Assessment 2-Clinical Governance Report
The following case study is presented so that you can write a formative investigative report. This case
study is drawn from an actual event and as such all details are a matter of public record. For the
purpose of this assessment task, all names of people involved have been de identified or an alias has
been used. Please be aware that this case study provides the details of a person who is now deceased
and as such may cause distress.

Case study
John aged 44 presented to the Emergency Department at a large metropolitan hospital on the early
hours of Wednesday morning at 0300hrs. By 0900hrs John had the first of 3 cardiac arrests. At
1043hrs John was pronounced dead.
John was a fit and healthy man of Indigenous descent. A father and grandfather from a large family.
He was well respected in his community. He had full time employment as a shift worker.
John presented to a large metropolitan hospital at 0302hrs on the 2nd February 2014. Three days
prior to the presentation at the ED department John had been involved in a physical altercation in
which he sustained fractured ribs, a broken nose and a swollen and bruised eye from being kicked
and punched in the abdomen, head, chest and groin by 3-4 assailants. He did not seek medical
assistance at that time. His family reported that after the physical assault, John was walking yet
holding the left side of his chest , complained that he thought he had “a broken nose” and that he
had said it was “a little hard to breathe”.
On presentation at the ED he was triaged as a Category 2 at 0306hrs by nursing and medical staff.
The nursing notes documented in the history that John had been “kicked” to the chest and stomach.
The doctor’s notes documented that John had been “punched” in the face, chest and abdomen.
Both of these documents were compiled separately on loose paper until the nurse placed them
together some time later as is the common practice.
Observations were recorded on the SAGO chart (Between the Flags Chart). A CT scan was ordered
which identified fractured ribs (5
th and 9th), a fractured nose and a small pneumothorax in the left
lung. The reporting radiologist noted consolidation in the right lung which was more likely to be
consistent with “blood rather than and infection” and that there was evidence in both lungs of
pulmonary contusion and/or oedema.
On admission at 0315hrs the nursing notes identified that John had increasing shortness of breath, a
respiratory rate of 30 breaths per minute, temp 35.1C, BP 98/90. The nurses noted that John felt
At 0345hrs his observations were BP 90/70, resps 35 per minute, pulse 120 bpm( this was only
recorded once during the time of presentation until John went in to full cardiac arrest) oxygen
saturation was 93% (SaO2) on room air. No further observations were recorded until 0645 hrs.
Oxygen was provided via a non-rebreather (NRB) facemask, there was no notation as to what the
oxygen flow rate was. During the course of events this was changed to oxygen being delivered by
nasal prongs at a high flow rate, there was no notation of when this occurred.
A pathology request was ordered by the doctor in the ED for a full blood count (FBC) and Arterial
Blood Gases(ABG) on admission. ABG’s were processed at 0335hrs which showed severe lactic
acidosis. Elevated lactate was 12.7 mmol/L and pH 7.22, serum creatinine was 302 mmol/L. The
blood gas results were available at 0445hrs. The doctor reviewed the results at 0515hrs and states
that he did not notice the low level white cell count (WCC) of 0.7 x 109
At 0520hrs the nurse signed for the administration of 2 x 1Litre Normal Saline given IV. This was
recorded on the fluid balance chart, the nurses noted that the patient had not yet voided.
At 0530hrs Antibiotics Ceftriaxone 1g IV and Azithromycin 500mg IV were charted and given.
At 0610hrs Endone 5mg (orally) was given to John for the pain in his leg.
At 0645hrs observations were charted SaO2 93%, BP 95/85, Temp 35.1(no record of pulse or
respirations taken)
The plan for John was to send him to HDU for further monitoring, continue with oxygen, blood tests
to be repeated, an indwelling catheter to be inserted and another chest xray to be performed.
At 0700hrs nursing night shift gave handover to the morning shift. A further 1g of Panadol (PO) and
Fentanyl IV 50 mcg were given at 0735 for pain management by the nurse on the morning shift.
At 0740hrs the nurse now caring for John noted that he was in respiratory distress- tachypnoeic and
hypoxic at 85% (SaO2). Oxygen via nasal cannula was increased from FiO2 28% to 30%.
At 0750hrs a third litre of Normal Saline was commenced to run over 4 hours and a further dose of
IV Fentanyl was given at 0755hrs for pain.
At 0800hrs the medical staff handover occurred. The doctor ordered an increase in Oxygen flow FiO2
to 60% via nasal cannula and a repeat ABG was ordered.
At 0820hrs the nursing notes document that John was coughing up brown type liquid and that he
sounded more congested in upper respiratory tract. An audible wheeze was present.
At this time the decision was made to intubate John.
At 0855hrs John had a seizure, no pulse was found and CPR commenced. A carotid pulse was
detected at 1001hrs and CPR ceased at that time.
At 1013hrs CPR was recommenced when John went in to the second cardiac arrest which lasted for
20 minutes. He then subsequently arrested a third time and was pronounced deceased at 1043 hrs.
The coroner report placed the cause of death as being multi organ failure secondary to septic shock
originating from pneumonia attributed to his fractured ribs.
The task in this assignment is to:
Write a ‘Formal Investigative Report’ about a critical incident that has occurred. The critical incident will be provided on the Interact2 site

Please use the below as a guide of what to include in this report;

Introduction/Background to the Incident: A short introduction including what the report is about followed by a brief background to the critical incident. Using the Severity Assessment Code (SAC) Matrix allocate a rating and explain why you gave this score.

Factors/ Flow chart: Critically examine the case to identify and explore all the predisposing factors that lead to the outcome, these factors are the ‘root causes’. This information needs to be supported by a flow chart with annotations to present the complex details of the incident in an easy to view format.

Analysis: Analysis of the information presented in the ‘factors’ section can be referred to as a ‘root cause analysis’ (RCA). The predisposing factors are explored in regards to why they existed and how they lead to the incident. Any relationships between the factors is also explained. Use a ‘patient safety model’ diagram to demonstrate the factors that were the root causes that lead to the incident and to identify factors that if mitigated would have prevented the incident from occurring.

Discussion: In this section of the report current evidence-based peer reviewed literature is explored in relation to the incident and the root causes of the incident to develop a deeper understanding of the why the incident occurred, what should have happened and how it could be prevented in the future. The NMBA competencies should be discussed in relation to professional best practice with two (2) relevant competencies being explored further. The literature discussed needs to be of a high quality and be current.

Recommendations: Evidence-based recommendations are made, which if implemented correctly would prevent the same incident from occurring again. Literature which supports the recommendations needs to be presented, otherwise the report will have little credibility. Any recommendations must address the identified pre-disposing factors, in particular the ‘root causes’ and explain how the recommendations will mitigate these factors using a clear and logical approach.

A Registered Nurse is expected to be able to reflect on and analyse their clinical practice and to be aware of the systems in which they function. It is important to be aware of and involved in quality improvement processes.

This assessment task will allow the student to explore these quality assurance processes and to gain an understanding of the importance of their role as a Registered Nurse in regard to patient safety.


**NSW risk management link (page 37 & 38)

***The Registered nurse standards for practice consist of the following seven standards:
1. Thinks critically and analyses nursing practice.
2. Engages in therapeutic and professional relationships.
3. Maintains the capability for practice.
4. Comprehensively conducts assessments.
5. Develops a plan for nursing practice.
Registered nurse standards for practice
Page 2 of 8
6. Provides safe, appropriate and responsive quality nursing practice.
7. Evaluates outcomes to inform nursing practice.