Portfolio Activity: Coroners Analysis - Report Example

On Monday, September 1, Mrs. Herbert arranged an urgent appointment with Dr. Rodney Kurtzer when she got worse after a night where she had not been feeling particularly well. Her major complaint was that she was cold, shivering, had muscular aches and pains and her migraines were acting up. Dr. Kurtzer diagnosed bacterial tonsillitis, which she had presented with previously from time to time. He took a swab of the tonsillar exudates for culture and administered intramuscular cilicaine. He prescribed oral penicillin with instructions to take one 500mg capsule four times daily and also recommended Ibuprofen 400mg one tablet four times daily with food to help reduce the pain and swelling associated with tonsillitis. Later that night she reported to her husband that she felt a headache and sore throat. On the next day which was Tuesday, September 2, Mrs Herbert was still feeling unwell and efforts to secure a home consult were futile due to the Dr. Kurtzer’s busy schedule and she was not attended to until 6.30pm. At this consult, she complained of headache, nausea and vomiting although the doctor thought she looked better than when she saw her last. After examination, the doctor found that the tonsils were not as inflamed as before but were still prominent. He observed a ‘thick tonsillar membrane’ which pointed towards the fact that she may have been suffering from glandular fever which was later confirmed. Dr. Kurtzer considered that her migraine had increased as a result of a combination of the severe tonsilitis and glandular fever. He decided to administer intramuscular morphine and in doing so claims to have ruled out any known contraindictions for its administration including any restriction to her upper airway. By 12:30am, she was vomiting and her migraines were back. Without expounding on the status of her headache, he ordered hospitalization and a second dose of morphine. At 3:15am when one of the nurses was doing the rounds, she noticed Mrs. Herbert lying face down, face in the pillow and she was not breathing. As at this time, Mrs. Herbert was dead. A coroner is an officer of the government who validates and certifies the demise of a person within a given jurisdiction. The coroner in this case, Elizabeth Ann Sheppard, was in charge of the inquest into the death of Raelene Vicki Herbert aged 29years. When the coroner examined the body, she ascertained that she was feverish, the lymph nodes in the neck were inflamed and she had pus or exudates on both tonsils. Of the medication that Dr. Kurtzer had prescribed, there was insufficient evidence to determine how many if any ibuprofen tabs or penhexal capsules she had took. The Dr. did not make any inquiry to establish whether, and which oral analgesia had been ingested during the day and what relief had been obtained from it. This he attributed to the fact that on previous occasions she had stated that oral analgesia prescribed to deal with her migraine headaches were generally ineffective. According Dr. Kurtzer the home visit request by Mrs. Herbert was bizarre since she had known her to be a fairly stoic patient with an elevated pain threshold. This made him take the complaints more seriously than he might otherwise have done. Mrs. Herbert had never been given morphine before and was regarded as “morphine-naïve” and therefore more vulnerable to adverse side effects of morphine such as respiratory depression, than in a person who had developed tolerance having received the drug previously. Dr. Kurtzer had an obligation to inform Mr. and Mrs. Herbert of all the aspects of their clinical management which included the possible adverse side effects of the narcotic which he didn’t. (Good Medical Practice: A Code of Conduct for Doctors in Australia. 2009) When Mr. Herbert called Dr Kurtzer to inform him of his wife’s continuous deterioration of health, the doctor agreed that she should be admitted into hospital. Mrs Herbert was vomiting and was still crook. The doctor didn’t question Mrs. Herbert on how she reacted to the first dose of morphine. He didn’t get to know whether in fact, the major problem was vomiting, rather than headache. The Dr. Was overworked as he was the only medical practitioner in Cleve and as to this was not there in person during the administration of the second dose, so he couldn’t check her throat or make an assessment of her general condition. This is partly due to the shortage of medical practitioners in the regional areas of South Australia. (Australian Journal of Rural Health) The Australian Department of Health and Ageing supports the view that there is a shortage of general practitioners and affirms that most rural and regional areas and numerous outer metropolitan areas are considered to be the districts of workforce shortage for General Practitioners. (Australian Department of Health and Ageing, 2005) It is a well-documented fact that rural Australians have poorer access to medical services than their urban counterparts, as in the U.S., Canada and Britain (Ellsbury, Doescher & Hart, 2000; Wilkinson, 2000). In reference to the administration of the second dose of morphine, the coroner was of the opinion that if Dr. Kurtzer had consulted the Monthly Index of Medical Specialities (M I M S), he would have realized that the maximum normal dose for adults was 20mg and was calculated in reference to age and not to weight as he had done. It is a medical practitioners and nurse’s responsibility to maintain proficiency essential to perform his/her duties according to current practice (A N M C 2006). Preservation of this competence is achieved through participation in constant professional advancement which also serves to develop knowledge and skills pertinent in the medical profession. As required by the Code of Conduct for Doctors in Australia, Dr. Kurtzer did not give instructions to the nurses about the need to make and document any more detailed observations or any adverse effects of morphine which the nurses were to look out for. As a medical practitioner, Dr. Kurtzer has an obligation to always communicate adequate information about the patient and the treatment they require and in so doing enabling the continuing care of the patient. (Good Medical Practice: A Code of Conduct for Doctors in Australia. 