Patient Safety: Analysis of Coroner’s Case

Running head: PATIENT SAFETY ASSIGNMENT
Patient safety assignment
Name of the student:
Name of the university:
Author note:

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PATIENT SAFETY ASSIGNMENT
Table of Contents
Section 1: Patient Safety: Analysis of Coroner’s case:..............................................................2
Section 2: Tort of negligence:....................................................................................................5
Section 3: Person-centred care: Ethics:......................................................................................6
References..................................................................................................................................8

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PATIENT SAFETY ASSIGNMENT
Section 1: Patient Safety: Analysis of Coroner’s case:
Patient safety is undoubtedly one of the greatest concerns facing the health care
industry and there are plethora of challenges that can facilitate any error in the medical care
delivery and can jeopardizes the patient safety. This assignment will shed light on the fatally
detrimental impact that negligence of patient safety can lead to in a care scenario, taking the
assistance of the case study of the Coroners case. This case study focuses on Christopher
Hammet, a healthy patient who had to suffer an untimely death due to the errors committed
by the health care professionals. Elaborating the case study, Christopher Hammet is a healthy
man from gold coast who had visited the health care facility for minor care reasons and the
impact led to the healthy man to have an untimely death. Elaborating more on the case study,
this 41 year old man had visited the health care facility for in April 2005 for an elective L5-
S1 disc replacement operation in the Pacific Private Hospital (then owned by Nova Health
Pty Ltd) in Southport. The errors in the health care delivery scenario involved limited and
presumably inadequate administration of pain relief \to the patients while in the operation
theatre. Along with that, the coroner assessment of the issues associated with the factors that
led to the dearth of Christopher Hammet also involved very poor decision making in the night
shift nurses when managing his low oxygen saturation levels in the patient as well.
It has to be mentioned in this context that post the operation the oxygen saturation
level of the patient continued dropping, and as a result of continued negligence and
incompetency of the nursing staff no proper and adequate measures had been to ensure that
the dropping oxygen saturation levels are managed and controlled to avoid any fatal risks to
the patient. This indicates at not just lapse of professional code of conduct of the health care
professionals caring for Christopher, however, this also indicates at the extreme unethical
practices of the facility as well. Elaborating further, it has to be mentioned in this context that
the oxygen levels of Christopher had dropped suddenly to 64 from 99 % while he was

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PATIENT SAFETY ASSIGNMENT
transferred from the operating theatre to the Post anaesthetic care unit and within very small
period of time his oxygen saturation levels again hiked to 80% while in the Post anaesthetic
care unit. This indicates at high levels of discontinuity and lack of stability in his vital signs
which can be an indicative sign of sepsis which was needed to be adequately assessed and
addressed by a medical practitioner at the earliest.
However, the coroner analysis report suggests that Mr. Hammet was only
administered two doses of morphine of 2 mg each during this time without any doctor ever
visiting him or investigating his fluctuating oxygen saturation level. Further investigation also
revealed that the registered nurse of the corresponding ward was not even informed of the
desaturation that the patient suffered before he was transferred which put him to massive risk
due to the negligence of the shift nurses. Furthermore, the registered nurse then
inappropriately took it upon himself to diagnose Mr Hammett's low oxygen saturations as
being a combination of sleep apnoea and the use of morphine and just increased the flow of
oxygen to combat the low saturation levels which was another massive error in clinical
decision making, which not only didn’t address the issues that the patient had been suffering
from but also exacerbated his current issues. Therefore, as per the nursing theories of card
and clinical decision making, not just the shift nurses, the head RN had also been associated
with errors in clinical decision making with respect to the scenario and lack of adhering to
professional standards of practice in accordance to patient assessment in the post-surgical
recovery unit.
The coroner analysis report suggests that even though the patient condition had been
deteriorating, the registered nurse Dean Manton had showed no signs of competent and
ethical engagement to the profession and had taken no steps to ensure safe and effective care
to be provided to the patient, which is one of the fundamental professional standard for the
care delivery for the nurses. Manton never informed Dr Woller about the condition of the Mr