Health Alert (Australia) - 12 August 2013

JUDGMENTS

Victoria. Coroners Court

19 July 2013 - Inquest into the death of Andrew Timothy Davies COR-2007-3554

The deceased, a 39 year old prisoner, presented at Her Majesty's Prison medical centre complaining of chest pain. The nurse who saw the deceased was a registered division 2 and 3 nurse and was the only person on duty. An electrocardiogram (ECG) was performed but the self-reporting function showed no signs of irregularity. He was therefore treated for cold and flu symptoms. Roughly 16 days later he suffered a ventricular tachycardia cardiac arrest from which he did not recover.

Medical services to the prison were provided by Pacific Shores Healthcare (PSH) through a contractual agreement with Justice Health.

The Coroner determined that the nurse had incorrectly relied on the machine's interpretation to dictate his conclusion regarding the patient's symptoms, having not been trained to interpret an ECG. He was not supervised by a division 1 nurse and did not subsequently notify that supervisor that an ECG had been performed, nor did he refer the results for review by the visiting medical officer. "The procedures in place under the control of [PSH]...enabled, permitted and encouraged [the nurse] to perform functions unsupported by a policy and procedures that ensured adequate follow up."

The Coroner concluded that, had the ECG been examined by appropriately trained personnel, an opportunity would have arisen for medical treatment to be administered and the prisoner's death could have been prevented. Numerous recommendations were made regarding PSH's policies for prisoner patients, including a staff induction program, ongoing professional development and an improved review process.

26 July 2013 - Inquest into the death of Amy Hauserman COR-2008-1116

The deceased was voluntarily admitted to Frankston hospital's psychiatric unit after showing signs of a relapse of schizophrenia and anorexia and placed on 15 minute interval observations, standard for newly admitted patients. She was prescribed medication for severe constipation but continued experiencing abdominal pain so a bath was suggested. During the bath she was verbally checked on every 15 minutes by nursing staff but not continually supervised due to privacy concerns. She was found face down in the bath and was cyanosed. Resuscitation was attempted but unsuccessful. Post-mortem examination concluded death was by hypoxic brain injury in the setting of immersion.

The nurse administering the bath believed there was no evident risk and was unaware of any relevant policy. However, the Coroner found existing protocols recommended full risk evaluation before offering a bath and therefore a failure in the administration of training updates had led to staff unfamiliarity. The Coroner concluded that, as the patient's risk presentation was multi-faceted, the staff erred in making the decision without an evaluation and allowing intermittent supervision. "The absence of [constant] supervision was a primary feature leading to her death, in that it caused or contributed to an inability to successfully intervene and to give effect to her rescue." Suicide was not evident.

The hospital subsequently removed the bath option from its psychiatric unit. The Coroner deemed this appropriate but cautioned that if it became available again, it should only be offered after improved training and an implemented policy of mandatory and continual nursing supervision.

United Kingdom (UK)

Anor, R (on the application of) Nicklinson and Lamb v Ministry of Justice [2013] EWCA Civ 961

"These appeals concern individuals who suffer from permanent and catastrophic physical disabilities. They are of sound mind and acutely conscious of their predicament. They do not want to suffer a painful and undignified process of dying. They wish to die at a time of their choosing. However, they are not physically capable of ending their own lives unaided. AM (known as "Martin", but that is not his real name) can end his own life but only with the...