Reviewing Coroner's Findings, Delivering High-Quality Medical Records to Provide an Effective Communication between Hospitals - Case Study Example

Reviewing Coroner’s Findings Name: Lecturer: Course: Date: Introduction Medical practitioners must strive to provide the best possible quality patient-care and to maximise patient safety. In instances where adverse events happen, opportunities exist to improve the care provided. This comprises learning from specific preventable deaths and monitoring the deaths. This paper assesses a coroner’s report of a case where the cause of death was aspiration of gastro-intestinal contents due to small bowel obstruction that had resulted from small bowel torsion. It further provides concise critique on how the deceased person’s death may have been prevented and a brief discussion on the coroner’s findings, with regards to the practicability of implementing recommendations. A brief summary of the coroner’s findings Margaret Dawn Ballard dies aged 76 years old on 2 January 2009, at Royal Adelaide Hospital. The cause of death was aspiration of gastro-intestinal contents, due to small bowel obstruction that had resulted from small bowel torsion. The deceased was not detained at the time of death. She had a past history of severe depression that needed electro-convulsive therapy. She had been admitted severally to different hospitals over a three-year period. At about midnight on 1 January 2009, the deceased was found unconscious on the floor. Dr. Buenviaje examined her and found that she was hypotensive. She was then referred for further assessment at the Royal Adelaide Hospital for assessment. Dr. Buenviaje’s transfer later stated that Mrs Ballard had suffered from vaso vagal syncope or unconscious collapse. Dr. Bruce, however, gave little weight to the severity of the deceased’s collapse, which promoted her admission to the hospital on 1 January 2009. At Royal Adelaide Hospital, the deceased was examined by Dr. Bruce who determined that she had transient hypertension and bradycardia, after her collapse, within the context of normal ECG and normal blood tests, indicated vaso vagal syncopoal episode. The deceased’ recent vomiting and diarrhoea symptoms, without abdominal distension or abdominal pains, are believed to have indicated gastroenteritis and caused hypovolaemia and dehydration that caused vaso vagal collapse. However, Dr Bruce diagnosis was based on an interview with the deceased who suffered from Alzheimer’s dementia. Documentation and communication Effective communication could have been a vital aspect of delivering high quality medical records to provide effective channel of communication, between Glenside Hospital and Royal Adelaide Hospital. This could have prevented Mrs Ballard’s death. In the case, rather than rely on the triage nurse records of the patient that indicated no diarrhoea, and notes from Glenside hospital that indicated she had dementia and that she had suffered hallucinations weeks earlier, Dr. Bruce relied on his diagnosis based on interviewing Mrs Ballard who misled him that she had suffered from diarrhoea. Such lack of quality information misdirected the treatment. As stated by Cheevakasemsook et al. (2006), quality information promotes quality care, since the information is made accessible to other health practitioners as part of superior care for the patients. In regards to the role of medical recording in communication information to the health practitioners and informing them of their care decision, quality records are intimately associated with quality health care. Hence, high standards of records management could have promoted improved quality of care. Additionally, Dr Bruce could have acknowledged that the key purpose of documentation is to record patient care, instead of addressing his accountability and that of others. Dr. Bruce should have applied the principle of accountability in justifying his approach to the records obtained from the triage nurse and the referral letter from Glenside hospital. This could have prevented the death from happening. Reliance on inconsistent information from the patient who had suffered from dementia contributed to inaccuracy of the records she used. Cheevakasemsook et al. (2006) shows that accuracy of documentation is based on three perspectives, namely veridical reflection of patient care, comprehensive and through detailing the patient journey and lastly, clarity in application of terms. Accuracy is essential in nursing documentation, since the recorded information requires complete reflection of the processes undertaken in patient care, in terms of textual and written chronicle of the healthcare processes (Prideaux 2011). Dr Bruce’s failure to maintain and respect standards of record management can be interpreted as professional misconduct. He should have understood that recordkeeping presents testaments to the care given, and can as well detail out the efforts to deliver care that have been declined by the patients. In this way, he could have respected and relied on the Dr Ballard’s medical histories and earlier diagnosis. Cheevakasemsook et al. (2006) clarified that record-keeping is an important component of nursing care, since it details out the patient’s journey through the medical care process and may as well protect a medical practitioners’ accountability to provide the care. Additionally, good quality care can improve the quality of patient care and hence Dr. Bruce should have ensured that the entire documentation process meets quality standards. It should, therefore, be understood that keeping of Mrs Ballard’s records should not have been separate from clinician care. Rather, it should have reflected her entire diagnosis to promote holistic care. Hence, the medical practitioners should have ensured that obstacle to the record-keeping are addressed and overcome to honour the duty of care obligated to the patients. Ethical decision-making The capacity to influence Mrs Ballard’s patient care outcomes depended substantially on a number of forces, each of which Dr Bruce should have considered, in order to positively influence the patient care outcomes in ethically-appropriate standards. Such forces included Dr Lawrence’s, the psychiatric