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Coroner's Report

Introduction to Finding of Inquest

A coroner’s inquest is a legal quasi- judicial proceeding in which the inquest is called into the manner or cause of death to investigate the cause of unexplained or sudden death (Akhtar 2019). This is an inquisitorial process in which the facts and circumstances are aired publically for a certain case (Martin 2019). It investigates the case of care that was being given to the deceased person and ensures that the medical health professionals complied by their duty by fulfilling the legal, ethical and professional standards (Binns and Arnold 2019). The coroner recommends the health ministry to note the findings and endorse the recommendations to prevent death under similar circumstances.

This assessment is based on the review of the coroner’s report that is based on the case of Mrs. Ballard a 74 year old lady who died on 2 January’ 2009. This assessment aims to provide a brief summary of the case along with the coroner’s findings of the case on relation to the death of Mrs. Ballard. A discussion will be presented on the nursing and medical practice in context of documentation and communication, ethical decision- making of health care professionals, advocacy, leadership and management and organisational culture. The last section of this assessment will provide a critique literature on the manner in which this death could have been prevented if certain measures were taken.

Summary of The Coroner’s Findings

Mrs. Ballard is a 74 year old woman who died on 2 January 2009 at Glenside hospital due to the reason of having aspiration of gastro- intestinal contents. These contents were the result of small bowel obstruction due to small bowel torsion. She had a history of major depression and was a patient with Alzheimer’s dementia. Her mental health was extremely affected and she was experiencing hallucinations and this added to her worsening health condition. Many alterations were made in her medication regime to address the symptoms. She was admitted in the Emergency Department and was triaged as a category three and the vitals were checked. At the time of admission she did not have abdominal pain and the major point of concern is that the doctor relied on the patient’s ability to provide a clear history. She has extreme mental health conditions and most of the times she feels heavy headed. She denied of any kind of pain in her abdomen or head. On the examination of past medical history the doctor learnt about Alzheimer’s dementia, hearing impairment and hypothyroidism. Her medications were also reviewed by the doctor.

Followed this procedure, an examination was made and blood tests were taken. The results of blood tests stated that only sodium and chloride were the electrolytes were not in normal limits and transient bradycardia and hypotension. As per the doctor, the symptoms that were described by the patient were considered as the symptoms of gastroenteritis and this might have resulted in the mild dehydration and hypovolemia. The patient Mrs. Ballard was shifted to another hospital few hours after being admitted to ED because she said that she feels better and as per the doctor she only has dehydration so he advised for her to increase the oral fluid intake. At Glenside hospital she refused to eat anything and felt cold. She then had a very small amount for dinner and slept. That midnight she vomited thrice and was also reported to be mobilizing and wandering to other patient’s rooms. Following the morning of 2 January, Dr. Lawrence who is a psychiatric registrar documented that her mental health is getting worse and his observations were that she has no loose stools and abdominal pain. No action was taken when the patient repeatedly vomited for two times that day and no medical review was performed. Finally at 10 pm she was found collapsed in the corridor and she became unresponsive but she had aspirated gastric contents and suffered a cardiac arrest and she died.

Documentation and Communication

Effective communication and documentation are two most essential part of the nurses and medical health care’s duty and responsibility. It ensures the flow of information that is safe and also ensures the patient safety (Halvorsen et al. 2016). In medical health care, the patient related information must be always effectively communicated through verbal and non- verbal cues and must be documented at every step because it acts as a source of written communication (Fakhr- Movahedi 2011). It serves as a purpose of transmission of the information among different health care workers and this smooth transmission of information is important for patient safety. In this case, when the patient Mrs. Ballard was shifted to the Royal Adelaide Hospital the doctor ineffectively communicated using the transfer letter that only mentioned about the unconscious collapse. This was an ineffective communication because the patient complained of the right- sided abdominal pain before the transfer and after the arrival in ED the triage nurse recorded no pain (Morris and Fernandez 2019). This is the example of ineffective communication in which the doctor failed to communicate with the medical staff of another hospital setting. This increases the risk of medical errors and patient’s safety is at risk. This is because even if the patient said that she has no pain in abdomen but the previous hospital’s doctors transfer letter would serve as the basis for further medical investigations for the cause of unconscious collapse.

