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Critical Analysis of Statement Related to Caring for Mr. Roy Jacob

This paper presents a critical analysis of the Coroner’s statement “while aspects of his care were suboptimal, no one individual was responsible for these failings; rather a cascading sequence of events led up to his sudden and unexpected death.” This statement is analyzed in relation to the communications or conversations held between the inter-professional team and the Registered Nurse’s accountability within their practice scope, while providing care to Mr. Roy Jacob. The areas covered in this paper are presenting concerns that result in issues in accountability and communication, missed opportunities and gaps in the care provided and communication involved, relevance of missed opportunities and gaps in relation to the nursing communication and the accountability exhibited or that should have been exhibited by the nurse, and suitable approaches to risk mitigate missed opportunities found in the case.

Presenting Concerns that Result in Issues in Accountability and Therapeutic Communication

Accountability and therapeutic communication play a significant role when it comes to ensuring patients’ wellbeing and safety. Miller et al. (2018) define accountability as being able to provide an account of an individual’s nursing omissions, actions, and judgments. Accountability involves the maintenance of competency and protecting quality outcomes of patient care and professional standards, while remaining answerable to individuals impacted by a person’s nursing practice. Therapeutic communication is associated with showing warmth and empathy to assist a patient to feel secure and relaxed (Mc Cabe, & Timmins 2013). The cultivation of therapeutic relationship is accomplished by employing questioning and listening techniques along with giving support, providing information, and ensuring care. For accountability to exist, there should be trust, and trust is established by engaging in honest dialogue characterized by respectful conversation and engagement. As such, it can be noted that accountability and therapeutic communication bear a robust association. The relationship between therapeutic communication and accountability lies in the fact that therapeutic communication offers a setting of respectful communication and engagement, which in turn lead to the realisation of accountability.

In the case of Mr. Roy Jacob, there exists a cascading sequence of events or key presenting concerns that resulted in accountability and communication issues, which in turn led to Roy’s sudden and unexpected demise. These concerns were the inability of RN Monaghan to observe Roy’s behavior after a handover from Nurse B, inability of RN Monaghan to maintain Roy’s medical history and monitor changes in the patient’s condition, the failure of RN Monaghan to follow up on Roy’s review by Dr Maja, RN Monaghan calling Nurse C to assist him in the emergency department and leaving Roy without someone to monitor him, RN Monaghan’s failure to undertake appropriate actions following a deterioration in the Q-ADDS score of Roy at 12:15 am, failure of RN Monaghan to take appropriate measure after being notified of Roy’s Q-ADDS score of 6 at 1:50 am, and RN Monaghan ordering Nurse C to initiate nebulised Ventolin at 4:30 without assessing Roy (Coroners Court of Queensland, 2018). As such, from these presented concerns, it can be noted that a cascading sequence of issues resulted in Roy’s sudden and unanticipated death.

Missed Opportunities and Gaps in the Care Provided and Communication Involved

There exist several gaps and missed opportunities in the case, which justify the argument that Roy’s sudden and unanticipated death was attributed to a cascading series of events. The first missed opportunity occurred when RN Monaghan did not proceed to observe and record Roy’s behavior even after being notified of the patient’s elevated Q-ADDS score by Nurse B. This event occurred after the registered nurse had received the shift handover from Nurse B (Coroners Court of Queensland, 2018). The second missed opportunity or gap in patient care transpired when RN Monaghan failed to inquire from Nurse B the reason for leaving the section of frequency of observations blank. Such an inquiry would have enabled the RN to establish that Nurse B had embraced this action because Roy’s score of Q-ADDs at that moment called for observations to be carried out at least half-hourly.

The third missed opportunity transpired when RN Monaghan failed to follow up with Dr. Maja on Roy’s review. The fourth gap in patient care occurred when RN Monaghan called Nurse B to assist him in the emergency department, thereby leaving Roy without a nurse to monitor his condition. The fifth missed opportunity occurred when RN Monaghan failed to consider whether Roy had been seen by Dr Maja despite the RN establishing that the patient’s Q-ADDS score was 7 at 12:15 am. The sixth missed opportunity occurred when RN Monaghan failed to communicate with Dr. Maja about Roy’s Q-ADDS score drop to 6 from 7. The seventh in patient care existed in the failure of RN Monaghan to review Roy prior to ordering for the administration of nebulized Ventolin at 4:30 am.

Relevance of Missed Opportunities and Gaps in Relation to the Nursing Communication and Accountability

Nursing communication and accountability play a significant role in preventing and eliminating risks in patient care (Zittel et al., 2016; Miller et al., 2018). In relation to this, the missed opportunities and gaps in the case bear a significant relevance to nursing communication and accountability. Dellefield et al. (2015) assert that a registered nurse in charge of maintaining reports associated with patients’ medical histories and observing changes in their conditions. In relation to the first missed opportunity, RN Monaghan could have proceeded to observe and record Roy’s behavior even after being notified of the patient’s elevated Q-ADDS score by Nurse B prior to resuming his responsibilities in the emergency department. Such an undertaking could have enabled the RN to identify any development in Roy’s condition and embrace appropriate measures such as calling for Dr. Maja’s assistance.

