Analyse the case and answer the following s; Case Study-…
Analyse the case and answer the following s; Case Study-… Analyse the case and answer the following s;Case Study-Introduction1. This is an inquest into the death of Mr Sam Cain who died whilst he was aninvoluntary patient at the High Dependency Unit at the Royal North ShoreHospital (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 toinvestigate 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 ofpsychiatrically unwell people who die while involuntary patients is that theyconstitute an especially vulnerable group within the community who aredeprived of many of their rights through no fault of their own, but because oftheir symptoms.”15. It is intended that a coronial investigation into the death of such patients ensurestransparency and accountability; including the consideration of any care andtreatment 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 housewhere they found him lying on the floor. Sam said, “I want to go tohospital.” The friends took him to Royal North Shore Hospital.””21-On the evening of 4 February 2019, Sam attended at the RNSH CMH service inthe company of a friend. He presented with a packed suitcase and requestedthat he be admitted as a voluntary inpatient to the mental health unit. Sam wasadmitted to the Psychiatric Emergency Care Centre (PECC) as a voluntarypatient under the care of the on-call psychiatrist.-The Hospital progress notes contained detail from Sam that he had beenexperiencing suicidal ideation for the past two days. He denied that he hadattempted to follow through with these thoughts. He stated that he had beenfeeling 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 feelinghighly anxious, that he had to lay in a foetal position, and felt that he could notstand. 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 unableto identify the trigger for these feelings and confirmed that it was not directed atanyone. He reported that his auditory hallucinations were at the baseline andare just occasional voices. He confirmed that he didn’t have any homicidalthoughts, and that the only person he feels like harming was himself. Hereported that he felt frightened and overwhelmed.-On the morning of 5 February 2019, the Hospital progress notes record asfollows:”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 reassurancegiven.”22Events on 5 February 2019-Prior to conducting the ward rounds and at hand-over, Dr Brahmbhatt wasadvised by Registered Nurse (RN) Ms Grace Nagory that Sam had indicatedthat he had attempted self-harm with his pyjama pants. She indicated that thiswas unwitnessed.-At approximately 09.30 hours on 5 February 2019, Dr Brahmbhatt, conductedand documented a detailed mental state examination. Dr Brahmbhatt statedthat:”…I also assessed whether Sam met criteria for being placed under theMental Health Act. Sam reported suicidal ideation and a deterioration ofhis mental state over the preceding two days. He told me that while hehad experienced suicidal thoughts before, these had never been asintense. He also admitted to thoughts of jumping off a building. He wasunable to identify why his mental state had deteriorated though he didadmit to financial stress.My opinion was that he was very distressed. I was very concerned abouthis risk of harm to himself and potentially to others, and I thus plannedfor him to be transferred to the High Dependency Unit (HDU) of theinpatient unit. I also placed him under the Mental Health Act as amentally ill person. I also determined that he needed closer observation,and I hence increased his level of acuity to Care Group Level 2 (15minute observations). Whilst waiting for transfer to the HDU, I ensuredhe remained in the common area of the PECC so that he could bemonitored at all times by staff. He was administered Lorazepam andOlanzapine for agitation, and he slept for an hour on the PECC whilstawaiting transfer.”-Dr Brahmbhatt completed the certificate of assessment required to schedule anindividual and stated that he:”presents as acutely psychotic with AH’s (auditory hallucinations) andpersecutory delusions. Also voicing SI (suicidal ideations) with plan andintent 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 EmergencyDepartment confirmed her attendance at the morning handover. Ms Riva alsoconfirmed that Dr Brahmbhatt, RN Nagory and herself went to assess, andensure that Sam had not sustained any injuries from the possible act of selfharm involving his pyjama pants. RN Riva recalls discussing her sharedconcerns with RNs Nagory and Zantos.-Sam was transferred to the HDU at around 12.15 hours on 5 February 2019. Hewas not seen by a doctor at that time; however, he was assessed by the nursingstaff and received a visit from his case manager, Mr Kimber.