Documentation of every vital check, medical information and history of the patient is important so that the medical health professional on shift can use it for reference (Tajabadi et al. 2019). The second error made by the medical health professional was by Dr. Bruce that he did not documented his examination results when the patient was there for 4 hours in ED and he arranged an ambulance to send her back only with one advice that she must increase her fluid intake. This created a lot of confusion and misunderstanding as further tests were not performed by this hospital staff.

Ethical Decision Making

The ethical decision making power is in the hands of health care professional and the patient’s safety is based on it (Lanzel et al. 2017). They must be competent in ethical decision making and the ethical competency must be checked before they address the patient (Ruppert 2017). Ethical decision making must always be done by the highly competent decision maker and the complicated cases must always be attended by the senior doctors who have a great experience of similar ethical issues. In this case, the patient Mrs. Ballard was attended by the emergency medicine trainee. There are six basic steps that complete the model of ethical decision making. These steps that helps in better performance are the identification of an ethical issue, the collection of extra information so that the problem can be identified and the solutions can be developed, development of alternatives for analysis and comparison, the selection of best alternatives and justification and the last step is the evaluation of the effects and development of strategies that prevent the occurrence of similar situation (Park 2012).

Identification of An Ethical Issue

The main ethical issue identified in this case is that no consent was drawn from the patient or any family member while performing the care tasks on the patient. The doctor at ED was a trainee and he practice out of his scope of practice and did not look at handover documents. The medical history was not given much importance and the actions were taken as per the presenting symptoms. He found the result in compliance with vaso vagal syncopal and he did not perform any other tests to learn about the patient’s condition. There is no evidence of obtaining informed consent in this case. The lack of comprehensive medical examination and the documentation led to this condition.

Collection of Additional Information and Development of Solutions

The health care professional failed to work in compliance with the ethical principle of non- maleficence. The report states that ED;s sub- optimal medical assessments has led to this condition because the doctor was a medicine trainee. A sub- optimal medical review was undertaken of a patient with physical illness in the mental health setting.

Development of Alternatives for Analysis and Comparison

The alternatives are developed that assist in analysis and comparison of the situation

Alternative 1: Disclose the case with the hospital staff about the error made by Dr. Bruce so that they can learn to practice within their scope of practice

Alternative 2: To disclose the complications that occurred after the examination and actions taken by Dr. Bruce

Alternative 3: To disclose the action of not communicating and documenting the condition of Mrs. Ballard to the doctor of ED in the form of handover

Best Alternative and Justification

The best alternative is the one in which the patient and the family members are satisfied with the medical health care professional’s ethical decision. If the history of Alzheimer’s dementia and hypothyroidism was taken into account then the doctor must have carried out other investigational tests to learn about the pathophysiology for the symptoms. The lack of comprehensive medical examination and the documentation led to this condition. The best alternative is to disclose the case with each medical health professional so that they put into practice the essential elements of care that is to be given when the patient arrives in ED. This patient’s history was not considered.

Development of Strategies to Implement Ethical Decisions and Actions

The best strategy development for this case is that the educational programs must be facilitated for all the medical staff members, physicians and all so that they can develop competent skills to make ethical decisions (Petterson et al. 2018).

Development of Strategies to Prevent Similar Occurrence

This strategy can also be used to prevent the occurrence of similar situation as when the health care professionals’ competency skills will be developed they will make better ethical decisions that will benefit the patient (Creamer and Austin 2017).


Advocacy in nursing is the capability of the nurses in which they advocate for the patients to protect them by speaking for them and their rights. These actions and words for the patients are based on their knowledge of patient safety and the patient’s rights (Kalaitzidis 2020). Nurses are among those medical professionals who instinctively advocate for their patients always. In this case, there was no one to advocate for the patient because no documentation was made for this patient. One of the most important part of patient care is advocacy and in this case no nurse came forward to advocate for rights of the patient and as a result of which the patient had to suffer the worst consequence (Porter-O’ Grady 2018). The allocated nurses did not perform in accordance with the nursing standards thus they also did not advocate for the patient’s rights and well- being. In this case, the two roles of nurses are mentioned.

