Critical Analysis of Jacob's Death: A NUR3201 Case Study Assignment

This case study critically analyzes the unexpected death of Mr. Roy Rodney Jacob, a 48-year-old Aboriginal man, at Cherbourg Hospital, highlighting crucial communication failures within the healthcare setting. The assignment investigates issues of missed diagnosis, the inability to recognize clinical deterioration, and the lack of adherence to clinical protocols, particularly focusing on the roles of nurses and physicians. The analysis emphasizes the importance of therapeutic communication, professional competency, and accountability in preventing medical errors. It examines breaches of nursing standards, inadequate knowledge of equipment, and insufficient documentation, leading to a discussion of risk mitigation strategies, including comprehensive staff training, performance evaluations, and the implementation of patient feedback mechanisms. The study underscores the need for improved communication and collaboration among healthcare professionals to ensure safe and responsive patient care, ultimately preventing future adverse events. The case refers to the Coroners Court of Queensland report and the Nursing and Midwifery Board of Australia standards to support the analysis and recommendations.

Running head: CASE STUDY OF JACOB
Name of the student
Name of the university
Author note:

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Introduction:
Communication issues are highlighted as one of the crucial issues in the health care
sectors which reduce the effective clinical practice (Abdolrahimi et al., 2017). Accumulated
research suggested that in recent decade patients has become interestingly informed about their
conditions in order to participate in the decision-making process for specific intervention
(MacLean et al., 2016). Therefore, the importance of therapeutic communication in clinical
practice is intensifying gradually for promoting the wellbeing of the patient. The case study
represents the investigations of the sudden death of Mr. Roy Rodney Jacob, a 48 years old
aboriginal man who died unexpectedly in 31st August at Cherbourg hospital. The team who were
investigating the unexpected death reported a serious of issues associated with missed diagnosed
and inability to recognize and respond to the clinical deterioration. This paper will provide
critical analysis of the case with the assistance of a statement in the following paragraphs.
Discussion:
In the clinical setting, therapeutic communication is defined as a process of the face to
face interactions with the aim of supporting the wellbeing of the patient (Arnold et al., 2016).
Therefore, it is the responsibility of the health professionals to be transparent to the patients for
promoting shared decision making and faster recovery. Therapeutic communication empowers
patients, boost self-esteem and provide a comfortable environment to a patient in order to gain an
understanding of the mental state of the patient. As discussed by Cook (2015), therapeutic
communication is highly associated with accountability as communication is a huge component
of accountability. According to Finnell et al. (2015), accountability is considered as self-
competency of health professionals which reflects through taking responsibility for their own

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actions, decisions, and judgment. Accountability encompasses interpersonal skills, safe
practice, communication and decision making (Leonenko & Drach‐Zahavy, 2016). For
examples, engaging patients in therapeutic communications before proceeding with the treatment
facilitates the diagnosis of patients because it provides the opportunity to the health professionals
to gain the adequate information regarding medical history, concerns and preferred treatment
which further assists in designing accurate interventions. Consequently, patients, feel safe,
comfortable and empowered which is a part of professional accountability. Hence, these two
domains are interconnected.
Health care issue:
The case study focused on the investigation of the unexpected death of Mr. Roy Rodney
Jacob, a 48 years old aboriginal man in 31st August, at Cherbourg hospital. The case report
suggested that the doctor issued death certificate highlighting lobber pneumonia because of
cirrhosis associated with heavy alcohol consumption as a reason behind unexpected death.
However, during detailed investigation review team identified a serious of issues such as missed
diagnosis, inability to recognize clinical deterioration (Coroners Court of Queensland, 2018).
Besides, the review team reported that the health professionals focused on the alcohol
intoxications that they neglected other probable of unexpected death. During investigations, the
review team highlighted that the miscommunication between physician and nurses also
influenced the unexpected death since they were unable to detect perform the regular clinical
observation despite the presence of clinical protocol of recognizing and on time responding to
the health issues (Coroners Court of Queensland, 2018).. Therefore, the paper intended to
provide an in-depth, critical analysis of unexpected death with the assistance of the statement
provided below.

