Nursing Care Analysis of Christopher Hammitt Case

NUR3020 Assignment 1 Kelly J Wilson
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This paper aims to analyse and examine the case of Christopher Hammitt’s coroner’s inquest
and address the following three sections.
The paper focuses on critiquing and conduct analysis of the nursing care provided to Mr
Hammitt, explore how tort of negligence would apply to the nurses involved in the case and
outline the criterion needed too fulfil for advance claim of negligence and lastly conduct an
analysis of ethical issues in addition to the legal aspects pertaining the event.
This paper will identify several concerns/aspects about the nursing staff which whom have
repeatedly arisen in the coronal inquest report.
Assignment Section 1: Patient Safety

Conduct Analysis of Nursing Care.
The nursing care that was provided to Christopher Hammett following his surgery in the
PACU and Ward care were overall below standard, the staff conduct fell short of what is
expected from the nursing staff whom were in charged of his care.
Failure to reduce risks of harm that were foreseeable and to appropriately recognise critical
events or signs of deterioration can lead to negligent care from the nurse/nurses responsible
for the care provided. ANMAC (Australian Nursing and Midwifery Council), 2005 outlines
in the National Competency Standards for Registered Nurse, section 1.2; a nurse will fulfil
the duty of care by recognising the ‘responsibility to prevent harm, perform nursing
interventions following comprehensive and accurate assessments’ (ANMAC, 2005). This is
further reaffirmed by the Australian Nursing Boards Code of Professional Conduct in
Conduct Statement 1 ‘Nurses practise in a safe and competent manner’ (AMBA, 2006)
stating basically that the responsibility of safe and competent nursing care is there own duty
to be accountable for, be mindful of own scopes of practice, know their limitations and
practise in ways that promotes safe and competent manner (AMBA, 2006).
Basic roles of the nurse involves monitoring and reporting of changes in a patients health
condition, (Elliott & Coventry, 2012) recognising and detecting early signs of clinical
deterioration and respond accordingly, safely and competently to reduce the risks or
likelihood of harm or errors (Elliott & Coventry, 2012; Rogers, Dean, Hwang, & Scott,
2008). Clinical deterioration can occur at any point throughout a person’s illness or care
process, most vulnerable following a surgery procedure (Luettel, Beaumont, & Healey,
2007).
In the coroner’s inquest of Christopher Hammett, a critical clinical incident had occurred in
the PACU; Mr Hammett’s oxygen saturation reading fell to 64% from 100% with suspected
airway obstruction, action was taken by Dr Wooler to correct this. Following the event
subsequent drop in oxygen saturation levels to 64% then rising to 80%, the nurse did notify
the doctor of the event however Mr Hammett was not physically examined nor was
additional assessments or investigation carried out.
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When the nurse had report the event to the doctor and asked to come and see Mr. Hammett
there had been an absence of formal report from the nurse in charge of Mr. Hammett’s care to
Dr. Wooller alerting him of the seriousness of the issue and information regarding the
situation pertaining health status such as basic observations (heart rate, blood pressure,
respiration rate, level of consciousness, pain level) and additional assessment data; lung
palpations or lung sounds. To ensuring continuity of patient care, effective clinical handover
or report to respective health professionals pertaining the care of a patient is vital component
of recovery (Australian Medical Association, 2006).
Effective incident reporting from nurse to doctor or between health professionals is crucial to
the continuum of effective and safe care of the patient (Kingston, Evans, Smith, & Berry,
2004). Failing to provide an effective transmission of information to another health
professional can produce unwanted outcomes, unwanted outcomes may include delays in
accurate diagnosis, treatment and effective care, missed tests, and incorrect treatment
(Australian Commission on Safety and Quality in Health Care, 2012). Whilst
communicating with another health professional and exchanging of information the
information that is generally conveyed is the patient’s identification details, current condition,
recent changes in condition, ongoing plan of care or treatments, concerns and changes or
complications that may arise foreseeably (World Health Organization, 2007). If the nurses
had structured their communication with the doctor of the event or issue of Mr. Hammitt’s
deteriorating or changed condition in a mnemonic form which helps to improve the content
and preciseness of information being conveyed (NSW Agency for Clinical Innovation, 2013),
this would have given Dr. Wooller accurate, precise information from the nurse reporting to
him, allowing him to be alerted to the seriousness of the situation quickly prompting him to
further investigate or explore all possibilities in management of Mr. Hammett. A structured
tool like the ISBAR can help to simplify and effectively organise information that is to be
used when communication information about a patient and their situation (Australian Medical
Association, 2006; NSW Agency for Clinical Innovation, 2013; Yee, Wong, & Turner,
2009).
Additional assessments and investigations could have been done by the nursing staff and
recommendations could have been presented to the doctor to investigate as the low
oxygenation saturation event continued more than 20 minutes (King Edward Memorial
Hospital for Women, 2014; Snowball, 2012). The assessments and investigations that could
have been carried out by the nurses in charge of care; Blood pressure, basic observations
which includes respiratory rate, heart rate, level of consciousness, appearance/colour, and
additional breathing/respiratory assessment; look, feel, listen (Jevon & Ewens, 2012; Steen,
2010), auscultation of the lungs, arterial blood gas analysis and chest X-Ray to evaluate the
effectiveness of breathing, quality of ventilation to a satisfactory level and to rule out other
underlying unfound issue causing respiratory complication and the inability to maintain
oxygen saturation levels above 95%.
The Nurses in charge of Mr. Hammett’s care in general ward on several occasions titrated the
oxygen supply levels to maintain adequate oxygenation saturation levels without any
consultation with the doctor assigned to Mr. Hammett and failed to report Mr. Hammett’s
oxygen saturation levels were not stable at the prescribed oxygen delivery rate from Dr.
Wooller instead of reporting the issue to the treating doctor or medical officer the nurse took
onus to prescribe additional oxygen without due care. Delivering unsuitably high rates of
oxygen can have the likelihood to harm (Snowball, 2012), exposure to high concentrations of
oxygen can lead to respiratory complications; effective monitoring and management is
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crucial to ensure effectiveness of the treatment (King Edward Memorial Hospital for Women,
2014; Snowball, 2012) for its intended purposes. When titrating oxygen therapy, the lowest
concentration should be used to meet oxygenation needs of the patient (Snowball, 2012).
Any patient that is on oxygen therapy should have initial and ongoing regular observations
recorded (heart rate, blood pressure, respiratory rate), level of consciousness/alertness and
oxygen saturation levels (King Edward Memorial Hospital for Women, 2014; Snowball,
2012). In addition a urgent review by a medical officer is needed as soon as possible and
arterial blood gas measurement taken and read as the patient had shown signs of deterioration
(Snowball, 2012); signs may include oxygen saturations below 90% and falling, oxygen
requirements increasing.
Throughout the inquest report there was mention of pain from Mr. Hammitt however there
was no evident action from the nurses to investigate or treat the said pain except to provide
pain relief via the patient controlled analgesia pump device (PCA) as ordered by the
anaesthetist in PACU, two additional administered bolus doses of morphine at 2mg each in
PACU and the administration of ongoing oxygen therapy. The main aim of pain relief is to
provide the patient with comfort and enhance ability to move freely whilst avoiding possible
complication postoperatively (Brown, 2008). For any patient undergoing surgery it is
important that pain assessment is made (Brown, 2008; McMain, 2008) effectively and in a
timely manner, failing to treat the pain from its onset can lead to physical and psychological
adverse outcomes for the patient. The assessment of all types of pain should be done in a
systematic manner and be part of the clinical process, the nurse will need to gather
understanding from the patient the magnitude, quality, location and meaning of their pain that
is being experienced in order to treat the pain appropriately (McMain, 2008).
In the PACU there was a pain scale recorded 4/10, which followed with administration of
two doses of morphine 2mg at 1917hrs and 1918hrs and then was transferred to the general
ward. The administration of opioid analgesic seems a big step especially failing to conduct a
full pain assessment and not following an analgesic pathway which is designed to provide
guidance in effective pain management (McMain, 2008), the idea of such guide is to ensure
that the analgesia is prescribed and administered according to the intensity of pain (McMain,
2008) ensuring safe dosing protocols are adhered too. Pain sensitivity, threshold and
tolerance differs from person to person (McMain, 2008), it is not up to the nurse to determine
the patients how much pain they are going through experiencing. The Code of Ethics for
Nurses in Australia (AMBA, 2005) outlines in statement 4 & 6 in point 2 & 6 that that nurses
have a vital role of being non-judgemental and non-prejudicial; detect and prevent error or
adverse events that may result in harm to the patient, understanding that the person in their
care are vulnerable to such events, the nurse must act as advocates for their patients
regardless what personal beliefs or opinions they themselves may have. The nurses had failed
on multiple occasions to report to the anaesthetist whilst in PACU and to the medical officer
in charge whilst on general ward in regards to changes in health status and properly ensure
the medical officer was fully aware of Mr. Hammitt’s declining condition (Beaumont,
Luettel, & Thomson, 2008; Cusack & Parry, 2014; Luettel et al., 2007; Macintyre, 2001;
McMain, 2008).
Assignment Section 2: The Tort of Negligence.

