through no fault of their own, but because of their symptoms.”1 5. It is intended that a coronial investigation into the death of such patients ensures transparency and accountability; including the consideration of any care and treatment issues associated with the hospital and medical staff. Events on 4 February 2019 -Sam’s mother stated that: “On February 4th, 2019, two of Sam’s work friends attended Sam’s house where they found him lying on the floor. Sam said, “I want to go to hospital.” The friends took him to Royal North Shore Hospital.””21 -On the evening of 4 February 2019, Sam attended at the RNSH CMH service in the company of a friend. He presented with a packed suitcase and requested that he be admitted as a voluntary inpatient to the mental health unit. Sam was admitted to the Psychiatric Emergency Care Centre (PECC) as a voluntary patient under the care of the on-call psychiatrist. -The Hospital progress notes contained detail from Sam that he had been experiencing suicidal ideation for the past two days. He denied that he had attempted to follow through with these thoughts. He stated that he had been feeling highly stressed and that this stress related to financial and work issues, and that he felt that he cannot see a way out. He indicated that he was feeling highly anxious, that he had to lay in a foetal position, and felt that he could not stand. He also stated that he felt panicked but denied that it was a panic attack. -He continued to indicate that he was feeling very angry, however he was unable to identify the trigger for these feelings and confirmed that it was not directed at anyone. He reported that his auditory hallucinations were at the baseline and are just occasional voices. He confirmed that he didn’t have any homicidal thoughts, and that the only person he feels like harming was himself. He reported that he felt frightened and overwhelmed. -On the morning of 5 February 2019, the Hospital progress notes record as follows: “Pt appeared very anxious, trembling. Reports that he is not feeling ok, admitted to just trying to hang himself with his pants and it “didn’t work”. Same unwitnessed. Admits to feeling very anxious, and would like PRN. Also still feeling suicidal, “Life, I can’t do it anymore” verbal reassurance given.”22 Events on 5 February 2019 -Prior to conducting the ward rounds and at hand-over, Dr Brahmbhatt was advised by Registered Nurse (RN) Ms Grace Nagory that Sam had indicated that he had attempted self-harm with his pyjama pants. She indicated that this was unwitnessed. -At approximately 09.30 hours on 5 February 2019, Dr Brahmbhatt, conducted and documented a detailed mental state examination. Dr Brahmbhatt stated that: “…I also assessed whether Sam met criteria for being placed under the Mental Health Act. Sam reported suicidal ideation and a deterioration of his mental state over the preceding two days. He told me that while he had experienced suicidal thoughts before, these had never been as intense. He also admitted to thoughts of jumping off a building. He was unable to identify why his mental state had deteriorated though he did admit to financial stress. My opinion was that he was very distressed. I was very concerned about his risk of harm to himself and potentially to others, and I thus planned for him to be transferred to the High Dependency Unit (HDU) of the inpatient unit. I also placed him under the Mental Health Act as a mentally ill person. I also determined that he needed closer observation, and I hence increased his level of acuity to Care Group Level 2 (15 minute observations). Whilst waiting for transfer to the HDU, I ensured he remained in the common area of the PECC so that he could be monitored at all times by staff. He was administered Lorazepam and Olanzapine for agitation, and he slept for an hour on the PECC whilst awaiting transfer.” -Dr Brahmbhatt completed the certificate of assessment required to schedule an individual and stated that he: “presents as acutely psychotic with AH’s (auditory hallucinations) and persecutory delusions. Also voicing SI (suicidal ideations) with plan and intent as well as thoughts of HTD/O???? Admitted to NS (nursing staff) that he tried to hang himself with pants in his room this morning.”24 -Ms Rebecca Riva, the Clinical Nurse Consultant (CNC) for the Emergency Department confirmed her attendance at the morning handover. Ms Riva also confirmed that Dr Brahmbhatt, RN Nagory and herself went to assess, and ensure that Sam had not sustained any injuries from the possible act of selfharm involving his pyjama pants. RN Riva recalls discussing her shared concerns with RNs Nagory and Zantos. -Sam was transferred to the HDU at around 12.15 hours on 5 February 2019. He was not seen by a doctor at that time; however, he was assessed by the nursing staff and received a visit from his case manager, Mr Kimber. -Between 12.30 – 13.00 hours, the Nurse Unit Manager (NUM) (3), Mr Andrew Nicholls, recalls receiving a call from the MHU HDU, requesting a safety blanket for a patient. Mr Nicholls recalls contacting the NUM (1), Ms Lauren Ashe to discuss the circumstances relating to the request. Mr Nicholls recalls being told by Ms Ashe that the safety blanket was being requested for Sam, after the report of an attempted self-harm incident the evening before, being an attempt to hang himself with his pyjamas.25 -Mr Nicholls recalls discussing with Ms Ashe at that time, whether an Individual Placement Support (IPS) was required. An IPS, sometimes referred to as a “special”, is where the patient is: “…under constant supervision, whereby, at all times, the patient must remain under visual observation, and at arms-length of a nurse. It was reported to me that Sam had been reviewed by a consultant, before transfer, and Level 2 acuity was assessed to be appropriate. Level 2 acuity, requires that a nurse must observe a patient every 15 minutes. It is also a requirement that the nurse must engage regularly, and randomly observe the patient, at least every 15 minutes.”26 -The Hospital Progress notes do not clarify whether the earlier attempt at selfharm occurred the previous evening (4 February 2019) or the morning of 5 February 2019. What does appear clear, is