MEDICAL ETHICS
A Brief Summary of the Coroner’s Findings
In the investigation of the demise of Richard Lesley Mann, Mark Fredrick Johns (2008), the state coroner, found that the Mr. Richard Lesley Mann died because of choking on food on 30th May, 2004 at the Stramouth hospital. A brief summary of his death investigation is mentioned below.
Mr. Mann was 45years old man. Since birth Mr. Mann was suffering from intellectual disability and severe psychiatric illness. He became aggressive, depressed, agitated and withdrawn because of his psychiatric illness. He had been admitted to the hospital to manage his severe psychiatric condition.
Care providers had noticed that during his state of agitation he gobbled food rapidly and push food forcefully into his mouth that made him at the risk of aspirating food to his lungs and lead to the risk of choking. Mr. Mann was found in a dirty condition in his room on the day of his death.
He had smeared faucal upon himself, floor and wall of his room. A nurse along with two care providers had taken him to washroom to give him a shower. Instead of administering Mr. Mann with antipsychotic drug to manage his aggressive behavior, he administered with wrong medication by wrong person.
An incident report was concluded for the error. It was found that Mr. Mann’s hands had been tied up with a medical tape behind his back and behind the back of a chair. Mr. Mann had been supported with a wheel chair from washroom to his bed and after removal of his hand tape he tried to stand-up on his own.
As he was not supported with anyone, he fell down on his face. An incident report was also documented describing his fall issue but no further investigation was performed. A staff claimed that it is of no use for further investigation regarding this issue and sending him to hospital.
During his dinnertime, nurse had put his meal next to him on the floor and assumed that he would eat his food by himself, once he wakes up and feels hungry. Afterward, when another nurse had come to his room, she shouted to nurse station mentioning that Mr. Mann did not give the impression of being well and might have undergone a cardiac arrest.
The supporting staff called ambulance and performed a cardiopulmonary resuscitation but without purpose. Mr. Mann’s autopsy was performed by Dr. Cala, who reported that the cause of his death was choking on food.
MEDICAL AND NURSING PRACTICE
Documentation and communication
From the summary of his death investigation it is clear that lack of records was not the basic issue. Rather, it can be said that poor and lack of communication among the nursing professionals, medical section and administration was the main issue in the investigation of this patient’s death.
Communication and keeping records are robustly associated within health care set up (Smeulers et al., 2012). Maintaining records are considered as the way of strong communication among the healthcare providers and other services.
Communication can be non-verbal and verbal, for example: transfer forms of patient and discharge notes. Health care providers, especially nurses hold an authorized liability to maintain valid and proper documentation for offered care. A well written record always has positive effect on offered care and the quality of care (Duncan, Best and Hagen, 2010).
Mr. Mann had been cared in various hospitals and diverse departments, due to his mental and medical illnesses. From the report it is known that Mr. Mann had been transferred between residential facility, Modbury hospital and Strathmont Centre.
This raised an important question on communication and documentation regarding patient care alteration between different health care services. Change in patient’s care poses various complicated issues in the context of continuity of care, patient safety and availability of required sources to accommodate patients’ need on other facility (Reilly et al., 2013).
According to Smeulers et al. (2012) handover among the healthcare providers in both services should be proper (Smeulers et al., 2012). A safe and appropriate transfer includes an appropriate handover, stating that patient is transferring between them.
Handover can be in form of documentation in patient’s clinical record or via oral communication between the healthcare providers.
It is apparent from the investigation report that Mr. Mann was having trouble in eating and swallowing. Modbury hospital staff had noticed that during his agitated state he gobbled food rapidly and push food forcefully into his mouth that made him at the risk of aspirating food to his lungs and lead to the risk of choking.
The question could be raised here is was this issue had been documented in his medical record and communicated properly among the health care providers of hospital and Strathmont Centre? And if this issue was communicated and documented, did the staff of the hospital or the centre authority have taken any action to prevent these unpleasant effects? A per Morgan, Dodrill and Ward (2012) the incidence of swallowing difficulty and its effects are common among the psychologically ill patients because of antipsychotic medicines they receive and their illness (Morgan, Dodrill and Ward, 2012).
As per Vogel et al. (2012) mostly medical assessment of such patients shows fast feeding is one of the important causative factors to dysphagia and its side effects, like: choking and pneumonia (Vogel et al., 2012). If Mr. Mann’s complication was communicated and documented in a proper way, the care providers would have constructed an effective care arrangement for Mr. Mann.
The effective care plan may include staying with Mr. Mann during his mealtime or referring him to speech therapists, specialized in swallowing complications.
Ethical decision making
As per Curtis and Vincent (2010) ethical standards associated with medical practices are crucial factors (Curtis and Vincent, 2010). Health care professionals should have a thorough knowledge and should obey the standards together with their nursing and medical knowledge and skills (Steinbrook, 2005).
