Analyse the case and answer the following questions; 1

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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.