First the role of triage nurse who recorded the well- being of the patient’s abdomen on physical examination in ED. The triage nurse then recorded the observations of the vital signs which were checked the moment she arrived in the ED. The second role of nurse was when the nurse assisted the patient in using washroom and at that time the nurse should have advocated for the patient that she should not be shifted back to the first hospital because she should be examined for at least 48 hours in the ED. The role of nurses is advocacy is important for the patient safety and for the well- being of the patient because they defend the patient’s rights and interests. Advocacy also has an advantage that it respects the patient’s autonomy and self- determination and it serves as a strong link between the health care system and the patient (Tomaschewski- Barlem et al. 2018). This also helps in making effective decision that is ethical and legal for the patient’s benefit.

Leadership and Management

Leadership is healthcare holds the paramount importance because it is a behaviour of an individual that facilitates effective communication and positive environment in the health care organisation (Weiser, Tappen and Grimley 2019). The nursing leader guides the subordinates in a manner that they focuses on the patient safety using several effective measures. The nursing leader also has a role to play in managing the things and events that takes place and demands for nursing actions and interventions. This case clearly reflects the lack of leadership and management in this particular health care organisation. There was no nursing leader as no nurse was reported to be documenting the examination results and the role of nurses in effective communication is also nowhere to be seen in this case.

The doctors also have leaders who are the senior doctors and in this case there is a lack of effective leadership and management because of which the errors were made in the context of communication, documentation, advocacy and so on. The nurse leader should have instructed and made it mandatory for all the nurses to use documentation to record the examination results so that it can be used as an effective tool of communication. The nursing leader also guides the nurses on carrying out comprehensive assessment for the patients who arrive in the ED and have complex physical- mental illness (Dyess et al. 2016). This is done under the supervision of doctors. The nurse should have carried out the comprehensive assessment for the patient under the guidance of the nursing leader so that the appropriate examination results would have resulted in patient safety.

Organisational Culture

The organisational culture of this health care setting was weak and inappropriate for the patient safety. The organisational culture of the health care setting is made of the behaviour of the medical staff members, beliefs, values and the culture of the medical health professionals working in the setting (Mannion and Davies 2018). This health care organisation lacked a good culture because there was no consistency of the health care workers working within the standards and ethics (Beardsome and McSherry 2017). This resulted in the death of Mrs. Ballard whose main reason was the negligence of the patient’s history and the lack of conduction of comprehensive assessment of the patient. The good organisation have shared values and beliefs and in this case there was no communication between the doctor and the nurse. The doctor completely relied on the patient’s description of the history and his negligence led to this result. There is lack of good leadership and management among the health care workers.

How the Deceased Individual’s Death May Have Been Prevented

Mrs. Ballard’s death may have been prevented with the effective organisational culture and effective team management. The health care setting in which the patient arrived in ED lacked good organisational culture. The death of Mrs. Ballard could have been prevented with the effective leader who would have instructed the nurse to take the vital signs upon presentation and record them carefully in the electronic health record. Then the leader must have managed to arrange a medical history and the handover from the previous hospital. The leader must have also obtained the details on the transfer letter as it only revealed a little information related to the patient’s unconscious collapse. The symptoms that the patient showed upon presentation were different. The death could have been prevented if the senior doctor must have attended the patient because this is a complex case of a dementia patient who have extreme physical illness as well.

The senior doctor must have carried out comprehensive examination assessment of the patient and this would have led to the investigation of better insight into the symptoms. The patient’s with dementia cannot be completely believed with their explanation of history because they have cognitive problem thus it is important to read the medical history of the patient. The death could have been prevented if the examination results would have informed on the patient’s health condition along with worsening mental health condition (Noyes and Barber- Westin 2019). The patient’s death could have been prevented in this manner with the effective communication with the patient, nurses and other medical staff. The use of ethical decision making in this process could have also resulted in the prevention of death of Mrs. Ballard who had severe mental and physical illness.

