In this assessment, an essay will be made to explain the inadequate care and a systemic hospital failure to recognize signs of a deteriorating patient which lead to Vanessa Anderson death. In November 2005, Vanessa Anderson which was only 16 years of age was hit in the back of the head near the ear with a golf ball. She was drven to Hornsby Hospital and later was transferred to the Royal North Shore Hospital. Due to the inappropriate hospital systems and no communication between all of the departments in the hospital, Vanessa’s family suffered a huge shock. She lost her life at a young age due to medical negligence. She was allegedly treated for a fracture to the skull, two days later, she suffered from a seizure and died. However, the coroner determined that Vanessa died from respiratory arrest due to the opiate medication that caused a depressant effect.
This case was made a huge focus on the importance of how the hospital systems need to change and the errors in the lack of communication that lead to the loss of Vanessa’s life.This essay will hopefully hut some light on the events that lead to the failure of communication in the hospital sector. Furthermore, this essay will give a in sight at the coroner’s findings and will show aspects that led to the death of Vanessa. Frist, The sequence of events of the factors include the following.
The doctors were indecision on whether Vanessa should go to Royal North Shore Hospital. The lack to communicate from Dr. Little, who Vanessa was first admitted to under his care, then a lack of neurosurgery’s as they there at training in Melbourne. When Venessa was transferred to Royal North Shore Hospital, she was put under the care of Dr. Bakar, who was performing registrar duties and was overwelled with his work and tired, he was considering anti-convulsants but ever prescribed. Dr.
Williams was a senior neurosurgical resident, however only has worked on the neurosurgery ward for two weeks. Then there was Dr. Bezyan, who was an intern on her first day in the ward. Dr. Little’s instruction after first seeing Vanessa was to chart and give Dilantin, this was not followed, even after the Concerns given by Mrs. Anderson about the side effects of Dilantin, this was not communicated. Dr. Ismail failures to recognize that Vanessa had been given Panadeine Forte.
He also failed to refer Dr. Little in regard to upping analgesia. The let-down by medical staff to be aware of policies which require consultation with the treating Doctor in cases there is limitations that the quantity and type of analgesia should have been known, also they failed to do examinations as to the set time frames. The knowledge, though with good intentions in regard to privacy, of placing Vanessa in a room that was the furthest away from a Nurses station. No records of what may have been a important event at about 1 am on 8th November 2005. Carayon et al.
(2014, p. 14) due to poor communication it is one of the major problems in the medical field. This is a concern that has raised within the people working in the hospital and the common people. Poor communication has been shown an increase in death in hospitals. However, the common issue is delayed communication, which may lead to the lack of safety provided to the patients. In addition, Dekker (2016, p.44) states that the main problem in the communication systems in hospitals is among physicians. This is due to the ego among the professional people, this leads to the lack of care of the patients.
This lack of communication blocks the advancement of the diagnosis. For Vanessa Anderson, the coroner shows that the death happened due to miscommunication with the nurses. The nurses that were taking care of Vanessa gave her therapeutic dose of codeine four times and never provided her with any anti-convulsive drugs to prevent a seizure. The coroner also stated that the death was due to the occurrence of the seizure, not due to the golf ball that hit her (smh.com.
au, 2016).Wu et al. (2013, p.723), the lack of communication between nurses and the lack of information about medications and the way they affect the health of patients. To try to prevent this, nurses need to be trained about various medications and their effects they can have.
In regards to this, Singer and Vogus (2013, p.373) show that the hospitals need a chart that will outline the effects and usage of various medications.With Vanessa case, the lack of knowledge and miscommunication in nurses lead to this disaster. However, in this event it is essential all nurses maintain an up to date record book that is detailed of the events that happened to the patient, this requires time when a medication was admitted. This helps nurses when they have to work in shifts.
The other way nurses can communicate batter is by using the clinical handover, which provides information to the next nurse of the patients (Mueller et al. 2012, p.1057).
Registered nurses primary duty is to provide safety to the patients in their care and the hospital. They need to know of any activity that leads to deterioration of the health of the patients and be able to alert this activity that deteriorates the health of the patients (fiabane et al. 2013, p. 2016). It is a duty of care for the nurse to report this deterioration to right professional for the right treatment for the patients. According to Dubois et al. (2013, p.110) points out that patients safety should be the high priority of the nurses.
To be able to achieve the success of nurses, the hospitals need to have a team that can respond to emergencies. The team will need to be able to avert the crisis and improve the deterioration signs. Kirsebom et al. (2013, p.886) shows that the hospital needs to develop an administrative structure that works with the team, this aim is to provide facilities, education, support and training to all nurses regarding to health deterioration, which will help with improving their communication (William et al. 2013, p.886).
Shown in the report from the coroner, it is understood that Vanessa death happened due to miscommunication and lack of medication knowledge. The non-appearance of the hospital having guidelines that increase the likelihood of prescribing multiple medications without knowing the side effects that can happen. The amount of codeine in Vanessa’s system led to respiratory problems. The absence of the team and nurses responsible also contributed to the deterioration of Vanessa health. The lack of knowledge about the different medicines and the antibiotics that contributed to the death.
The lack of communication has played a huge role in the death of Vanessa. The nurse did not have an appropriate understanding of each other and this led to the high amount of medicine. Other influences are that the symptoms that later developed from the excess amount of medicine was not observed and properly reported by the nurses (The Australian, 2016). These are the main factors that led to the death of Vanessa. From the coroner’s report, Vanessa death was solely by medical negligence.
Williams et al. (2013, p.80) showed that it is important that patients safety is the most important factor that all hospitals need to commence. However, the staff at Royal North Shore Hospital all failed to provide the right treatment for Vanessa. She was admitted to a room that was not equipped for surveillance, thus, the nurses did not do their observations on Vanessa effectively and never wrote the notes. Nurses need to keep a record book that can help them keep up to date information about all patients. This also helps nurses and doctors to provide the right care and know what the right action of treatment.
Hence, it can be concluded that communication is a high importance in all hospitals and that the lack of communication can impact the lives of patients and their families. Communication will reduce the gap between all hospital staff and help to understand between them all. The roles that nurses take on should be delegated that way they don’t feel overburdened. It is a major importance that nurses maintain an up to date activities on their patients. this will help any misunderstanding of the diagnosis of any patient.
Education is also another major role that nurses need to undertake to gain the right knowledge about medications. As negligence of the nurses led to Vanessa Anderson Death. The lack knowledge between the nurses and coordination between them led to a tragic that tainted Royal North Shore Hospital reputation. Thus, it’s important that those flaws are identified that prevented the proper diagnosis of Vanessa. Medical flaws can be rectified so this does not happen to another family. The death of Vanessa Anderson at a very young age of 16 years was a tragic and a avoidable death.
Vanessa’s case should be used as a precedent to highlight how individual errors of judgment, failure to communicate, failure to record accurately and poor management of staff resources, cumulatively led to the worst possible outcome for Vanessa and her family