Conduct Analysis of Nursing Care.
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Negligence occurs when there had been conduct performed by a person that is wrong because
it fails to meet minimum standard of what a reasonable person is expected to do in protecting
persons in their care from foreseeable risks of harm (Then & McDonald, 2014). Nursing
negligence occurs when a competent nurse fails to provide safe, effective, ethical and
professional standard in such a way that a reasonable prudent nurse would and as a result the
patient suffers unnecessarily. A nurse owes her patients a duty of care in accordance to the
Code of Professional Conduct for Nurses in Australia (AMBA, 2006) however for an cause
of action to be taken against a nurse there are elements that must be met to successfully prove
negligence. The keyword in all this is “reasonable,” What is reasonable for a nurse?, a nurse
is held to reasonable nursing standards of care and professional conduct which is set out by
the Nursing and Midwifery Board Australia; judged against what another nurse would do in
the similar set of circumstances in the same situation (Then & McDonald, 2014).
The elements needed to substantiate a claim of negligence are; the nurse owed a duty of care,
the nurse had breached of duty (the standard of care) and the patient was injured (Then &
McDonald, 2014; Tingle, 2002; Todd, 2011). When a duty of care has been established it is
then determined whether it had been breached by establishing the standard of care and
finding if that had been breached (Then & McDonald, 2014). The standard of care is
described by common law where a ordinary, competent nurse in the same situation would
reasonably act and expected to act in relation to the provision of professional advice, care or
treatment (Then & McDonald, 2014; Tingle, 2002).
During 2200hrs and 0300hrs RN Gibbons and EN Valentine was in charge of Mr. Hammitt’s
care throughout night shift, throughout this shift the nurses had failed to recognised critical
events and uphold their standard of cared to prevent likelihood of harm foreseeable to occur.
The nurses failed to notified the medical officer of the decline of oxygen saturation levels and
inability to maintain adequate oxygen saturation levels instead they increased oxygen flow
and changed delivery device without further consult with a medical officer, a medical officer
in both instances needed a medical officer to be notified and be reviewed by the medical
officer (King Edward Memorial Hospital for Women, 2014; Snowball, 2012).
RN Gibbons had failed to investigate into reasons as to why Mr. Hammitt was continuing to
remove oxygen mask despite having handed over from previous shift that he was
complaining of high pain levels and the PCA displaying high demands for analgesia. RN
Gibbons should have investigated to why Mr. Hammitt is in pain, conduct assessment of his
pain, sought advice and review from the medical officer to better manage his pain and
investigate the cause of his pain (Ashley & Given, 2008; McMain, 2008; SLM, 1998; Tan,
Law, & Gan, 2014).
RN Gibbons showed admission of guilt and wrong doing when observed by the EN Valentine
removing papers from Mr. Hammitt’s chart and making alterations to the recorded alterations
to the observations. By doing this is an offence against the Criminal Code Act Chapter 46
section 430 and 488 part 1 (Office of the Queensland Parliamentary Counsel, 2015) states
that altering/tampering of a record document is unlawful by having the intent to defraud by
making a false entry in records and in knowing that it is incorrect.
RN Gibbons failed to uphold a duty of care, breached her duty or did not act as a reasonable,
prudent nurse would (Then & McDonald, 2014; Todd, 2011) and Mr. Hammitt was harmed
due to proximate breach of duty of RN Gibbons.
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Assignment Section 3: Ethical Issues.