registrar’s, knowledge and skills, clear perception of the ethical principles, relationship with the patient, the health care team at Glenside Hospital and Royal Adelaide Hospital and the communication skills that could have nurtured such relationships. In terms of ethics, what should have been done to Mrs. Ballard’s patient care situation was at the centre of the medial practice dilemmas that Dr. Buenviaje, Dr. Bruce and Dr. Lawrence faced. Dr Buenviaje appears to have exercised the principle of justice, by seeking to treat Mrs Ballard fairly and seeking to act in a way that permits equal distribution of risks and benefits. For instance, he referred Mrs Ballard to the Royal Adelaide Hospital while knowing that she could not receive medical care at home. She also knew that the deceased had used up the day allotted for her medical condition. Such shows that dilemma linked to the ethical issue of distributing scant resources. The ethical principle of justice guided her equal and fair treatment of the patient (Mitty 2012). Her decision weighed the consequences of the limited family and organisational resources. The medical’s knowledge and skills also significantly contributed to the forces that add to the capability to influence the patient care ethically. The power originated from Dr. Bruce’s dependence on the Dr. Lawrence’s, the psychiatrics’, knowledge and expertise. However, Dr. Bruce’s failure to use evidence-based research based on the medical histories provided by Glenside Hospital led to the pitfalls. Hence, Dr. Bruce failed to influence the patient-care outcomes ethically. At the same time, Dr. Bruce needed to have sufficient understanding of the ethical principles and models. Application of ethical principles, such as beneficence and autonomy could have equipped him with the power to influence the decision-making ethically. An understanding of the principles could have allowed her to influence the healthcare team at Royal Adelaide Hospital to apply the principles, and hence could have used the power to influence the nurses’ actions by asking them to monitor Mrs Ballard closely, through the night, rather than by strictly using the alarm monitor system. Hence, Mrs Ballard could have been saved from falling off her bed to the floor. Parker (2007) argues that ethical principles provide solutions that can be reached within the atmosphere of honestly, openness, respect and caring. The process could have been based on evidence-based practice. Ethical decision-making could have been refined and applied in addressing the ethical dilemmas. By complying with the principles of beneficence and autonomy, ethical decision-making could have been ensured. In the case, Dr. Bruce respected Mrs Ballard’s autonomy by involving her in the decision-making process. For instance, it is perceived that Mrs Ballard told Dr Bruce that she had been suffering from diarrhoea, which was not true. However, reliance on Mrs Ballard’s, who was suffering from dementia, misled Dr Bruce. As a consequence, Dr Bruce perceived that her present symptoms of diarrhoea and vomiting without distension and abdominal pain were lined to the gastroenteritis and hence were likely to have caused dehydration. This made decision making problematic. On the other hand, Dr Lawrence’s decision not to take any action for medical review despite Mrs Ballard’s worsening condition and intermittent vomiting disregarded the principle of beneficence, which seeks that medical practitioners excise their duty of doing good, rather than harm. In this case, the conflict arose in deciding between doing good and meaning no harm. Advocacy Advocacy implies pleading on behalf of another. According to MacDonald (2006), the nurses must protect their patients, as well as the hospital facility from potential risks associated with the technology used. To this end, acting as Mrs Ballard’s advocate was the responsibility of nurses at Glenside Hospital and Royal Adelaide Hospital. By taking this role, they could have prevented the death. These signify the tensions that emanated in the case of Mrs Ballard’s case, where the nurses at both hospitals failed to exercise their rights of advocacy, since the patient and the hospital’s best interests or the nurses’ decisions and those of the doctors’ were not compatible. In the case, the nurses appear to have feared the potential damage to the physician-nurse relationships that the advocacy may have caused. For instance, the triage nurse determined that Mrs. Ballard had a soft and painless abdomen. Later, Dr. Bruce examined Mrs Ballard during which Mrs Ballard told Dr Bruce that she had currently had some diarrhoea and vomited yet had no pain. However, it appears that Dr. Bruce overlooked the nurse records that did not indicate diarrhoea. Dr Bruce, therefore, recommended treatment based on the belief the diarrhoea may have caused the mild dehydration. At this stage, it was the duty of the triage nurse to question Dr. Bruce, who was an Emergency Department trainee’s, judgment concerning his inference. Rather, she complied with the instructions. At the same time, Dr Bruce decision to discharge Mrs Ballard and refer her back to Glenside within 4 hours of Mrs Ballard’s admission to Emergency Department was ill advised. Knowing that Dr Bruce is an Emergency Department trainee, the nurse should have exercised her advocacy role by questioning Dr Bruce’s decision and asked that Mrs Ballard be retained at Royal Adelaide Hospital for at least 24 more hours to be closely monitored. This is since after Mrs Ballard was taken back to the Glenside Hospital, Dr Lawrence noted that her condition appeared to be worsening. Laskowski-Jones (2012) observe that nurses are seen to act as advocates when there is the danger or the risk of the patient getting hurt and when the nurse is asked to follow a treatment plan that may not help the patient’s condition. The nurses, at Glenside Hospital, also failed to exercise their advocacy roles. For instance, Dr Lawrence had noted that Mrs Ballard’s condition had worsened. However, no action had been taken to organise for medical review even after vomiting intermittently between 11am and 5pm on 2 January 2009, and later in the day between 8pm and 9pm. Clearly, the