The health care professionals should always complete their ‘duty of care’ appropriately, to ensure the maximum well being of the client. Sometimes, due to failure of proper diagnosis, service users suffer a lot, which also impacts negatively upon the entire health care system. One such case of misconduct was recorded in 2007, when due to continuous misdiagnosis and delay in treatment led to an inconsolable death of a 2 years old child named Ryan Saunders (Abc.net.au, 2017). A significant lack of communication, poor handover and negligence has been revealed in several steps of care provided to Ryan.
Ryan was brought to his GP, Dr. John Evans on 20th September, 2007. He diagnosed him as having mumps; instead of the fact that Ryan got the MMR vaccine from his clinic. He prescribed regular analgesia in the form of paracetamol, to help him with his pain. Ryan was advised not to attend child care until the swelling had subsided; however, the GP did not recommended follow up appointment, not contacted Ryan further (courts.qld.gov.au, 2011). Therefore, from the beginning, the GP has shown a communication gap and lack of in-depth assessment in resolving Ryan’s heath issues.
Communication plays a significant role in nursing and medical practice. For instance, in health care practice, communication within patient-physician, patient-nurse, nurse-physician, physician-physician and nurse-nurse are key player in delivering information regarding significant patient care (Liaw et al., 2011). A significant communication gap has been identified in Ryan’s case.
Ryan’s mother took him to Emerald hospital, upon witnessing his inconsolable pain at 1.00 am on Monday 24th September 2007. At this point, the nurses at Emerald hospital shown significant communication through maintaining the patient’s medical status report. At Emerald hospital, the physicians and nurses were unable to detect the appropriate reason for Ryan’s illness, but undertook immediate actions through systematic process, with no visible communication gap. Ryan arrived RBH with a great pain (courts.qld.gov.au, 2011).
From the beginning at RBH, Ryan faced a significant communication gap. Instead of the provision of calling a “off duty” physician on emergency case, the hospital authority, i.e. Ryan’s paediatric consultant Dr. Roper did not took initiative to communicate with the sonographer, leading to one step delay in his care provision and diagnosis. He was observed by Dr. Roos at 6.00 pm; however, examination was difficult due to his irritability. Dr Roos did note all physical indicators of meningitis. Dr. Roper was contacted and ordered for a lumbar puncture. He acknowledged no abnormal sign in Ryan’s abdomen, upon examination, he also denied his continuous crying and was unaware what pain medication was he taking at that time. However, he did not go through his medical chart from Emerald hospital or RBH ED and relied upon the verbal briefing of Dr. Roos and Dr. Kende’s letter. It represented one of the key miscommunication done by Dr. Roper, he continuously showed communication errors throughout Ryan’s case and on his interview, he attempted to deny most of his communication issues. A significant lack of clinical handover has also been shown here.
At around 9.10 pm, Dr. Roper got to know the test result was negative and he neither undertook any further examination, nor spoke to Ryan’s parents directly, leaving it to nursing staffs. Dr. Roos asked Dr. Roper, whether a blood culture needed to be done, but he denied its urgency. Again a miscommunication was noted from Dr. Roper’s side, he did not prioritize other physician’s suggestions. However, he suspected a viral infection. Ryan did not visited by any doctor since the lumbar puncture at 7.30 pm to 9.15 am on the next day (Flatley, 2011). In the morning, Terry asked the nurses, when Ryan will see a doctor, they replied that doctors don’t start their rounds till 8.00 am. With the irresponsibility of Dr. Roper, here, the nurses also shown significant lack in their communication process; instead of witnessing Ryan’s pain, they did not informed doctors or attempted to relieve him from the condition.
Considering the likeliness of viral myosotis, he believed that the source of pain was from his limbs, but unable to identify the source. Dr. Kamal suspectes abdominal source of pain, Dr. Ropper nominated retrocaecal appendicitis. Dr. Kamal suggested blood culture for “toxic work up”, followed by IV fluids and antibiotics. However, Dr. Roper denied about these suggestions. He also refused Dr. Kamal’s suggestion for administering morphine, as it may mask the source of pain. He continuously suggested administering less pain relief medication, Codeine, which Ryan received 12.05 pm, a poor interaction of Dr. Roper with other physicians or staffs has been shown. The Nurse Wood asked for taking blood to examine “toxic work up”, as Ryan’s stomach was rigid. CT scan was performed, though it was not marked urgent (Flatley, 2011). Here, the RN represented significant skill of conflict management along with effective management. As she witnessed the deterioration in Ryan’s health, she attempted to do her best to make the diagnosis and care accurate.
One of the significant ways of communication in medical care is patient handover, which is done when a patient’s responsibility is handed over from one medical staff to the other during the change of shift. Appropriate clinical handover is important for delivering adequate and in-depth information about the patient and avoiding misdiagnosis or medication error (Craig et al., 2012). During the handover of Ryan’s case in the next shift, Dr, Roper showed negligence, he was not present during clinical handover. To help his breathing he was attempted to intubate and ventilated, shortly after, he got a cardiac arrest, leading him to death on 26th September 2007. During Ryan’s last few hours, Dr. Roper also showed poor communication, as he left the communication part with Ryan’s parents over the RN. However, the RN significantly communicated with them and empathized them for Ryan’s situation (Liaw et al., 2011).
From the case study and coroner’s findings, it has been found that there were significant communication gap among the key physicians involved in Ryan’s case, which include miscommunication, insufficient information distribution and poor handover. Dr. Roper has been shown to avoid other physician’s suggestions on Ryan’s health. However, it has also been shown that during Ryan’s last time, after he got a cardiac arrest, Dr. Roper left the job of informing Ryan’s parents about his condition, over the nurse; instead of communicating directly with them (Flatley, 2011). In this interview, he also depicted controversial comments about the information shared by other physicians regarding Ryan’s blood culture results. In the evening shift, Dr. Roper was not involved in the hand over procedure of Ryan.