2009) When Dr. Kurtzer called the hospital to give the order, the nurse who took it (Nurse Darling) claims to have passed on the phone to another nurse, Nurse Price, for confirmation of the order in accordance with common practice for telephone drug orders. This was later found to have been a false statement. In light of this, the process of drawing up the morphine and administration of the drug was actually witnessed and documented in accordance with the required procedure for drugs of dependence. During admission, Nurse Darling, who undertook the admission process claimed to have weighed Mrs Herbert during the admission process but did not make any records in that regard (Hull, R.T. 1980) There is paperwork that is required to be filled for admission to hospital and apart from recording a set of observations, the normal forms required to be filled out for admission purposes were largely left blank. Precise record keeping and careful documentation is a critical part of the nursing practice. The Nursing and Midwifery Council (N M C 2002) state that ‘good record keeping helps to protect the welfare of patients and clients’ – which of course is a basic aim for nurses the world over. According to the Nursing and Midwifery Council guidelines (N M C 2002) a nurses’ record keeping and documentation should express a full account of the patients’ assessment and the care intended and given and also a confirmation of any arrangement made for the continuing care of a patient or client. (Nursing and Midwifery Council guidelines, 2002) According to the testimonies given and the evidence collected during the inquiry, it is evident that Nurse Darling and Nurse Price ignored these basic nursing procedures. According to Nurse Darling, she witnessed Nurse Price draw up and administer the morphine and Stemetil as ordered by Dr Kurtzer. Both nurses did not consider that the 30mg dose of morphine might be in excess. Although they both had little knowledge or experience with morphine. The nurses were required to ensure that the patient obtains safe, superior quality, effective and ethical care (Australian Nursing and Midwifery Council 2006). It is a nurse’s responsibility to uphold competence required to perform his/her duties according to current practice (Australian Nursing and Midwifery Council 2008). In this case, the two nurses could have easily consulted the Monthly Index of Medical Specialities (M I M S) which is freely available to all medical practitioners for free. With this simple act of proactive character from one of the nurses, Mrs Herbert’s life could have been saved. A nurse's interaction with a patient is far more comprehensive and personal, focusing on values and the restorative processes. Some professionals refer to this as the nurse's "ever-presence," that is, they are there, 24 hours a day, 7 days a week, offering bedside care (Breier-Mackie, 2001). It is through this notion of "ever-presence" that nurse’s ethic of care differs from that of medicine, and that has a lot to do with the credulous relationships that are built with their patients with whom they are deemed to spend so much time. Practicing in a safe and proficient manner is very imperative in the nursing profession as the recipients of the health care are vulnerable persons who call for the best care they can get. Identifying sudden changes in a patient’s condition of health and implementing instantaneous and appropriate interventions could be a matter of life and death and for that reason safe practice and current competency is very essential (Australian Nursing and Midwifery Council 2006) Nurse Price and Nurse Darling overlooked these basic nursing values. They did not have a proper system of knowing who was going to check on the patients at any given time although they had agreed on a four-hourly observation of the patient. This caused an overlap and it took them two and a half hours before any of them made the rounds and by the time they did that it was too late for Mrs Herbert. When Nurse Price finally got around to Mrs Herbert’s room, she was lying immobile, face down and she was not breathing. She immediately alerted Nurse Darling who responded quickly and they initiated resuscitation measures which were in vain. For a 29-year-old woman, the recommended intramuscular dose is within 7.5-15 mg (Australian Medicine Handbook. 2003) which can be re-administered after two hours, depending on the patient’s response. The dose is adjusted according to the response, so these patients need to be observed more often than four-hourly. The post mortem examination was conducted by forensic pathologist, Professor Roger Byard on 4th September at the forensic science centre. The professor was unable to estimate the time of death. A blood sample obtained at post mortem and subsequently examined confirmed that Mrs Herbert was indeed suffering from glandular fever at the time of death. After the death of Mrs Herbert, toxicologist, Donald Sims acknowledged a level of morphine calculated as 0.16mg per litre in her blood. There is an overlap involving the remedial and lethal concentrations of morphine (Acute pain management: scientific evidence. 