Assessment 2: Critical Incident Analysis Case Study of Ian Trengove

This case study analyzes the death of Ian Trengove, an elderly patient admitted to the hospital for a pelvic fracture, focusing on the critical incidents that led to his demise. The analysis highlights failures in documentation, communication, ethical decision-making, advocacy, leadership, and organizational culture within the healthcare setting. Key issues include the lack of blood tests before treatment, improper documentation of the patient's declining blood pressure, and insufficient communication between nurses and doctors. The study critiques the doctors' failure to recognize and address internal bleeding, the inappropriate prescription of warfarin, and the nurses' failure to advocate for the patient. It emphasizes the importance of proper protocols, thorough patient assessment, ethical practices, and effective leadership in preventing medical errors. The case underscores how these failures, compounded by a lack of organizational culture, ultimately resulted in adverse patient outcomes. The study uses the coroner's report to identify the key aspects of nursing involvement and provides an evidence-based critique of the nursing care provided.

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CRITICAL INCIDENT ANALYSIS
CASE STUDY OF IAN TRENGOVE
4/29/2019

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BRIEF SUMMARY OF THE CASE
An aged patient was admitted in the hospital for the treatment of the trauma on his left pelvis due
to falling. The patient was already taking the warfarin drug as prescribed by his cardiologist.
Before the treatment, no tests were done to find out the level of warfarin in the blood. Further,
inappropriate diagnosis was done which lead the doctor to fail in finding the hemorrhage which
was leading to the internal bleeding. The nursing staff was also not able to detect any missing
reports about the blood tests and also, they were not able to manage the situation. Although, the
nurse knew about the regular deterioration of the blood pressure of the patient, she was not able
to communicate it with the doctor. All these lead o the worsening of the health conditions and
finally it lead to the death of the patient.

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DICUSSION
Documentation and communication
For any job, documentation is required in order to maintain the records. Proper documentations
can help in the proper communication between two units of any organization (Harter, Levine and
Henderson 2015). When talking about the perspective of the nursing, documentation of the
patients’ health information and then, arranging the information in such a form that it can be
easily read by the doctors who are in charge is very important. Main problems arises when the
documentation about the patients records are not done properly by the nurses, which leads he
doctors to skip the major points about the health of the patient. This made the doctors to make
wrong decisions and hence it can be failure of the treatment.
In the case of Mr. Trengove, there we can find that there were no proper documentations of the
reducing blood pressure of the patient. Further, the main reports of the blood tests samples were
also missing which should be documented, but there was nothing mentioned about that, and the
busy doctor interpreted the information which he can see in the unordered documents. There was
lack of communication also between the nursing staff and the doctor about the regular decrease
in the blood pressure of the patient. This can be proved by the statement of doctor that if he
would know about the low blood pressure of the patient earlier, then the treatment would be
totally different. This shows the importance of proper documentation and communication about
each and every minute activity in the patients’ health amongst the nursing staff and the doctor.
Ethical decision making
While practicing in any medical field, there exist several ethical dilemmas or situations which
the nursing staff has to manage. Some of the decisions which are taken by the doctors and
medical staff are against the ethics of the job which they are doing. Not following the guidelines
for the treatment and handling of the patient can also be included as the ethical offence in the
medical premises. These unethical decisions may be taken by the doctors and nursing staff due to
stressed conditions or by the manual errors (Wang, Kong, Lee, Ng and Ko 2014).

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When looking at the ethical issues in the case of Mr. Trengove, the first step should be take prior
to the any treatment was blood test. Neither any doctor, not the nursing staff followed this
guideline. Due to this, the rise in the level of warfarin drug was unable to be estimated and it
results in failure of the treatment of the patient.
Advocacy
Advocacy in the perception of the medical practices for the nurses is to protect and promote the
health of the patient by preventing the illness while also taking care about the rights and dignities
of the patient. Right from the proper diagnosis of the patient to the proper treatment of the
patient, everything comes under advocacy of the patient. While advocating the patient, nurses
can maintain the dignity of the patient by helping them in making decisions when they are
confused and also by helping the doctors in suggesting the tests which can help in the diagnosing
process of the patient. Understanding the whole case of the patient and finding out any mistake
which the doctor may have done and informing about this to the doctor is also a part of the
advocacy (Giugliano et al. 2014). For this purpose, nurses should have full knowledge about
various tests and how to present the critical data to the doctor prior to any other data.
In the given case study, there was failure of advocacy in two ways: firstly, the documentation of
the patient’s data was not done properly by the nurses, which hid the main results of the falling
blood pressure of the patient, and secondly, the reports of the blood tests were missing in the
documents, which the busy doctor also not able to identify. It was the duty of the nurses that they
should care about the reports of the patients and at least inform the doctor about the blood tests
as this is the basic test which must e done in any cases of trauma of the elderly people. Due to
improper advocacy, there were certain misleading arose in the case.
Leadership and management
A leader in the medical field is someone who takes all the decisions regarding the treatment of
the patient. Doctors who are assigned to the particular patients are the leaders of the treatment.
Being a leader of any organization is not an easy task. Being a leader, it is must that they should