According to Lubbe and Roets (2014), the registered nurse’s scope of practice provides for the responsibility of monitoring every aspect of patient care including physical activity and proper diet. In relation to the second missed opportunity, RN Monaghan should have focused on the maintenance of Roy’s medical history and monitor changes in his condition. There was no accountability on the nurse practitioner, who had placed Roy on a non-rebreather mask even though he had been on an oxygen face mask. As such, Roy’s Q-ADDS score stayed at 7 for next one hour (Coroners Court of Queensland, 2018).  By monitoring Roy’s care, the RN could have established the nurse, who placed the patient on a non-rebreather and the reason for the patient’s Q-ADDS being constant at 7. In relation to the third missed opportunity, RN Monaghan could have communicated with Dr. Maja about Roy’s review, as the team leader. The RN should have followed up with the doctor on the patient’s review, as opposed to assuming that the physician could perform the review.

In relation to the fourth missed opportunity, RN Monaghan should have called EN Allen to help him in the emergency department and not Nurse C. The handover was made to RN Monaghan and Nurse C, and not EN Allen. As such, Nurse C was aware of Roy’s condition including the patient’s observation frequency, which was not known by EN Allen. As such, by calling Nurse C to help him in the emergency department, RN Monaghan left Roy under the care or observation of a nurse practitioner, who was not informed of the developments in the patient’s condition.

In relation to the missed opportunity five, RN Monaghan should have considered whether Dr. Maja had reviewed Roy after noting that the patient’s Q-ADDS score was 7 at 12:15 am. Such an undertaking could have resulted in the optimisation of Roy’s care with medical review and reassessment of the patient’s management plan. When it comes to the sixth missed opportunity, the RN should have consulted Dr. Maja concerning the drop of Roy’s Q-ADDS to 6 from 7, as opposed to assuming that this score signified an improvement in the patient’s condition. Such an undertaking could have triggered a 30-minute review interval of the patient as demanded by a Q-ADDS 6-7 (Coroners Court of Queensland, 2018). As a result, the patient’s condition could have been revivified.

Dellefield et al. (2015) assert that the scope of practice of a registered nurse requires him or her change the medication of the patient as indicated by the patient’s responses and conditions. In relation to the seventh missed opportunity, RN Monaghan should have executed a clinical assessment on Roy prior to ordering Nurse C to administer nebulised Ventolin after the patient’s was established to be 6. Such an undertaking could have enabled the RN to reassess the patient’s condition without introducing a medical review.  As such, from these missed opportunities, it can be argued that a series of events resulted in Roy’s sudden and unanticipated demise.

Suitable Approaches to Risk Mitigate Missed Opportunities Found in the Case

Risk mitigation approaches in nursing include accept, avoid, control, transfer, and monitor. Accept involves the embracement of the risky event’s management followed by planning for response (Beardwood & Kainer, 2015). Avoid refers to an attempt to completely eliminate or prevent the risk event (Beardwood & Kainer, 2015). Control involves the management of the event after the risk analysis. Transfer is associated with the release of the obligation a different entity. Monitor focuses on the establishment of a plan and observation of changes.

Following Roy’s incident, the organisation should focus on embracing accept and control approaches to risk mitigation. In relation to this, strategies should be embraced to risk mitigate missed opportunities established within the case. These measures are subjecting nurse practitioners to a 2-week training program on therapeutic communication within the healthcare setting, and implementation of a training program on all nurse practitioners including the RN on best practices such as using the Q-ADDS and its significance, and developing robust policies and penalties in relation to patient monitoring. Moreover, handover should be subjected to restructuring to that is develops opportunities to cross-examine the information in relation to many information sources, as recommended by Drach‐Zahavy et al. (2015). During handover, the organisation should devote special time to reading or perusing written notes and reports, particularly when outgoing nurse practitioners are accessible via telephone or email, or are still on the ward, as suggested by Kaya et al. (2019). Moreover, team discussions within the organisation should focus on the achievement of agreement concerning the manner and order of delivering succinct information and expediting trust and understanding among nurses, as suggested by Drach‐Zahavy et al. (2015).

In conclusion, this paper has critically analysed the “while aspects of his care were suboptimal, no one individual was responsible for these failings; rather a cascading sequence of events led up to his sudden and unexpected death” by focusing on the case of Roy. Embracing the measures recommended in this paper will contribute significantly to mitigating the risk associated with the missed opportunities in the case.