2nd ed. 2005) In essence, even though 0.16 mg/L is well within the therapeutic range, this concentration was too high for morphine naive person (Macintyre PE, Schug SA. 2007) In Mrs Herbert’s case, the levels were adequate to stifle respiration and cause respiratory arrest. In professor Bochner’s experienced opinion, the cause of death was “respiratory depression caused by morphine intoxication on a background of upper airways narrowing which was a consequence of infectious mononucleosis” The administration of supplementary medications such as metoclopramide (Maxolon) and prochlorperazine (Stemetil), according to professor Bochner, increased the potential sedative effect of morphine and as a result increased the risk of respiratory depression. In this case, there is a clear suggestion that there is a gap between the demand and supply of health practitioners as well as cultural competency amongst them. Studies have shown that as more culturally competent service providers enter the workforce, the communities they serve will benefit (Smith, 1998, cited by Kim-Godwin, 2001) and the organisations they work in can provide more rewarding work experiences (Paez, Allen, Carson, & Cooper, 2008). This is very true in this case as it is very evident that Dr. Kurtzer was heavily burdened by the large number of patients that he had to attend to. Cultural competency can be described as harmonious behaviours, attitudes, and policies that coalesce in a among professionals and enables those professionals to vocation efficiently in cross-cultural situations (Thomson, N. 2005) Professionals in the medical field have addressed collaboration among the general practitioners and the nurses, undertaking a notion analysis to produce operational definitions of the term and provide the basis for tool development and evaluation. (Henneman et al. 1995) They identified defining attributes such as shared authority based on knowledge or expertise as opposed to role or occupation, and non-hierarchical relationships. More behaviours that characterise autonomy were listed as follows: knowledge of up to date trends and issues in their respective fields; meeting in collective activity with other professionals to develop patient care and advance the profession; proficiency in both medically independent and medically dependent patient related activities; assertiveness in making the first move, documenting and expressing nursing actions and their outcomes and eagerness to take risks on the patient’s behalf or to safeguard the integrity of the profession (Taylor 2002) If the two groups hold on to this type of approach, it is expected to lead to enhanced patient outcomes in the form of decline in mortality. If the two nurses had shown initiative as described above, the outcome of this case would have been different. Findings from studies on ethical decision making conducted in Western Australia (Le Sueur & Barnard, 1993), South Australia (Willis et al., 2000), Victoria (Bonawit & Watson, 1996; Keyzer et al., 1996) and Queensland (Patterson et al., 1999a) demonstrate that, to date, the Practicing Nurse’s role has been mainly that of assistant to the General Practitioner to make possible the efficient running of the practice. The practising nurse performs this role in three ways: one, by undertaking fundamental physical evaluation tasks to assist the medical diagnosis; two, by performing delegated therapeutic actions to facilitate management of the medical condition, and three, by contributing to the clerical functioning of the practice. The practising nurse emerges to be primarily task or condition oriented and dependent on medical delegation. Greater awareness can be helpful in empowering nurses to make every effort for an enhanced role if they choose and this will lead to greater accountability and involvement of nurses in the treating process. In reference to this particular case, the nurses would have been in a position to question the doctors’ prescriptions and possibly save a life. The coroners’ recommendations to the Minister of Health are very practical and in fact should have been implemented a long time ago. Nurses are required to be up to date with developments relevant to their field of operation which is patient safety and welfare. The discrepancy in the practice between large hospitals and smaller regional hospitals should be done away with so as to promote high medical standards for all. The Royal Adelaide Hospital guidelines for the administration of intermittent subcutaneous and intravenous opioids for the management of acute pain should also be readily available to all health practitioners so as to reduce the likelihood of or even completely avoid similar cases in the future. REFERENCES: Analysis by state and territory using census data’, Australian Journal of Rural Health Australian Nursing and Midwifery Council (2008) code of ethics for nurses in Australia Australian Nursing and Midwifery Council (2006) code of professional conduct for nurses in Australia Australian Department of Health and Ageing (2005) ‘Health Workforce Definition’ Australian and New Zealand College of Anaesthetists and Faculty of Pain Medicine. Acute pain management: scientific evidence. 2nd ed. 2005 Australian Medicine Handbook, 2003 Breier-Mackie, S. (2001) Patient autonomy and medical paternity: Can nurses help doctors listen to patients? Ellsbury, K. E., Doescher, M. P. and Hart, L. G. (2000) ‘US medical schools and the rural Family physician gender gap’, Family Medicine Good Medical Practice: A Code of Conduct for Doctors in Australia (2009) Hull, R.T. (1980). Defining nursing ethics apart from medical ethics Kim-Godwin, Y. S., Clarke, P. N., & Barton, L. (2001) A model for the delivery of Culturally competent community care. Journal of Advanced Nursing Macintyre PE, Schug SA. Acute pain management: a practical guide. 3rd ed. Edinburgh: Elsevier Saunders; 2007. Paez, K. A., Allen, J. K., Carson, K. A., & Cooper, L. A. (2008) Provider and clinic cultural competence in a primary care setting. Social Science & Medicine Thomson, N. (2005). Cultural respect and related concepts: a brief summary of the literature. Ruth Terwijn (2010) Core values -Responsible nursing practice Wilkinson, D. (2000) ‘Inequitable distribution of general practitioners in Australia: Australian Indigenous Health Bulletin Read More