Nurse’s role is vital in care service, as she has the responsibility to communicate with patient, his family and physician regarding any kinds of health issues faced by the patient. In addition, communicating with other members in multidisciplinary team is also important for achieving success in care plan (King et al., 2013). Nurse King and Nurse Wood have shown to convey several times about Ryan’s pain, however, he continuously failed to manage his pain (Flatley, 2011). Moreover, after Ryan’s transfer from Emerald hospital to RBH, he only relied upon the verbal communication with the doctor of Emerald hospital; instead of checking Ryan’s medical history, his medical chart or thorough physical examination. These have been shown a poor communication, lack of patient safety and poor handover procedure (King et al., 2013). It has also shown that at the day before Ryan’s death, he was left over throughout the night since 7.30 pm to next day 8.00 am without visited by a doctor. Nurses noted the child was screaming, but the doctor was not informed; showing a significant lack of communication and poor patient safety.
It has been revealed that the GP, physicians at Emerald hospital as well as the on call consultant Dr. Roper at RBH ED played the key role in promoting the adverse effects in Ryan’s case. Reviewing the case, it has been revealed that Ryan was not at state of having fatal consequences, if he got proper diagnosis and care. However, from his GP Dr. Evans, he was being misdiagnosed and neglected regarding his severe pain. His GP was aware of the fact the that he undergone MMR vaccine, which reduces the chance of occurrence about 95%, though he diagnosed him with mumps and did not recommended for follow up visit. On the other hand, physicians at Emerald hospital also unable to diagnose the cause of his illness, however, they provided appropriate analgesia and referred him to a secondary hospital for advanced treatment (Flatley, 2011). However, a continuous negligence and misdiagnosis was observed from the on call consultant at Rockhampton hospital, Dr. Roper, who misdiagnosed his cause of illness more than one time, did not considered the positive recommendations of other physician and nurse at the multidisciplinary team, nor attempted to reduce Ryan’s pain, instead of witnessing him suffering continuously (Craig et al., 2012). These were the human factors contributed towards Ryan’s health deterioration.
The paediatric consultant, Dr. Peter Roper explained that he did not attempt to relieve Ryan’s pain, as he did not want to mask Ryan’s symptoms with analgesia. However, coroner disapproved his explanation. Initially, Dr. Roper believed a viral infection of the child, but did not ordered a blood culture, despite of being suggested by junior doctor and repeatedly made serious errors in judgment, when he declined to do so. Cororner reported that after lumbar puncture report was positive, there was no initiative by Dr. Roper to urgently find the root cause; rather Ryan was left in pain, not visited by any doctor till next day morning (Miko, 2011).
According to expert witness, blood culture should be done and antibiotics given, when physician thinks a lumber puncture is warranted. Interventions for ceasing bacterial infection were undertaken too late. Ryan’s parents described uncaring attitude of physicians, lack of urgency and poor communication. The coroner acknowledged Dr. Roper’s years of committed service with inadequate resources (Ong, BiomedE & Coiera, 2011). However, the Medical Board of Australia found no grounds for disciplinary action against Dr. Roper. Dr. Roper also failed to be involved in proper handover process as well as ignored the information in handover and patient chart made by nurse, where several times nurses mentioned about Ryan’s inconsolable pain. The adequacy of care at RBH included incomplete history, Dr. Roper did not investigated Ryan, instead only relied upon the verbal communication with the Emerald hospital’s doctor; failure to examine, no septic work up or antibiotics and failure to pain management (Miko, 2011). When a CRP test was done, it demonstrated highly infective process, but at that stage, Ryan could not be saved.
Nurse’s role in Ryan’s case was significant in addressing his problems. However, according to Ryan’s parents, Ryan screamed through the night in pain, but nurses didn’t seem interested in following up with doctors. Nurse Wood approached Dr. Roper regarding Ryan’s pain and urgency for prompt attention. She also requested to give morphine to combat with Ryan’s pain, but was denied by Dr. Roper. RN King also noted Ryan was wailing. RN king asked for blood culture, which was a right diagnosis for Ryan. RN was also concerned that Ryan was not receiving adequate pain relief. Finally, as a result of RN’s concern, Dr. Roper agreed to administer morphine to Ryan. Therefore, the RN, Nurse King her role significantly for Ryan, identifying him to be readily deteriorating, she was in deep distress at Ryan’s death. Therefore, according to the professional codes and competency standards, RN King met her standards of practice while taking care for Ryan, showed significant concern regarding urgency, showed empathy towards his distress and pain and attempted to continuously report Ryan’s deterioration to Dr. Roper and other physicians (Nursingmidwiferyboard.gov.au, 2017).
Coroner agreed with 15 recommendations made by HQCC along with not taking any disciplinary action against Dr. Roper. The recommendations included inclusion of adequate training about service capability levels through Queensland hospitals; ensuring appropriate access to tertiary level telemedical advice through rural and regional medical team; state wide implementation of CRP reporting tools; to ensure radiological imaging is available at Rockhampton Hospital 24 hours per day, with state wide expansion of the process; to ensure handover process at RBH; to implement an escalation procedure for pathology reports and a automated alert process; to ensure nursing processes; to consider whether any further investigations are required (Miko, 2011).
Communication plays a key role in these kinds of cases, as supported by a wide range of medical evidences. To reduce these kinds of issues, several national and federals legislations and policies has been implemented. In this context, the health care professionals hold the key responsibility of service user’s well being as well as any kinds of negative health consequences, as a result of services provided. Therefore, health care practitioner should be to avoid medical error or misdiagnosis like Ryan’s case in 2007.
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