Background • James MacDougall is 38 ears

Background • James MacDougall is 38 ears of age. • James has been admitted to ward 4E with a three day history of a headache (occipital region), which he describes as throbbing and continuous in nature. • He is married and has three young children. – James is described as having a great sense of humour and fun. He is a caring and very engaging father to his sons, and a loving partner, son and friend. Presenting assessment • Headache accompanied with neck pain and stiffness. – Increasing severity of headaches over 3 day history • Febrile 38.3°C • GCS15/15 . Pupils equal and accommodating to light – Past medical history: Viral meningitis (4 years ago), severe obstructive sleep apnea (diagnosed 3 years ago), and generalised anxiety disorder • Normal medications: Diazepam, Sertraline Date 7/7 Time: 14:40 hours Nursing notes Patient receiving treatment for suspected viral meningitis Lumbar puncture performed results indicate nil increased in white cell count and CT head reported as normal with no evidence of intracranial hemorrhage. 10mg IV morphine administered for headache (8/10 with effect (pain rating 5/10, GSC 15/15, pupils equal and reactive to light and accommodating, Episode of desaturation (5002 79%) recorded at 19:20 hours, spontaneously reversed on rousing patient, Plan – to be admitted to 4W for ongoing antivira treatment and analgesia, K Roberts (ED RN) Ward admission 4W (day 2) • 8/7: Patient admitted 20:15hours with suspected viral meningitis and history of anxiety. Patient appears anxious and reporting severe headaches (8/10) – patient states head is pounding, with neck and back soreness. GCS 15/15, nil disturbance to visual acuity. Analgesia administered as per medication chart with effect. Vital signs stable. E Simpson (EEN) Nursing entry day 3; 9/9/21 21:30hours • James alert and coherent, mobile and self caring over the shift. Vital signs stable and febrile as documented. Continues to report ongoing headaches with pain reported as 7-8/10, Ordine 40mg administered with some effect (pain 6/10).Medication administered as per chart. Appears anxious watching television in bed at time of report. A Greecezel(RN) – Vital signs documented 20:00 hours • Temperature 36.9°C, heart rate 77 beats per minute, Blood pressure 124/64Hgmm, respiratory rate 14 breaths/minute, Sp02 94% on room air. Nursing entry night shift 9/9/21 21:30 10/9/21 07:00) • Patient in good spirits at commencement of shift, appears happier. Slept intermittently overnight. Headaches remain an issue medications administered as charted. Nil further changes. E Simpson (EEN) – Vital signs reported 02:00 • Pulse 95 beats/min, Sp02 89% increased to 93% with patient rousing on room air, respiratory rate 14 breaths/ min Nursing notes Day 4 (10/7/21) morning shift * James distressed this morning reporting intolerable headache and neck stiffness, OxyContin 40 mg administered 07:15 hours for ongoing headaches. Dr Brokett contacted at 07:50 hours to clarify PRN Ordine order – Dr Brokett confirmed Ordine order can be administered third hourly, verbal order confirmed to RN Juan. Ordine 20 mg administered 07:50 hours secondary to poorly controlled pain. A Risedale (RN) – Vital signs 08:00 Temperature 37,2°C, heart rate 87 beats per minute, Blood pressure 118/64Hgmm, respiratory rate 12 breaths/minute, Sp02 85% initially, increasing to 88% on room air. • 3 litres of oxygen applied with Sp02 increasing 92%. Patient reports no prior or underlying respiratory issues, patient does not appear to be distressed, no evidence of cyanosis, alert and interactive. • 10.00 hours – responding to patient call bell; James reported increase in headache intensity, vital signs remain stable, 5p02 93% on 3L/min of oxygen. 40 mg Ordine administered, with effect – patient reporting headache improved, mobilising independently and preparing for a shower. • Vital signs 11:30 hours: temperature 36.9°C, heart rate 97 beats per minute, Blood pressure 115/68Hgmm, respiratory rate 18 breaths/minute, Sp02 93% on 3L/min of oxygen • 15:30 hours: Ongoing headaches over this shift, patient requesting analgesia frequently, administered 40 mg Ordine 13-40 hours and additional oral adjuncts. Patient appears fatigues this afternoon, requesting curtains to closed and lights off Remains alter or orientated. Nursing notes Day 4 (10/7/21)afternoon shift • 16:30 hours patient resting this afternoon, headaches remain a concern patient reports headache as severe , 40mg Ordine administered with paracetamol 1G. Nasal prongs reapplied and repositioned – patient finding them irritating, remains alert and interactive • Vital signs(16:00hours): Temperature 37.7°C, heart rate 100 beats per minute Blood pressure 120/72mmHg, respiratory rate 18 on 2L/min oxygen via nasal prongs. A Greecezel (RN) • 20:00: Patient alert and orientated, resting this evening. Medications administered as charted. Headaches remain severe +++ • Vital signs (20:00 hours): Temperature 37.1°C, heart rate 102 beats per minute Blood pressure 130/84mmHg, respiratory rate 20 on 2L/min oxygen via nasal prongs. Patient encouraged to keep nasal prongs insitu. A Greecezel (RN) Nursing note: Day 4 (10/7/21) Night duty • Midnight: Patient appeared in good spirits this evening at commencement of shift. Changes to analgesia made by treating doctor earlier this afternoon, patient continues to report headaches with some decrease in intensity. Visual checks performed – patient asleep and snoring.Sp02 90% on room air. E Simpson (EEN) • 11/7/21: 02:00 hours visual check performed patient asleep and snoring intermittently. E Simpson (EEN) • 11/7/21: 04:40 Code blue initiated, patient found unresponsive and pulseless on assessment. CPR commenced 04:42hours , Guedel airway inserted 04.44hours 11/7/21: 05:15hours resuscitation efforts ceased. Patient declared deceased at 05:15hours. Analyse the Coroner’s case to identify the issues (what happened and why it happened) in care delivery that contributed to a failure to recognize and respond to clinical deterioration. Discuss how the issues identified, in conjunction with the patient presentation, medical history, and underlying pathophysiological processes led to the clinical deterioration

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