-Between 12.30 – 13.00 hours, the Nurse Unit Manager (NUM) (3), Mr AndrewNicholls, recalls receiving a call from the MHU HDU, requesting a safety blanketfor a patient. Mr Nicholls recalls contacting the NUM (1), Ms Lauren Ashe todiscuss the circumstances relating to the request. Mr Nicholls recalls being toldby Ms Ashe that the safety blanket was being requested for Sam, after the reportof an attempted self-harm incident the evening before, being an attempt to hanghimself with his pyjamas.25-Mr Nicholls recalls discussing with Ms Ashe at that time, whether an IndividualPlacement 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 mustremain under visual observation, and at arms-length of a nurse. It wasreported to me that Sam had been reviewed by a consultant, beforetransfer, and Level 2 acuity was assessed to be appropriate. Level 2acuity, requires that a nurse must observe a patient every 15 minutes. Itis also a requirement that the nurse must engage regularly, andrandomly 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 of5 February 2019. What does appear clear, is that the medical staff at both thePECC and the HDU, were sufficiently concerned about Sam’s presentation, thatnone of the medical staff doubted the veracity of his assertions.-Given those abovementioned concerns, Sam was placed in a room on the HDUward close to a nursing station to ensure close visual monitoring. Sam appearsto have also been encouraged by the medical staff to approach them if he wasfeeling more unwell. His belongings were removed, and he was not given accessto 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 at16.05 hours. He remained with Sam until 16.50 hours.-Mr Kimber recalls the following:”…He reported feeling low, overwhelmed and hopeless, with frequentthoughts of suicide. He also described having attempted suicide while inPECC. We discussed the stressors associated with Sam’s request foran admission as well as psychological skills and a safety plan formanaging distress and risk. We also discussed reasons for living andtreatment options, to engender hope and future orientation.At the time, my impression was that Sam’s risk of suicide was high, particularlygiven his description of a recent suicide attempt and his reports of ongoingsuicidal ideation. I suspected that Sam’s recent increase in insight my havecontributed to heightened distress, despair and risk of suicide. I believed thatSam’s risk of suicide was managed via his inpatient unit admission and histransfer to HDU, with 15 minute checks from staff.”-At the conclusion of their meeting, Mr Kimber stated that he then approachedthe Nurse’s station in HDU and spoke with Ms Kerry Foley, RN. He stated thathe relayed some physical health concerns that Sam had mentioned to him; aswell as the need to explore the issue of administering anti-depressionmedication at future medical reviews. In Ms Foley’s statement, she does notrefer to this conversation.-In Ms Foley’s statement, she describes her earlier interactions on 5 February2019 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, Samappeared to be:”…more reactive, his mood seemed brighter, eye contact was improvedand Sam was less isolative, spending time in common areas andinteracting 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 hadclosed his door. Mr Gunter indicated that Sam had told him he had closed thedoor to his room as it was “noisy”. Mr Gunter stated that he had asked Sam ifhe had any suicidal thoughts and Sam told him that he didn’t. Mr Gunter toldSam that he needed to keep his door open. Mr Gunter stated that he noticed thedoor shut again. In addition, he stated that he heard other nursing staff speakingwith 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 roomarea.85.Mr Gunter recalls seeing Sam’s door shut again at 18.00 hours. He stated thathe was aware that his 15 minute observation was due and went to see him. Hesaw that his door was closed and that he was hanging from the door. Mr Gunterattempted to force the door open, however, was unable to open the door.Mr Taylor Clancy, an Enrolled Nurse (EN) appeared and forcefully kicked thedoor open and Sam fell to the ground. The noose, fashioned from his pyjamapants, fell away from his neck. Mr Gunter, Mr Clancy and Ms Foley immediatelycommenced 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 thenotification at 20.30 hours. The officer in charge of the investigation, Leading28 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 1.16Senior 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 numberof items had been cleaned away. LSC Smith was advised that this had beendone to reduce the distress to other patients. Police were able to confirm thatthe second room had been secured and locked by Hospital security guards priorto the arrival of police, but only after Sam had been moved. S: 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 Conduct2.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 inhad followed their duty of care, do you think the outcome of their case would have changed?6.If the EN inhad 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.Health Science Science Nursing NR- 506
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