nurses who had been monitoring Mrs Ballard failed to take up their advocacy roles to protect the rights of the patient. Later, at 10pm. Mrs Ballard collapsed in the corridor, apparently looking for the nurses. She was taken back to the bed and fats became unresponsive. Despite performing suction and CPR, she aspirated gastric contents and immediately suffered cardiac arrest. To this end, the roles of nurses in advocacy should have had a wider understanding of the accountability and responsibility. Additionally, they should have been based on an understanding and recognising Mrs Ballard’s rights. Leadership and management Good leadership and management styles are significant elements of progressive healthcare. Management consists of successfully controlling things, such as human resource, or supervising and directing the behaviour of others (Paterson 2010). Leadership on the other hand are the roles performed by leaders (Stanley et al. 2006). In promoting quality healthcare, a symbiotic relationship has to exist between leadership and management. However, in the case of Mrs Ballard’s treatment and the events that led to her death, it is clear that both the leadership and management lacked. From analysis of the case of Mrs Ballard, it is clear that effective leadership and management at Glenside Hospital and Royal Adelaide Hospital lacked, leading to loss of focus on quality improvement and promotion of patient safety, as well as achieving positive outcomes. Additionally, there was no teamwork on the part of nurses and the doctors. Teamwork should have been approached as a complex social activity where by the nurses and the doctors collaborated to achieve positive treatment outcomes for Mrs Ballard (Nesley & Brownie 2012). However, it appears that the doctors at both hospitals believed in working independently and giving orders to the nurses. On the other hand, the nurses were used to taking orders rather than seeking to work collaboratively with other nurses. It is therefore perceivable that teamwork could have resulted in synthesis and interaction of patient care skills that could have promoted the patient’s health. Due to the dysfunctional teamwork in Mrs Ballard’s treatment, cohesion lacked, causing group conflicts between the nurses and the doctors. In the case, it is clear that ward nurses at Glenside Hospital and Royal Adelaide Hospital failed to take leadership roles by being able to call the shots. Cultural competence which may include work culture Health and illness made up cultural concepts in the case of Mrs Ballard’s failed treatment. This is since the perceptions, experiences and management of her health appeared to be acculturated within the cultures of the hospitals she had been admitted to (Leever, M 2011). To this end, culturally competent care did not link with the professional knowledge at both hospitals to address the needs of Mrs Ballard’s health needs or cultural preferences. Additionally, culturally competent care involved respecting the patient or the patient’s family’s cultural values, practices and beliefs (Chenowethm et al. 2006). It further involves acknowledging that the families are the patient’s best advocates when it comes to understanding the patient’s cultural values and likes. Analysis of Mrs Ballard’s case shows no indication of an attempt by the nurses and the physician’s to interview the patient’s family members, in order to incorporate their values in the treatment. Additionally, no attempts were made to understand Mrs Ballard’s cultural values. Hence, it appears that the physicians worked essentially on assumptions. The care should have been culturally sensitive to avoid the likely conflicts, where the nurses were likely to feel frustrated and the patient alienated. As indicated in the case, it is clear that at Royale Adelaide Hospital, Mrs Ballard should have been monitored at the Emergency Department, through physical presence of the nurses, by making frequent visits rather than through the strict use of the alarmed monitor that recorded her oxygen saturations and ECG output, which apparently remained within the normal limits. Cultural sensitive could have involved satisfying Mrs Ballard’s need for physical presence of people or nurses spending more time with her. According to DeRose and Kochurka (2006), culturally competent health care involves efficient use of time with the patients and decreasing the patient’s stress levels, as well as compliance with the medical standards. Conclusion Effective communication could have been a vital aspect of delivering high quality medical records to provide effective channel of communication between Glenside Hospital and Royal Adelaide Hospital. This could have prevented the death. Due to lack of effective documentation and teamwork, several possible diagnoses had not been given the required gravity or adequate time to develop. It could have ensured that the deceased is taken through periods of observation. Hence, the deceased had failed to get an effective medical review. The capacity to influence patient-care outcomes depended substantially on a number of forces, each of which should have been considered in order to positively influence the patient care outcomes in ethically-appropriate standards. These include the Dr. Lawrence’s experience and skills, clear perception of the ethical principles, relationship with the patient, the health care team at Glenside Hospital and Royal Adelaide Hospital and the communication skills that could have nurtured such relationships. The nurses also failed to take effective roles as the patient’s advocate. By taking this role, they could have prevented the death. Effective leadership and management at both hospitals also lacked leading to loss of focus on quality improvement and promotion of patient safety, as well as achieving positive outcomes. Effective teamwork should have been approached as a complex social activity where by nurses and the doctors collaborated to achieve positive treatment outcomes for Mrs Ballard. The patient-care should have been culturally sensitive to avoid the likely conflicts, where the nurses were likely to feel frustrated and the patient alienated. 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