Conduct Analysis of Ethical Actions.
Ethics in nursing is simply to engage in acts that are morally and ethically right that are in the
best interests of the patient (“Ethics in Nursing,” 2003). RN Manton had not upheld his
ethical obligation as he did not respect his patient or provide kindness in his care, Code of
Ethics for Nurses in Australia statement 2 point 2 (AMBA, 2005). Whilst handing over to the
oncoming shift, RN Manton describes Mr. Hammitt as a “wimp” because he was continually
complaining of pain however there is no record of RN Manton advocating for his patient to
be reviewed or seen by a medical officer to better manage his pain, no record of pain
assessment, and did not report or escalate the issue to the medical officer instead he ignored
Mr. Hammitt and gave him a label discriminating him to the oncoming shift and not provide
any relief for his pain (Todd, 2011). RN Manton should have took a positive action in
protecting and advocating for his patient right for effective pain relief and to be reviewed if
not working; having the respect to not label a person regardless of their behaviour
(Beauchamp & Childress, 2009; Luettel et al., 2007).
Throughout the all proceedings of the case there was evident that the nurses made no attempt
in reporting or escalating issues regarding Mr. Hammitt’s deteriorating health status
(Chiarella & McInnes, 2008), there were times that warranted the medical officer to be
present, needed consultation and be reported too (King Edward Memorial Hospital for
Women, 2014; Snowball, 2012; Steen, 2010). The nurses had taken onus to themselves
thinking they knew best to manage Mr. Hammitt.
EN Valentine observed RN Gibbson removing papers from Mr. Hammitt’s chart and making
alterations to the recorded alterations to the observations, altering/tampering of a record
document is unlawful by having the intent to defraud by making a false entry in records and
in knowing that it is incorrect, Criminal Code Act Chapter 46 section 430 and 488 part 1
(Office of the Queensland Parliamentary Counsel, 2015). This contravenes the Code of
Ethics for Nurses in Australia statement 7 (AMBA, 2005) where the nurse values ethical
management of information that includes a patients health care recording containing records
of observations, progress notes, medication and history . All information is to be recorded
accurately, non-judgemental, relevant and respected with dignity ensuring privacy (AMBA,
2005; Chiarella & McInnes, 2008; Tingle, 2002).
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NUR3020 Assignment 1 Kelly J Wilson

Assignment Section 1: Patient Safety

Assignment Section 2: The Tort of Negligence.

Assignment Section 3: Ethical Issues.

Sussex: Wiley-Blackwell. Retrieved from

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