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Nishtha answered on
Apr 22 2021
NURSING CASE STUDY
Table of Contents
Summary of Coroner’s Findings 3
Pathology and Condition causing the Death 3
Findings and Recommendation 4
Documentation and Communication 6
Ethical Decision-Making 7
Advocacy 7
Leadership and Management 9
Culture of the Organisation 10
References 12
Summary of Coroner’s Findings
Mr Ian Trengove was 81 years old when he died on March 30, 2008, as a patient at Adelaide's St Andrews Hospital (St Andrews). On the following afternoon, he had already been transfe
ed to St Andrews. Despite his lengthy medical history, Mr Trengove seems to have been a fairly active man. He was conducting his tasks as a verger at St John's Anglican Church in the city when he fell and hurt his right hip. Mr Trengove seemed to have missed a move when staffs were planning for a wedding. The likelihood that Mr Trengove's pelvic injuries would cause him to bleed profusely was not properly assessed at St Andrews.
His management strategy, in particular, failed to account for anything that should have been easily determined from the start, namely that he was heavily anticoagulated. Throughout that night, a medical professional could have examined Mr Trengove’s deterioration. On the morning of Sunday, March 30, 2008, Dr Lakshmanan considered hypertension and a myocardial infarction as potential diagnoses for Mr Trengove. Mr Trengove's appearance was consistent with his having bled from his pelvic injuries, so I believe that there was a more probable diagnosis, which should have been considered.
A CT scan of his pelvis was ordered right away because the coefficient of suspicion for such a diagnosis was high enough. Mr Trengove's bleeding into his pelvis could have been discovered as soon as Dr Lakshmanan learned of Mr Trengove's blood findings, which showed an acute decline in his renal function. On the balance of probability, I believe Mr Trengove's odds of living would have been greatly increased if his pelvic bleeding had been discovered during the morning of March 30, 2008. It is hard to know for sure if he would have lasted. It is also difficult to say with certainty when Mr Trengove may have not been recovered.
Pathology and Condition causing the Death
Two independent experts assessed Mr Trengove's clinical management at St Andrews in light of his unquestionable cause of death, separate in the sense that neither specialist was involved in Mr Trengove's treatment. Professor John Cade is the Royal Melbourne Hospital's Principal Specialist in Critical Condition and a consulting physician with a specific importance in haematology. Professor Cade was hired by counsel supporting the State Coroner to look at Mr Trengove's clinical care at St Andrews and give an expert opinion on its suitability and efficacy. He prepared a report dated August 21, 2009 in the very first case. He was later asked to prepare a follow-up report, which was due on July 6, 2010.
This study dealt with the medical practitioners participating in answers to his first report of Mr Trengove's care. Professor Cade prepared a follow-up report on 4 January 2011 after giving testimony in the Inquest, which addressed questions that had been raised by the second expert in the case. Mr John Homburg, counsel for Dr Lakshmanan, hired a second expert to look into the matter. Dr Michael Waters, a general practitioner, were the expert in question. Dr Waters is a private practitioner who works at a variety of hospitals, including Calvary Wakefield Hospital and St Andrews. The report and cu
iculum vitae of Dr Waters were presented to the Inquiry. Dr Waters make it obvious in his study.
Despite Mr Trengove's history of cardiac disease, there were no acute ischaemic changes in the myocardium. The heart's tissue and no myocardial sca
ing suggestive of prior myocardial infarction were noticed at autopsy. As a result, there is no proof that Mr Trengove has ever had a myocardial infarction (heart attack), either recently or previously. Despite the fact that Mr Trengove did not seem to have had a myocardial infarction or a heart attack, Dr Gilbert clarified that his ischaemic and hypertensive cardiovascular disease led to his death. He proposed that in a case of acute blood loss, such as Mr Trengove's, the oxygen ca
ying capacity of his blood was diminished, causing his circulation to fail to keep up with his heart muscle's oxygen needs.
His rapid decline and death were most likely caused by a cardiac a
hythmia, which would have resulted from the haemo
hage's compromise of his heart's blood flow. The retropubic and retroperitoneal haemo
hages were clearly caused by the fractures in Mr Trengove's pelvis, in my opinion. I also discovered that Mr Trengove's anticoagulation caused by warfarin was the primary cause of the haemo
hage's severity. I also believe that Mr Trengove's rapid decline and death is triggered by an a
hythmia induced by the haemo
hage, which compromised Mr Trengove's circulation of the blood.
Findings and Recommendation
When Mr Trengove a
ived at the St Andrews Emergency Department, he should have been subjected to blood tests. A test for INR anticoagulation, in particular, should have been performed. This would have revealed an INR level that was similar to the one measured the next morning, namely. The likelihood that Mr Trengove's pelvic injuries would cause him to bleed profusely was not properly assessed at St Andrews. His management strategy, in particular, failed to account for anything that should have been easily determined from the start, namely that he was heavily anticoagulated. During that night, a medical professional could have examined Mr Trengove’s deterioration. Dr Lakshmanan considered dehydration and a myocardial infarction as potential diagnoses for Mr Trengove. I have come to the conclusion that there was a more probable diagnosis that should have been considered, namely that Mr Trengove's appearance was abnormal. A CT scan of his pelvis was ordered right away because the index of suspicion for such a diagnosis was high enough. A CT scan of Mr Trengove's pelvis will almost certainly have shown the bleeding. On the balance of probability, I believe Mr Trengove's chances of survival would have been greatly increased if his pelvic bleeding had been discovered mostly during morning of March 30, 2008. Hence, it is hard to know for sure if he would have survived.
It is also difficult to say with certainty when Mr Trengove would not have been recovered. I am allowed to make recommendations under Section 25(2) of the Coroners Act 2003 that, in the discretion of the Board, can prevent or minimise the probability of a recu
ence of an incident similar from the one that was the subject of the Autopsy. On request of St Andrews Hospital, Mr Coppola of counsel appeared. Mr Coppola presented photographic evidence relating to improvements in practises at St Andrews. There is now a guideline for warfarin over-anticoagulation, which acknowledges that a patient's existing INR will normally have an effect on their treatment plan.
All presenting patients undergoing anticoagulation therapy must have an INR examination done as part of an emergency service evaluation, according to the manual. In bold, the document advises clinicians to be informed of occult or hidden leakage risks in even mild head, thorax, abdomen, or pelvis trauma and to examine or closely observe as required. Mr Coppola has produced...