© Coroners Court of Victoria 1

Forensic Nursing in the Coronial Jurisdiction: Lessons Learnt

“We speak for the dead to protect the living”

Jacqui Hawkins Coroner

Coroners Court of Victoria

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Overview of Coronial System

• Inquisitorial rather than adversarial

• May identify system failures or inadequacies

• May make recommendations

• Prevention focussed

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The role of the Coroner

• Investigate reportable deaths

• Make findings as to

• Identity

• Cause of death

• Circumstances of death

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Reportable Deaths

Death is connected with Victoria and

Death is:

– Unexpected

– Accident or injury

– Violent or unnatural manner

– during or following a medical procedure

– death occurred in ‘care or custody’

– under control or custody of the Secretary of the Dept of Justice or Victoria Police

– death of a patient within the Mental Health Act 2014(Vic)

– death of a person subject to a non-custodial supervision order

– identity is unknown

– medical practitioner not signed a death certificate

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“In care” or “custody”

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Coronial Investigation

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Inquests

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Coroner’s findings may go to…

• The Attorney-General

• The Minister for Health/Aged Care

• The Australian Nursing Federation

• The Australian Nursing Homes and Extended Care Association

• Australian Health Practitioner Regulation Agency

• Hospital/Aged Care/Mental Health facility in question

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Professional accountability in the Coronial System

• Coroners Court does not determine guilt or apportion blame

• Aim of investigation is generally to ascertain whether adequate systems were in place

• Even if system not sufficient/fails, there must be a causal link between insufficiency/failure and cause of death

• any problems in patient management & emergency protocol

• safety procedures & information provision

• staff training & communication

• Was the death preventable?

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Professional accountability

Adverse Finding

Matter referred to professional organisation/OPP

by Coroner

Matter referred to professional organisation by another

party

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Mr Lecek (2007)

• Mr L 68 yo • Attended Bendigo Police Station • No health concerns • Complained of feeling ill • Next morning Mr L requested to see a Doctor • On call custodial nurse called • Transferred to MCC– unwell during transfer • No paperwork reporting he had a medical condition,

that custodial nurse had been contacted or that needed to see a doctor

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Mr L

• Hourly obs due to multiple medical problems

• Overnight unwell – cellmate buzzed custodial officers on two occasions

• At 8am, custodial nurse (nurse 2) administered meds.

• Nurse did not ask how Mr L was feeling.

• Checked file and suggest review by nurse clinic

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Mr L

• Custodial officer observed Mr L lying on his stomach

• Did not respond to questions

• CO could not understand what he was saying. Noted to be blotchy with a blue tinge.

• Request nurse assistance (nurse 2).

• CO’s unable to move him. Requested nurse attend cell.

• Nurse 2 observed Mr L semi-conscious

• Requested ambulance attendance

• Transferred to Hospital died short time later

• COD 1(a) ischaemic small and large intestine complicating cardiogenic shock in the setting of ischaemic heart disease

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Mr L

• Dangers of making assumptions about the ‘health’ of prisoners

• Laissez-faire approach to maintaining effective lines of communication in general and to the nursing assessment of Mr L specifically

• The nursing approach to Mr L did not accord with the standard of nursing care expected to be provided in the community

• Nurses did not have immediate concerns for Mr L’s health and wellbeing.

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Mr L

“the ‘system’ of communication between custodial centres lacked structure and certainty and in this case, failed Mr L”

Coroner Audrey Jamieson

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Mr Chandler (2009)

• 49 yo

• Placed on remand at MAP pending sentencing

• 6/3 – had 3 assessments at MAP

• 8/3 – cell check – found unresponsive with a wound to his arm and a plastic bag over his head

• Forensic nurse conducted a psychiatric assessment and circled “not known”

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Mr Chandler

• No proper risk assessment

• Lack of planned or required follow up to clarify risk of self harm/suicide

• Coroner Spooner recommended processes at MAP be improved

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Ms Castro (2011)

• 26 yo

• Feb 2011 – admitted to Sunshine Hospital

• Assessed by ECATT - discharged following day

• 5 hours later – re-admitted to same ED

• No medical review

• Discharged to family members care

• Later found hanging at a motel

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Ms Castro

“I am heartened that lessons learnt from this tragic case will result in improving

the care of future patients of NorthWestern Mental Health.”

Coroner John Olle

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Ms Castro

Recommendations:

• Risk assessment tools must be updated upon each admission

• Planned follow-up arrangements with CATT must be clearly detailed post-discharge

• When a patient is discharged to a family member – they need to understand what is required of them

• Plan must be realistic

• If a medical review is not considered necessary – this needs to be clearly documented

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Mr Ngor (2013)

• 28 March 2013 – Mr Ngor was arrested by police for murdering his mother

• Thomas Embling hospital due to presenting with psychosis

• Forensic nurses filled in the observation sheets stating that they had observed Mr Ngor

• At around 10.15am a forensic nurse was unable to locate Mr Ngor

• Found hanging in a disabled toilet/bathroom

• Investigation revealed forensic nurses had not conducted observations but had admitted to recording that they had

• Due to their admission Coroner was not critical and in fact said “I find both nurses…were honest in their testimony”

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Mr Bernacki (2009)

• Involuntary patient at the Werribee Mercy Inpatient Psychiatric Unit (WMPU)

• Escorted day leave

• Found hanging from a high voltage electricity pylon

• Issue at inquest – sufficiency of communication between WMPU staff and escorts

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Mr Bernecki

• Communications between WMPU staff and leave escorts were not in good clinical practice in that they failed to establish: – The nature and purpose of escorted leave – The necessity for and extent to which patient supervision was required – Leave arrangements including expected destinations while on leave

and agreed time of return – Agreed strategies for crisis management – The identity of an escort and the means through which she or he could

be reliably contacted during a period of leave

• Suboptimal practice and inadequate communications • Documentation of leave arrangements was poor

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Mrs Montalto (2011)

• 76 yo with dementia

• Living in an aged care facility

• Death certificate provided by GP

• Investigation revealed staff had covered up her death

• Coroner Spooner: “This collective disregard for professional and employment requirements and guidelines, suggests a culture of personal rather than resident focussed care.”

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Common themes…

• Poor documentation

• No contemporaneous notes

• Inadequate handover

• Communication between clinicians lacking

• Inadequate risk assessments

• Lies

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Documentation is your best defence

• Critical evidence

• Legal document

• Aide memoir

• Means of communication between clinicians

• Getting questioned about your notes maybe years down the track

• Addendums – write notes at home and add as retrospective note next shift

• Don’t change dates

• Won’t be criticised for retrospective notes

• Admit when discussed with other clinicians

• Poor documentation can lead to inquests

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Some tips…..

• Aim for best practice • Maintain accurate documentation

– Clear notes – Write notes immediately after an incident to refresh your memory – Be truthful

• Be aware of applicable policies and procedures • Risk assessments • Handover • If in doubt, speak to your employer and request legal advice • Don’t embellish or over exaggerate your recollection • You will be assessed/questioned and asked to explain • Deaths – affect clinicians too!

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