Healthcare professionals face ethical complications on a regular basis while delivering care to their patients. The main question is terms of ethical decision making within healthcare system is whether the patient is able to make decision about the offered care.
Park’s integrated moral decision making representation comprises family, patient and healthcare providers’ opinions, inputs to assemble a complete understanding of particular issue and to formulate shared and morally depended decision, which respect all the parties (Park, 2011).
Park’s representation considers moral dilemma from various perspectives. Generally, it is seen that the care providers find it hard while dealing with patients suffering from mental illness and make decisions for them.
Physicians usually prefer consulting psychiatrists who can assess and find out the psychological capacity of patients whether they can or cannot decide treatment or reject procedure (L\’egar\’e et al., 2010). A standard moral decision making structure should be present for the psychologically ill patients (Gillies et al., 2012).
From the investigation report it is known that Mr. Mann was not offered with alternatives in his care and his choices were neither assessed nor respected. He was totally treated as a psychic patient. He was forced to visit washroom to take bath, forced to sit on bathroom chair, his arms were tied up with medical tape to his back or back of a chair.
It was stated as entirely unethical behavior, by the Strathmont Centre Operational Service Officer, Mr. Malcolm Tulett. He stated that it was against their Centre procedures and policies.
He was asked about his advice, he would offer to his Center staff if complained about Mr. Mann’s aggressive nature and violent toward the staff and Mr. Tulett replied that he would have recommend his staff members to leave Mr. Mann unaccompanied until he calms down.
Advocacy
Advocacy in nursing is considered as essential component in nursing practice. The competency standards have mentioned role of advocacy as minimum expectation of registered nurses. The ethical codes for the Australian nurses describes both professional and moral obligations, this profession has in protecting the equal value and inherent dignity of everyone (Pitt et al., 2013).
Fresher nurse students learn the advocacy role from observing their seniors or experienced nurses who give constructive role models and support patients. This is said to be an effective way of constructing advocacy role on the basis of individual patient.
Nevertheless, to fully meet the specialized accountability of advocating for communities and individuals, nurses should develop successful political support (Myrhaug et al., 2006). Few might not have that support or they might not in the position of making choice between professional responsibility and personal ideals and thus often remain silent.
These days advocacy is greatly addressed and acknowledged in the healthcare setup worldwide. In some states and nursing schools advocacy is considered as component of nursing curriculum.
While in some other countries it is considered as the core nursing competencies that the nursing professionals need to have to retain their licenses, for example: in Australian Nursing Council patient encouragement is a core capability that all the nursing professionals should maintain. However, individuals with psychological complications are treated badly and ignored due to public’s prejudice and their weakness (Rook, 2014).
From the investigation report it is apparent that Mr. Mann was unable to convey his feelings, symptoms and wishes that made the situation difficult for the doctors to identify his mental illness. Throughout the report no where it was mentioned about Mr. Mann’s family, hence it can be said that he might have no family representative.
So, in this case the nurses will be at frontier to be most proficient and skilled people to advocate for Mr. Mann. From this report it is clear that Mr. Mann’s voice was ignored and the nurses failed to play their responsibilities as patient advocate.
Mr. Mann was having complication in swallowing and dysphagia, which put him at aspiration risk and death. Despite of being aware of Mr. Mann’s condition, nurses were reluctant to advocate him and refer him to a specialist or speech therapists, specialized in swallowing complications, who could have constructed an effective care arrangement for Mr. Mann.
It was also reported that when he had fallen on his face, not a single nurse had attended him to provide initial care or to check for any internal bleeding. A careful assessment of Mr. Mann after his fall was recommended. The assessment could have comprised performing CT scan to exclude the chance of brain hemorrhage and other difficulties (Taylor et al., 2014).
Therefore, if the nursing staff advocated for this patient and referred him to other specialists and consulted with physician then the serious consequences could have been prevented and saved Mr. Mann’s life.
Leadership and management
Leadership is said to be the ability of an individual to understand organization’s objectives and vision and guide personnel to accomplish these vision and objectives (Mannix, Wilkes and Daly, 2013). Nurse leaders play an essential role in supporting teamwork and continuing personnel relationship to accomplish the finest productivity.
Being supportive, passionate, role model, commitment, advocate, decision making; good communication and honest are few of nursing leader qualities which found to support nurses’ performance to accomplish organizational goals (Elliott et al., 2014). However, nursing leaders play an important role in supporting nurses to appreciate patients’ values and needs.
As per Harris, Bennett and Ross (2013) expert and competent leaders are crucial for any association and they help in accomplishing organizational goals by offering patients’ care with quality and guaranteeing staff development (Harris, Bennett and Ross, 2013).
From the investigation report it was clear that the nursing leader and registered nursed worked for Mr. Mann at the day of his death was Ms. Cama. Unluckily, she had failed to establish herself as the role model for other nursing professional in various occasions.
