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Analyse the case and answer the following questions; 1.Which of the above 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. CASE: Inquest into the death of Ms Shelley Young Ms Shelly Young was a 65 year old woman who died at Manly Hospital, Sydney on 29 September 2007. She died from choking on a tangerine. She had been identified as a choking risk and as needing to be supervised while she ate. She obtained the tangerine from a fruit bowl that was left out for patients. Admission to Manly Hospital: -Ms Young was seen in the emergency department on 20 September 2017 and was ultimately admitted to Medical Ward 1 with a provisional diagnosis of delirium, potentially due to cellulitis or a urinary tract infection. Because she required treatment for her physical illness but also needed ongoing psychiatric care, Ms Young was referred to the consultation liaison psychiatry team, a service catering for the mental health assessment and treatment of patients admitted to the medical and surgical wards of the hospital. Ms Young regularly saw Dr Anna Bolliger, Staff Specialist Psychiatrist during her admission and Dr Bolliger also had several discussions with Dr Alle (Ms Young’s community psychiatrist), with Ms McGregor and with the admitting physician and treating team managing Ms Young’s other medical care on Medical Ward 1. -Various pro re nata (PRN) medications were administered to Ms Young across the course of this admission, in addition to the routine medications she was taking at the time of her admission. – In addition, at the time of admission Manly Hospital received and included within their records, various documents from RSL Tobruk which in turn included some material that had been provided by Macquarie Hospital. This material included reference to Ms Young being at risk of choking because of, amongst other things, her lack of teeth, a swallowing/chewing disorder, reduced mastication and impulsivity. – A swallow assessment conducted on 18 September 2017 whilst Ms Young was at RSL Tobruk, led to recommendations noted in the records available to Manly Hospital, that Ms Young be fully supervised at all time during meals and a soft moist food diet be trialled. – Ms Young was supervised with her meals whilst a patient on Medical Ward 1 and arrangements were made for Ms Young to be further assessed via a formal speech review. The speech review did not, however, occur. – Ms Young was ultimately transferred to the Specialist Mental Health Ward for Older Persons at Manly Hospital on 28 September 2017. She was placed on Level 2 observations, requiring observation every 15 minutes. On 29 September 2017 Ms Young spent some time with Ms McGregor. – On the same day Nurse Unit Manager (NUM) Muriithi contacted the registrar on the treating team and requested a medical review because she was concerned Ms Young might still be experiencing delirium. Ms Young was reported to be agitated, walking around the ward and knocking on windows. Ms Young was assessed by a Junior Medical Officer who recorded the impression of resolving delirium on a background of manic relapse of schizoaffective disorder. – At some time around 1pm Ms Young was given 1 mg Haloperidol (an antipsychotic) with some effect. – According to the nursing observation charts Ms Young was observed in the corridor at 1300 and 1315 and was back in her room at 1330 and 1345. The observation at 1400 had Ms Young in her room and courtyard, perhaps she was walking between the two. At 1415 Ms Young was seen in the corridor. – At 1430 NUM Muriithi carried out a walk-thru of the ward and discovered Ms Young in her room, slumped in a chair. She was unresponsive. According to NUM Muriithi, when she discovered Ms Young, she was seated peacefully and the witness’ first impression was that Ms Young had experienced a cardiac arrest. – NUM Muriithi called for help, a call for the rapid response team was made and CPR attempts continued until about 1535 that afternoon. During resuscitation and on direct laryngoscopy 4-5 pieces of tangerine were seen in Ms Young’s airway and removed. Resuscitation was unsuccessful. – At the request of Ms McGregor a limited autopsy was conducted, limited to external examination and toxicology. The forensic pathologist concluded that the cause of death was choking. – The forensic pathologist informed this court that it is not uncommon for first responders not to be able to see obstructing food boluses in the airways, food could be too deep into airways and also the tongue can obstruct their vision. She said that the possibility that the tangerine originated from the stomach (in the course of CPR) cannot be completely excluded however, based upon the medical records that tangerine pieces were removed, that there was the absence of upper teeth and limited lower teeth, past choking episodes, documented choking risks, documented delirium and confusion, eating without supervision and not eating soft foods, she determined the cause of death as in keeping with choking – On balance, for the reasons set out by the forensic pathologist I am satisfied that the cause of Ms Young’s death was choking. The adequacy of steps taken to assess Ms Young’s ability to swallow and supervise meals during the admission to Manly Hospital: – By the 1990s Ms Young had lost all but two of her teeth. – Ms McGregor reports that in 2009 Ms Young was taken to Ryde Hospital from Macquarie Hospital with a piece of apple lodged in her throat. – On 16 March 2016 an “alert” was entered in the LHD EMR recording Ms Young “choked on food”. – The discharge summary from Macquarie Hospital on 18 July 2017 as provided to RSL Tobruk identifies Ms Young’s choking risk. This also noted that Ms Young had returned to a full diet at the request of Ms McGregor, despite the identified choking risk. -Further problems were observed at RSL Tobruk. On 17 September 2017 Ms Young choked on her food at lunch prompting a speech pathology assessment the next day. – Ms Young then choked on a small piece of biscuit at Tobruk on 19 September 