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Critical analysis:
For the critical analysis, the chosen statement would be “notwithstanding an
employer’s obligation to provide effective training for its clinical workforce, it remains the
responsibility of individual health practitioners to maintain their professional competency and
professional standards”
Taking an insight into the situation, a massive communication gap observed between
physicians and nurses along with the incompetency of nurses influenced the unexpected death of
Roy. When Roy was admitted to the Cherbourg hospital because of rib injury and alcohol,
intoxications, he was examined by the clinical nurse (CN) whereas because of high pain score
(7/10) the assessment should be conducted within 30 minutes. However, because of
incompetency, CN neglected the urgency of immediate clinical review of the patient, indicating
the breaching of standard 1 of NMBA standard RN should use critical thinking and the best
available evidence for rational decision making (Nursingmidwiferyboard.gov.au, 2019)..
Moreover, CN interrupted the ward round of dr. Nhapi for taking order of analgesia where dr.
Nhapi gave the verbal order, indicating a lack of documentation. As discussed by Gausvik et al.
(2015), documentation is the evidence which ensures safe nursing practice as it helps to keep the
record of the patient and act as official information. After giving approval, Dr. Nhapi neglected
the urgency of the medical review and said that he would assess the patient after the round,
indicating negligence and lack of accountability in an emergency situation. After gaining the
approval, CN gave him paracetamol based on the verbal communication and instructed to wait
when CN would look after other patients, whereas it is should be the priority of nurse to assess
patient considering the clinical urgency (Coroners Court of Queensland, 2018). Considering the
details of the investigations, Queensland Adult Deterioration Detection System is present in the

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clinical setting for monitoring the vital sign where for each sign, separate charts are present and
interventions are designed according to the score provided by the tool (Coroners Court of
Queensland, 2018). The investigation highlighted that when nurse B was assessing Roy she was
not concerned about the elevated heart rate, she wanted to prescribe pain reliever, indicating
inadequate knowledge regarding the detection system (Halcomb et al., 2016). She neglected the
need for ECG and referred to the medical officer. According to NMBA standard 4, a registered
nurse should accurately conduct comprehensive and systematic assessments in order to provide
safe and responsive care to the patient (Nursingmidwiferyboard.gov.au, 2019). Besides, no
communication took place between nurse and Dr.Nhapi regarding the plan considering high
scores derived from the device. Health professionals should design accurate interventions with
collaborations and proper communications considering the abnormal vital signs which were not
observed in this case (Nursingmidwiferyboard.gov.au, 2019). While transferring the patient,
Nurse C and RN were aware of the elevated heart rate but neglected the urgency. The proper
communication was missing between the nurse and Dr. Maja regarding Roy. Consequently,
lack of receiving standard care in the emergency situation, he died of cardiac arrest the next
morning (Coroners Court of Queensland, 2018).
Risk mitigation:
Taking an insight into the situation, there was an array of missed opportunity and
breaching of standard clinical practice for safe and responsive care observed inpatient.
Considering the statement, it is the obligation of the employer to provide effective training for
building a competent workforce. Therefore, in order to resolve the issues, the first strategy would
be an evaluation of each health professional or organization. The employer is required to
evaluate the capabilities and competencies of health professionals based on their performance

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compared to standard practice as a benchmark (Safetyandquality.gov.au , 2019). The bench mark
would NMBA nursing standard, ICN code of conduct and ethical conduct. The employers should
monitor the performance and the skills of the new health professionals in order to provide safe
care to each patient before recruitment, especially the skills of the health professionals to
successfully handle the emergency situation. The skills that reflect competency, critical
thinking and adequate knowledge of handling any situation are required to consider to strengthen
the workforce, improve the quality of practice (Ortega et al., 2016). As discussed before, the
nurses involved in the unexpected death of Roy had inadequate knowledge of equipment’s,
therapeutic communications and documentation. Therefore, an employer should arrange training
session for the health professionals where training would be given to each health professionals
regarding interpersonal skills, therapeutic communication, comprehensive assessment,
identifications of cues that indicate severity of work (Halcomb et al., 2016). After the training
process, the employer is required to monitor the performance of the health professionals for
evaluating the effectiveness of the training. The employer should implement the policy for
providing the feedback form to every patient who would be admitted to the hospital where
patients and their family members would have opportunity to share their concerns and issues
they faced during treatment. The actions would be taken based on the feedback shared by the
patients and their families (Ortega et al., 2016). The employers would be in charge of monitoring
the performance of the professionals through workshops, training, simulations and cross-cultural
interactions. The policies regarding shared decision making, patient center care, and transparency
are required to implement in the organization. The health professionals who will breach the
practice would be penalized based on their severity of the medication error.

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Conclusion:
To conclude, in order to provide safe and responsive care, therapeutic communication
between health professionals and nurse and patient is crucial. The case study represents the
investigation of the unexpected death of Roy Rodney Jacob because of the considerate number of
the missed opportunity of the communications, incompetency and clinical accountability. The
nurses and physicians neglected vital cues that indicated the clinical deteriorations. The
negligence regarding documentation, information, and incompetency of nurses for recognizing
the signs led to the sudden death. Therefore, considering the situation, it is the responsibility of
evaluate the performance, competency, skills and provide training in order to prevent future
medical errors.

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