Her administration was wrong for MR. Mann as she was unprepared and this practice was measured as against medication policy. She was so anxious that she didn’t even bother to ask for advice if Mr. Mann requires additional investigation after the fall.
This is the reason why the nursing leader received warning letter as she had failed to guarantee proper observation after Mr. Mann’s fall. It was reported by Ms. Jones, the nursing manager that the registered nurses who practice at hospital were incompetent enough and did not have proper skills to deal with patients with behavioral issues, for example: Mr. Mann.
Cultural competence
According to Norton and Marks-Maran (2014) cultural competency initiated because of cultural diversity and rising number of diverse service consumers in different industrial societies (Norton and Marks-Maran, 2014). Cultural competency in nursing means nursing staff are motivated to practice in cultural context of the patients.
To achieve this, nurses need to respect and understand patients’ values and should work in ethnically appropriate setting (McGee and Johnson, 2014). To achieve cultural competency within the healthcare setting, nurses should have knowledge, cultural awareness and proficiencies, as these are important factors in the cultural competency.
It is not essential for a group to reside in same geological area to share same culture; rather they might have same culture depend on their language, region, ethnicity, mental disability and gender.
According to some experts the notion of competency is not an exact term that can be applied in assessing cultural awareness or skills (Roberts et al., 2014). Culture is the concept, which is dynamic, individual and complicated and it is not just a restricted set of data to be measured. Therefore, this cannot be applied to calculate cross-cultural interaction.
In the context of this investigation report it can be said that the Center staff were not ethnically competent enough to manage psychologically ill patients with violent behaviors.
This was stated by the nurse manager in her verification at investigation. If nurses would train to manage psychologically ill patients as weak cultural group, they could have offer competent and better care to Mr. Mann. Nursing professional can use their knowledge of cultural variety to structure a constructive plan and offer appropriate care which is ethnically suitable.
Caring people and marginalizing cultural variety has shown the way to intolerable consequences, for example: treatment non-adherence, client dissatisfaction and diagnosis error.
At present in various nursing literature the importance for teaching the nursing personnel regarding cultural diversity is well addressed. Cultural competency is already incorporated in nursing curriculum internationally at bachelor and master level.
Concise critique
Mr. Mann’s death could have been prevented if hospital nurses maintained proper observation. The nurses also failed to maintain proper documentation and communication between other nursing staff and service providers from different facilities.
They behave badly with Mr. Mann by tying up his hands which was unsafe and improper behavior within nursing practice. The registered nurse could have understood the importance of correct medication administration while serving the patients.
It was also seen that the hospital staff mentioned the factor useless to send Mr. Mann in the hospital after he had fallen on face and also nursing staff kept his food on the floor believing the patient would eat it while he feel hungry.
This kind of attitude is totally against the nursing practice and hence the care providers should understand the psychological aspects of mentally ill patient and behave properly with them.
By focusing on these factors Mr. Mann’s death could have been prevented, which was because of choking on food and for what the health care providers could be entirely blamed.
Brief of the findings
Mr. Mark Fredrick Johns has mentioned on his report that on 30th May, 2004, that means on the day of Mr. Mann’s death, he was administered with wrong drug and the nurse administered and dispensed in dangerous practice, which was unauthorized by nursing protocol as well as by the hospital management.
Though no adverse effect of wrong medication had been reported but closer observation was required which was not taken place within hospital. On the same day in morning Mr. Mann was restrained by tying his arms behind him by a medical tape.
It was not cause his death but can be considered as a part of situation directing up to MR. Mann’s death. After releasing his arms, he tried to get up from his wheel chair and fell down and hit on his face, which measured an injury to his head but unfortunately no medical intervention and neurological assessment had been conducted.
It can also be said that his choking on food would have been avoided if the nursing staff were little responsible and carefully observed him that night and after his fall as well. As per the state coroner these findings should be considered by South Australian Nursing Board, Strathmont Centre, Department of health to make sure that the set of rules are constructed to set up clear responsibilities and roles while residential staff and nursing staff are working together within the health care set up.
It can be undoubtedly stated that nursing practice in hospital was infringing the professional conduct code and no legislations or rules have been found that might have added to principles to guarantee safe practice. Healthcare organizations, for example: hospitals or other care centers should incorporate protocols and rules that make sure staff compliance and adherence to safe practice within the healthcare setup.
According to the coroner’s recommendation addressing role conflict and leading among the care providers is worldwide recognized concern in each residential services, which employ residential staff and nurses (Johansen, 2014).
This is because of the reason that sometimes residential care provider undertakes nursing responsibility and vice versa. It is of utmost importance to consider when nursing professional work with residential staff to simplify roles and responsibilities.
It was concluded that if social care employees are considered as profession, then it should require a professional structure: a code of conduct, representative organization and should clarify new responsibility activities.
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