2017. – There were several contributing causes: lack of teeth, tardive dyskinesia (abnormal tongue movement likely due to the use of first generation anti psychotics in particular), dysphagia (impaired swallowing associated with multiple complications of anti-psychotic use including impaired function of the musculature of the mouth,pharynx and oesophagus), and behaviourally, Ms Young’s tendency at times to eat and talk at the same time. – Manly Hospital were on notice of these problems with choking. The records provided by RSL Tobruk included the speech pathology assessment of 18 September 2017 which said, amongst other things, “Other directives” Swallow AX 18/09/17 Ms Young presents with mild predominately oral phase dysphagia on b/g of missing dentition and cognitive issues associated with a mental health background. Due to limited food trials today unable to ascertain extent of dysphagia and impact missing dentition has on her mastication ability, however given recent change in behaviour ?infection and recent choking episode, she is to commence a soft moist diet with hard meats cut finely and thin fluids in isolation. Softer meat alternatives such as flake fish are appropriate. Please ensure she is FULLY SUPERVISED at all times during meals and please ensure staff are reminding her not to speak while eating. Sister Ms McGregor called and updated on recommendations and outcome of ax. Recommendations: 1 soft moist diet with all meats cut finely. Softer alternative provided if available (flake fish and mix with sauce or soft processed ham) ALL FOOD CUT FINELY 2. Ideally avoid all hard, dry, particulate, stringy, gristly or mixed consistency foods. No bread or toast please until further ax can be conducted. 3. Extra sauce to help keep moist and to add flavour, 4. Thin fluids ideally in is olation 6. No dual consistencies 7. Medications as tolerated 8. FULL set up assistance 9. FULL supervision with intake 10. To be 90 degrees upright with neck fixation during and 30 mins post all intake 11. Rigorous oral care post intake 12. Small mouthfuls at a slow pace encouraged (requires prompting) 13. r/v 1/52 to check tolerance and adherence to regime. Please contact SP immediately if signs of aspiration (coughing, choking, throat clearing, wet voice) observed on current regime, if chest declines or she is unable to swallow – Ms Young had been transferred to Manly Hospital by the time her follow up speech pathology review was due at RSL Tobruk. – Dr Alle specifically raised this issue with Dr Bolliger who discussed it with NUM on Medical Ward 1, Genevieve McKinnon. NUM McKinnon recalled a discussion around Ms Young impulsively gulping food or water, something she had observed for herself. She further told the Court that Ms Young’s swallowing risk was also an alert in the Powerchart system which was the hospital electronic medical records system. – NUM McKinnon further noted that Ms Young was getting meals under the ‘blue mat/red mat’ system. Because Ms Young was classified as being ‘red mat’ that meant staff were alerted to the fact that the meals were not to be delivered to Ms Young in person but rather only a nurse could take a meal into her. In addition, Ms Young was being ‘specialled’ 1 to 1 during her time on Medical Ward 1. – The treating doctors on Medical Ward 1 were alerted to the risk. An entry in the EMR for Saturday 23 September 2017 referred to a medical review by Dr Sanela Redzepagic saying nurses observed Ms Young to eat well – no coughing or difficulty with food but that she should have a formal speech pathology review on Monday (25 September 2017). No speech pathology review followed. -The London Protocol Report, dated 11 December 2017, observed “despite the alerts to choking risk, and extensive documentation in the consumers’ EMR file regarding speech assessment findings and recommendations of a soft diet, there was no nursing notes on the medical ward apart from two references to diabetic diet that was initiated on 21 September 2017” – The handover from Medical Ward 1 to the Specialist Mental Health Ward for Older Persons, including details of the increased risk of choking, was patently inadequate. – The London Protocol Report stated as follows “Nursing/clinical handover from medical to older persons mental health unit did not include speech/diet alerts nor history of two prior choking incidents on the 18/09/17 and 19/09/17 nor care planning to ensure risk mitigation. The older persons mental health unit inpatient admission checklist has a prompt for diet but not for speech assessment. An RN did make a referral for speech assessment on 29/09/17 at the same time as referring five other patients however this was no recorded in the consumer’s EMR file.” – This omission at handover meant that no arrangements were in place on the Older Persons Mental Health Unit to monitor Ms Young at mealtimes or when eating. – This was particularly important as Ms Young was in all probability still experiencing delirium at the time of her transfer to the second ward. Symptoms of delirium can fluctuate over time, including fluctuating across any given day and so observations of delirium resolving are not reliable in isolation. Associate Professor Wijeratne emphasised that delirium can be quite prolonged and was previously prolonged for Ms Young during the RNSH admission. – Furthermore, NUM Muriithi on the day that Ms Young died, requested a medical review because she was concerned that Ms Young was still experiencing some delirium. 7 Upon review Ms Young was reported to be disoriented, emotionally labile and exhibiting some psychiatric phenomenology. Continuing supervision of eating was all the more important in that circumstance – There was a fruit bowl on the Specialist Mental Health Ward. – The inappropriateness of that fruit bowl, as arose in the case of Ms Young, was that fruit was available to those who should have been supervised whilst eating but who lacked the capacity to remember to wait until supervised before helping themselves to a piece of fruit.

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