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be able to take the precise decisions which can bring about the positive results. Leader is also
responsible for the wrong decisions and for the failure of any task assigned to their group (Sim,
Kacevska and Ingelman-Sundberg 2013). When talking about the aspects of medical field, doctor
should have complete knowledge about the treatments and the consequences of any
misinterpretations. They should be able to manage all the patients without compromising with
the quality of the treatment given to any patient. They must have the ability to take the precise
decision in no time as their schedule is very busy and they do not have enough time for thinking
and taking decisions. They should also have great management.
In the case of Mr. Trengove, more than one mistake was committed by the doctors who were
assigned the case. The major mistakes were in the proper diagnosing of the patient. Although the
doctor knew that bleeding is occurring, and he is not able to find the hemorrhage in the simple
X-ray, then he must prescribe CT-scan of the patient. This would have told about the exact
position of the hemorrhage and also the condition of it. It was the careless act by the doctor.
Another mistake done by the doctor was he did not prescribed any blood test of the patient
although he was knowing that patient is suffering from cardiac diseases and is taking warfarin
whose level has to be maintained regularly. There was also the case of improper management of
the doctor as he just skipped the report of the blood pressure of the patient. This all were poor
leadership activities which lead to the death of the patient.
Culture of the organization
Healthy culture is very important for the good working of any organization. Healthy culture
includes the good communication amongst the different units of the organization and the proper
interactions. In any medical premises, good culture includes the proper interaction and
understanding of the nurses and the doctors (El-Naby, Hashem and Ismail 2014). Due to lack of
proper interactions and understandings between the nurses and the doctors, the case lead to the
death of the patient.

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CRITQUE OF THE CASE
In the case of Mr. Trengove, there were multiple regions where mistakes were committed by the
doctors as well as by the nursing staff. When the patient was admitted in the hospital, he was
prescribed an X-ray for his pelvis to know the hemorrhage in the pubic bone. Along with this,
the doctor should also prescribe the blood test of the patient was already a patient of
cardiovascular diseases. When the reports of the X-ray came, doctor was unable to identify the
exact position of the hemorrhage and also the condition of the hemorrhage. It was clear with the
doctor that there is some bleeding occurring at in the patient but then too he just assumed the
hemorrhage to be a minor one. At this point, there were two problems. Firstly, doctor was unable
to know about the level of warfarin in the blood of the patient which can totally alter the result of
the clotting of the hemorrhage vessels. Doctor’s assumption misleads him that the trauma is
minor and can be corrected with the help of normal medicines.
If in the beginning only, when the doctor was not able to locate the hemorrhage, he would have
prescribed the CT-scan of the patient, then he would have been able to know that the trauma was
not the minor one, but it was a major trauma. Along with this, blood test reports can also be able
to grab the attention of the doctors towards the severity of the blood loss due to excessive
thinning of the blood. As the warfarin drug is used for the thinning of the blood, and therefore,
even a small trauma can lead to the excessive blood loss due to thin blood cannot clot easily. If
all the guidelines would be followed by the doctors in spite of doing assumptions, the patient can
be given the treatment following the correct path and patient may survived (Machtay et al. 2012).
All these reports were collected together by the nurses and were documented by the nurses. It
was the duty of the nurses that they should ask or inform the doctors about any missing
documents, but nurses also did not paid attention on the missing reports of the blood test. Prior to
any treatment, blood tests are prescribed by the doctor, nurses also given the training about the
important tests. If nurses would have informed about the blood tests reports prior o starting of the
treatment then it may click the doctor about the step of blood test which was skipped.
When the patient was diagnosed on the next day for the level of the warfarin in his blood, it was
found that, his blood was having very high concentration of warfarin. After trauma also, as
doctor did not prescribed the blood test, the patient was given the usual amount of the warfarin