that the medical staff at both the PECC and the HDU, were sufficiently concerned about Sam’s presentation, that none of the medical staff doubted the veracity of his assertions. -Given those abovementioned concerns, Sam was placed in a room on the HDU ward close to a nursing station to ensure close visual monitoring. Sam appears to have also been encouraged by the medical staff to approach them if he was feeling more unwell. His belongings were removed, and he was not given access to any hospital linens, in an attempt to minimise any associated risk. -Mr Kimber is recorded as meeting with Sam in the courtyard area of the unit at 16.05 hours. He remained with Sam until 16.50 hours. -Mr Kimber recalls the following: “…He reported feeling low, overwhelmed and hopeless, with frequent thoughts of suicide. He also described having attempted suicide while in PECC. We discussed the stressors associated with Sam’s request for an admission as well as psychological skills and a safety plan for managing distress and risk. We also discussed reasons for living and treatment options, to engender hope and future orientation. At the time, my impression was that Sam’s risk of suicide was high, particularly given his description of a recent suicide attempt and his reports of ongoing suicidal ideation. I suspected that Sam’s recent increase in insight my have contributed to heightened distress, despair and risk of suicide. I believed that Sam’s risk of suicide was managed via his inpatient unit admission and his transfer to HDU, with 15 minute checks from staff.” -At the conclusion of their meeting, Mr Kimber stated that he then approached the Nurse’s station in HDU and spoke with Ms Kerry Foley, RN. He stated that he relayed some physical health concerns that Sam had mentioned to him; as well as the need to explore the issue of administering anti-depression medication at future medical reviews. In Ms Foley’s statement, she does not refer to this conversation. -In Ms Foley’s statement, she describes her earlier interactions on 5 February 2019 with Sam, as: “…difficult to enage [sic] with as he responded with one word answers, having a low mood, appeared withdrawn, had poor eye contact and a ‘blunt affect'”… -Ms Foley later comments that after Sam had spoken with Mr Kimber, Sam appeared to be: “…more reactive, his mood seemed brighter, eye contact was improved and Sam was less isolative, spending time in common areas and interacting appropriately with staff when approached.” -After the meeting with Mr Kimber, Sam returned to his room and shut the door. Mr Anthony Gunter, RN, recalls speaking to Sam and asking him why he had closed his door. Mr Gunter indicated that Sam had told him he had closed the door to his room as it was “noisy”. Mr Gunter stated that he had asked Sam if he had any suicidal thoughts and Sam told him that he didn’t. Mr Gunter told Sam that he needed to keep his door open. Mr Gunter stated that he noticed the door shut again. In addition, he stated that he heard other nursing staff speaking with Sam and indicating to him that it was important that he left his door open. Mr Gunter stated that he last saw Sam at 17.45 hours, sitting in the dining room area. 85.Mr Gunter recalls seeing Sam’s door shut again at 18.00 hours. He stated that he was aware that his 15 minute observation was due and went to see him. He saw that his door was closed and that he was hanging from the door. Mr Gunter attempted to force the door open, however, was unable to open the door. Mr Taylor Clancy, an Enrolled Nurse (EN) appeared and forcefully kicked the door open and Sam fell to the ground. The noose, fashioned from his pyjama pants, fell away from his neck. Mr Gunter, Mr Clancy and Ms Foley immediately commenced CPR, using compressions and a defibrillator. -A “Code Blue” alarm was called and the Code Blue Team arrived within minutes. CPR continued with additional assistance; however, Sam could not be saved. His time of death was recorded at 19.12 hours. -Police were contacted and attended the Hospital shortly after receiving the notification at 20.30 hours. The officer in charge of the investigation, Leading 28 Statement of Kerry Foley, dated 26 June 2019, [10], Tab 20, Exhibit 1. 29 Statement of Kerry Foley, dated 26 June 2019, [14], Tab 20, Exhibit 1. 16 Senior Constable Stephen Smith (LSC Smith) became aware after Sam’s death, that his body had been moved from his room to another room and that a number of items had been cleaned away. LSC Smith was advised that this had been done to reduce the distress to other patients. Police were able to confirm that the second room had been secured and locked by Hospital security guards prior to the arrival of police, but only after Sam had been moved. QUESTIONS: 1.Which of these NMBA Guidelines have been breached by the nurse and how? Enrolled Nurse competency standards for practice Professional boundaries Professional practice guidelines Decision-making framework (DMF) including the nursing flowchart Re-entry to practice Registration guidelines Recency of practice Code of Ethics Code of Conduct 2.Who, in the case, is responsible for the Mandatory Reporting? 3.Which of the following Ethical Principals were amiss in each case and why? Autonomy, beneficence, non-maleficence, confidentiality, justice, rights and veracity. 4.What current Commonwealth and State/Territory legislation relate to the issues within each case? 5.If the EN in question had followed their duty of care, do you think the outcome of their case would have changed? 6.If the EN in question had followed the principals of open disclosure, do you think the outcome of their case would have changed? 7.Which of the following could have impacted on the case if there had/was one in place and why: power of attorney, living will and advanced directives. 8.Which of The National Safety and Quality Health Service Standards (NSQHS Standards), have not been adhered to in each case? What was the impact? 9.Were there any human rights/access to healthcare that were violated in these cases? 10.Give a brief reflection on your thoughts of each case and how you can relate what you have learnt into to your practice.

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