References for Coroner's Report

Akhtar, Z., 2019. Coroners court and directions to juries in Article 2 inquests. Journal of Forensic and Legal Medicine, 65, pp.1-4.

Beardsmore, E. and McSherry, R., 2017. Healthcare workers’ perceptions of organisational culture and the impact on the delivery of compassionate quality care. Journal of research in Nursing, 22(1-2), pp.42-56.

Binns, A. and Arnold, S., 2019. Death of a Watchdog: Reduced Coverage of Coroners’ Inquests by Local Media. Journalism Practice.

Creamer, A.M. and Austin, W., 2017. Canadian nurse practitioner core competencies identified: An opportunity to build mental health and illness skills and knowledge. The Journal for Nurse Practitioners, 13(5), pp.e231-e236.

Dyess, S.M., Sherman, R.O., Pratt, B.A. and Chiang-Hanisko, L., 2016. Growing nurse leaders: Their perspectives on nursing leadership and today’s practice environment. OJ Nursing.

Fakhr‐Movahedi, A., Salsali, M., Negharandeh, R. and Rahnavard, Z., 2011. A qualitative content analysis of nurse–patient communication in Iranian nursing. International Nursing Review, 58(2), pp.171-180.

Halvorsen, K., Eide, H.K., Sortland, K. and Almendingen, K., 2016. Documentation and communication of nutritional care for elderly hospitalized patients: perspectives of nurses and undergraduate nurses in hospitals and nursing homes. BMC Nursing, 15(1), p.70.

Kalaitzidis, E. and Jewell, P., 2020. The concept of advocacy in nursing: a critical analysis. The health Care Manager, 39(2), pp.77-84.

Lanzel, A.F., Soucie, J.M., Meeks, S.L., Sidonio, R.F., Ortmann, L. and Barrett, D.H., 2017. Ethical decision making framework in previously untreated severe hemophilia A patients. Blood, 130(Supplement 1), pp.5583-5583.

Mannion, R. and Davies, H., 2018. Understanding organisational culture for healthcare quality improvement. BMJ, 363.

Martin, P.M., 2019. Coroner inquest into ‘hospital non-attendance’management in primary care. Br Journal of General Pract, 69(681), pp.195-195.

Morris, M. and Fernandez, A., 2019. Quantity of Documentation by Nursing Students using Paper and Educational Electronic Medical Record System. Nurse Educator, 44(6), pp.293-294.

Noyes, F.R. and Barber-Westin, S., 2019. The Physician’s Comprehensive Examination for Return to Sport. In Return to Sport after ACL Reconstruction and Other Knee Operations (pp. 459-480). Springer, Cham.

Park, E-J 2012, 'An integrated ethical decision-making model for nurses', Nursing Ethics, vol. 19, no. 1, pp. 139-159.

Pettersson, M., Hedström, M. and Höglund, A.T., 2018. Ethical competence in DNR decisions–a qualitative study of Swedish physicians and nurses working in hematology and oncology care. BMC Medical Ethics, 19(1), p.63.

Porter-O'Grady, T., 2018. Leadership Advocacy. Nursing Administration Quarterly, 42(2), pp.115-122.

Ruppert, S., 2017. NU02. 03 Ethical Decision Making. Journal of Thoracic Oncology, 12(1), pp.S199-S201.

Tajabadi, A., Ahmadi, F., Sadooghi Asl, A. and Vaismoradi, M., 2019. Unsafe nursing documentation: A qualitative content analysis. Nursing Ethics, p.082.

Tomaschewski-Barlem, J.G., Lunardi, V.L., Barlem, E.L.D., Silveira, R.S., Ramos, A.M. and Santos, J.M., 2018. Actions of nurses in the exercise of patient advocacy: An integrative review. Texto Contexto-Enferm, 27(2), p. 014.

Weiss, S.A., Tappen, R.M. and Grimley, K., 2019. Essentials of nursing leadership & management. FA Davis.

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