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drug overnight. This again led to the increase in the amount of the warfarin which reduces the
property of blood to make a clot at the place of trauma. As a result of this, he was bleeding for
the whole night, but no clinicians noticed the internal bleeding. Mr. Trengove was showing
regular changes in the blood pressure towards low, but then too, clinicians available at the night
time were not able to detect the internal bleeding of the patient. If the internal bleeding was
detected before, then the patient might be saved from the death.
Another mistake done by Dr. Miller was that, he prescribed the warfarin to the patient again.
This increased the daily dosage of the warfarin drug to be 0.5 mg per day. This meant that he
should be given the next doses of warfarin at 8 pm.
Right from the admission of the patient in the hospital, the blood pressure of the patient was
regularly decreasing, which was the major sign of the bleeding. When all the reports were
diagnosed by the doctor for the first time, he skipped the reports of the blood pressure and thus,
did not know about the patient’s low blood pressure. Along with this, no nursing staff informed
the doctor about the decreasing blood pressure of the patient. Also, in the night, there was a
fluctuation in the saturation of the oxygen in the blood level of patient, which was not reported to
the doctor on time. Physician prescribed the patient to refer to some cardiologist just for the
precautions, without knowing the severity of the case.
In the night when patient was unable to void, he was prescribed for the x-rays, which was a good
decision. From the reports it was found that, the patient’s bladder was almost half filled but then
too he is unable to void. This may be due to the trauma in that region. Doctor prescribed catheter
for the patient. When catheter was fixed in the patient, there were evidences of very low amount
of urine or no urine flow after catheterization also. This fact was not known by the doctor. He
only knew that the patient had undergone catheterization and is now able to void. He was not
able to co-relate the thing that, the low urine production is maybe due to the excessive internal
bleeding and the action taken by the body to maintain the blood pressure (Soto and Anderson
2012). On checking the blood pressure of the patient, it was found to be very low than the normal
range.
Dr. Lakshamnn in the interview also revealed that, although nurse Clayton mentioned in her
reports about the fluctuating bradychardia another activities overnight, but he was never able to

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gone though those notes. The documentations were not done correctly by the nurses. It was the
mistake of the doctor as well as mistake of the nurses. Doctor did not pay full attention on the
reports and nurses also did not bother to tell the doctor about the conditions of the patients
overnight. Here, there was lack of communication skills between both the units of the hospital.
This poor communication did not allow the doctor to get the full information about the patient’s
condition and the half information misleads the doctor (Larimer et al. 2013). As the doctor when
asked the patient about the condition, patient said he was not having any pain, but there was
some problems in breathing, for which, doctor though about the myocardial infarction and
referred the patient to cardiologist on next day.
The urinary problem was also misunderstand by the doctor due to the negligence f the reports of
the last night fluctuations in the health of the patient by the doctor. Doctor thought that the
patient was also going through some urinary problems. As there were no evidences of prior renal
problem so he considered it as acute renal problems and prescribed saline water to the patient.
He was still not having any idea about the internal bleeding of the patient.
At last, when the blood pressure fell below critical level due to excessive bleeding, it leads to the
hypotension and ischemia in many vital organs of the patient’s body. Due to this, the patient died
suddenly.
Overall, if some of the measures and guidelines which any medical practitioner learns during
their course were followed properly, then the life of the patient might be saved. When the doctor
knew that patient might be taking any medicine related to heart diseases then too he did not give
priority to it. He still worked with the reflective knowledge and did not bother about the facts. If
he would prescribe the blood test earlier to the treatment then it would have helped. When the
doctor was not able to find the exact position and type of the injury or hemorrhage, then too he
did not prescribe any CT-scan (Yeung, Lapinsky, Granton, Doran and Cafazzo 2012), and just
assumed that the trauma must be minor and no injury is on the blood vessels. Clinical tests have
its own importance; the doctor should take them as priority than his assumptions to know about
the exact problem. If the doctor would have prescribe about the CT-scan, then the main problem
which was the internal trauma which was causing internal bleeding would be notes and proper
treatment would be given to the patient. When the patient was showing regular deterioration in
his blood pressure, the nurse was unable to communicate the exact problem to the doctor. If

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communication was proper between the doctor and he nurse about the irregular blood pressure of
the patient, then the main cause may get identified by the doctor. All these measured were the
leading causes of the death of the patient.

