Critically examine the case to identify and explore all the predisposing factors that lead to the outcome, these factors are the ‘root causes’.

Clinical Governance Report

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