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Coronial Law – Cause and manner of death

Inquest Into The Death Of Troy Almond

Objectives: Assignment Task 

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  1. Identify and analyse the concepts of integrated risk management as they relate to inter-professional healthcare.
  2. Demonstrate understanding of digital literacy and communication to promote and lead patient safety initiatives and wellbeing as they relate to inter-professional care.
  3. Describe and apply risk management legislation, regulations, policies, and or guidelines when making decisions.
  4. Understand and demonstrate corporate and clinical governance as it relates to quality and safety standards and the importance of leading risk mitigation in healthcare.

Overview

The importance of communication in healthcare teams is paramount. As a registered nurse our communication of cares and the evaluation of these cares is a key area of written documentation. In our current health care climate this written format is often digitalised.

The implications from the Case: Inquest into the death of Troy Almond outlines concern in relation to communication and accountability from the roles of the health professionals and the electronic documentation that was completed.

Written electronic communication ensures that all members of the health care team are aware of a person’s health status and of the relevant therapeutic interventions that are required.  The electronic documents completed as a nurse are purposeful and provide an ongoing chain in healthcare team communications.

Areas in the Inquest into the death of Troy Almond address concerns where the accountability and documentation from the registered nurse as a member of the health care team is less than desirable. There are significant areas within this case where the Coroner has highlighted concerns.

Assignment Brief

Students are to conduct a critical analysis of the case and use the literature to support the analysis. The analysis should specifically relate to the accountability and documentation provided from the Registered Nurse within their scope of practice whilst caring for Troy Almond.

Conduct The Analysis

  • The analysis should commence with a discussion surrounding electronic communication and the accountability requirements of the registered nurse.
  • Students should use examples from the case to highlight missed opportunities and areas where gaps are noted in the RN’s electronic communication and accountability.
  • Students must address the relevance of these areas as it relates to nursing communication both electronically and verbally and the accountability that the nurse exhibits or should have exhibited in these interactions.
  • The analysis should include a rationale as to why early warning tools and documentation policies-For example CEWT (Between the Flags in NSW) are specifically important in caring for paediatric patients.
  • Discuss how escalation systems –Ryan’s Rule (REACH in NSW) specifically pertaining to paediatrics can be applied and implemented into RN practice.
  • Students must provide a synopsis of suitable strategies to risk mitigate missed opportunities for communication & accountability found in the Case.
  • Students need to demonstrate synthesis of published material with the student’s own analysis to demonstrate appropriate conclusions. The analysis must be supported by relevant and contemporary literature including journal articles and relevant policy documents. It is expected that a minimum of 8 journal articles will be used.