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DISCUSSION ON CORONER’S FINDINGS
Although the patient was an aged man; he was quite active and healthy person. As the patient
was taking the warfarin drug, but how it was the cause of his death and what were the mistakes
committed by the doctors and nurses which lead t his death were to be find out, and therefore, the
inquest was done. Coroner’s findings were as follows:
1. Patient was taking warfarin drug and was also undergone some cardiac problems
but the time at which he died , the chances of his death due to cardiac arrest were very
low.
2. Doctor neglected the blood tests and worked on his own assumptions. Due to this,
the high level of anti-coagulant was not detected by the doctor. If the doctor would have
prescribed the blood test prior to the treatment, then he must get to know about the level
of anti-coagulant in the blood of the patient.
3. Although there was already excessive amount of warfarin in the blood of the
patient, but he was given more warfarin. This lead to the decrease in the property of the
blood clotting and thus, trauma was unable to clot.
4. On examining the x-ray, doctor was unable to detect the positions and type of
trauma which the patient was suffering from.
5. Doctor must have prescribed CT-scan even he was not able to note the trauma
from the X-ray. But he again worked on the basis of his reflective learning and did not
prescribe the CT-scan, which gave no chance to the doctor for knowing about the internal
bleeding in the patient.
6. Due to excessive bleeding and blood loss, the blood pressure of the patient was
decreasing.
7. Due to abnormal blood pressure, patient was suffering from the irregular
bradycardia. Nurse in charge noted this. But she was unable to communicate the results
and the health conditions of the patient to the doctor. This was due to bad communication
and documentation of the patient health records.
8. As the level of anti-coagulant drug warfarin was very high in blood, it was not
able to make a clot. This lead to the regular loss of the blood.

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9. The patient was unable to void also. This was due to the fact that, body was not
able to excrete the water from the body as to compensate the amount of blood loss and to
maintain the blood pressure (Briggs et al. 2015).
10. There were no proper evidences present that after catheterization of the patient, he
was able to void and he eliminated urine at that time. There was possibility that the patent
did not produce any urine, but the staff did not pay attention on that too.
11. Mr. Trengove's seeping into his pelvis should have been recognized no later than
the time at which Dr Lakshmanan ended up mindful of the blood results which
demonstrated an intense weakening in Mr. Trengove's renal capacity.
12. It was discovered that on the equalization of probabilities that if Mr. Trengove's
seeping in his pelvis had been distinguished amid the morning of 30 March 2008, his
odds of survival would have been altogether improved. It is difficult to be sure beyond a
shadow of a doubt that he would have endure. It is likewise difficult to be sure beyond a
shadow of a doubt of the point in time at which Mr. Trengove couldn't have been
recovered.
13. Due to the excessive blood loss, the patient underwent hypotension which further
leads to ischemia in vital organs and then patient died (Collins et al. 2013).
Recommendations
 Court should take some decisions and should also suggest some of the guidelines
which should be followed by all other hospitals so that this type of mistake should not be
repeated again (Balas et al. 2012).
 Prior to any emergency treatment, the patient must be prescribed with the blood
test. So that, any abnormality in their blood can be noted before the treatment
(Khademian et al. 2013).
 The tests for the measuring of the warfarin drug in the blood should be done as a
compulsory so that any type of anti-coagulant can e detected prior to the treatment
(Clements, Curtis Horvat and Shaban 2015).
 Any trauma, from minute to the severe, should be investigated without any
compromise. Guidelines for the closely investigation of the trauma of head, thorax,

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abdomen or pelvis should be provided to the nurses as well as to the doctors (Longden,
Madill and Waterman 2012).
 Guidelines for the treatment of the patient who is taking warfarin drug should also
be given to the medical staff.
 A clear management plan should be devised. Nursing practice manual should be
updated for the improvement of the management planning skills of the nurses (Duarte
and Pinto-Gouveia 2017).
 The St Andrews Hospital guarantee that patients with pelvic cracks who present
in an anticoagulated or over-anticoagulated state be liable to the nearest perception
conceivable. This ought to incorporate normal observing of the patient's essential signs,
ordinary perception of the individual's renal capacity, liquid parity perceptions and
recording, standard testing of an individual's hemoglobin and condition of hostile to
coagulation what's more, steady perception with regards to the patient's clinical
introduction.