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Negligence in Hospitals by Healthcare Providers

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Negligence in hospitals by healthcare providers puts the lives of patients in danger and extreme instances it is the cause of death. When patients die in such incidences the matter is presented to the coroner for an investigation into the conduct of the health workers in question to establish the role they played or failed to in order to safe guard the life of the patient.

A good example of a case study of such an incident is the nursing case study of RN Pandya & RN Prasad (Dobrowolska, Wrońska, Fidecki, & Wysokiński, 2017). The two were the nurses on duty when Patient A who had been admitted in the acute ward of a mental health facility in the western Sydney district. (Dobrowolska, Wrońska, Fidecki, & Wysokiński,2017). Patient A apparently took his own life when RN Pandya was about to end his shift and hand over to RN Prasad who was beginning her shift.

Inquiries into the death of Patient A, by the coroner found the two nurses in violation of their professional code of conduct i.e., the registered nurse standard practice and in violation of the general information policy document of the western Sydney local health district, as well as The National Safety and Quality Health Service (NSQHS) Standards (Boyd & Sheen, 2014).

The obvious mistakes committed by the two nurses was that one nurse, RN Pandya left half an hour early from his shift on that day and that RN Prasad who took over from him, went against the stipulated guidelines by inappropriately signing the behavioral record of the patient before the end of the shift among many other offenses, as a result, the Professional Standards Committee had to inquire into the conduct of RN Prasad and RN Pandya during their shifts on that particular day and the care they gave the patient.

The following paper seeks to identify and highlight the professional practice issues that arise in the case study in question. It also discusses measures to be taken to avoid the occurrences of such incidences in the future.

Patients and all healthcare consumers put their lives in the hands of healthcare providers trusting they will be taken care of and they expect the utmost care and high-quality services because they trust they are in good hands (Bryce, Foley & Reeves 2017) Quality health services are consumer-centered, they seek to ensure healthcare consumers are rendered to, the service and healthcare they deserve.

In Australia, The National Safety and Quality Health Service (NSQHS), gives guidelines based on set standards on the level and quality of care consumers can expect from health care providers. The commission (NSQHS) came up with eight statements and it is based on these eight statements that the commission in collaboration with the Australian governments seeks to achieve a nationally consistent level in the quality of health care in Australian territories and states (Flanigan, 2016).

To discuss the professional practice issues arising from the incidence we will look at the individual mistakes each of the nurses committed. To start the discussion, we will focus on the mistakes of the nurse at the center of the scandal (Roughead & Semple 2019).

Professional Practice Issues on RN Pandya

According to the (NSQHS) guidelines on communicating for safety standards, one of the errors committed by RN Pandya the nurse on duty during the day Patient A took his own life was a failure to communicate with the team leader that he intended to leave from the shift early (Bryce, Foley & Reeves, 2017).

Effective communication in the health sector is key to providing fast and timely health care (Dobrowolska, Wrońska, Fidecki, & Wysokiński, 2017). Clear and concise communication is required throughout patients’ care, it helps identify high-risk times and allows effective and timely response. The general information policy document of western Sydney local health district presented during the hearing required that all staff request permission before proceeding for meal breaks or on completion and for any other reason (Flanigan, 2016)

By not effectively communicating about his intentions to leave the shift early for another, He did not let the team leader know they were understaffed for appropriate measures to be taken. He was also in violation of the general information policy document of the Western Sydney Local Health district which stipulated that he had to obtain permission before leaving (Pryzwansky & Wendt, 2019).

According to the registered nurse standard practice guidelines for nurses, RN Pandya had also acted against the set standards of practice.

The registered nurse standards require that a nurse thinks critically and analyze the nursing practice (Ritchie, Gaca, Siemensma, Taylor & Gilbert, 2018). In leaving without obtaining consent, RN Pandya failed to analyze the situation through critical thinking and make decisions based on the guidelines of the registered nurses. He was required to give notice to the team leader that he was completing his shift; by giving notice to the team leader alternative arrangements would have been made to cover his absence (Ritchie, Gaca, Siemensma, Taylor & Gilbert, 2018). He also failed to conduct proper handover of his allocated patients but instead left the floor short staffed; having not completed his behavioral observations for the patient (Ritchie, Gaca, Siemensma, Taylor & Gilbert, 2018).

Professional Practice Issues on RN Prasad

The first professional issue concerning RN Prasad, it is that he inappropriately signed the behavioral observations records for Patient A for times when she had not been in any direct contact or having interacted. She was prompted to do so, upon the departure of RN Pandya (Dobrowolska, Wrońska, Fidecki, & Wysokiński, 2017).  On her volution, she decided to take the initiative to complete the unfilled entries of the patient who was under the care of her colleague who left without filling the behavioral observation records of the patient (Dobrowolska, Wrońska, Fidecki, & Wysokiński, 2017).

The second issue against RN Prasad is that she inaptly left the floor to go to handover when she ought to have been aware there was inadequate staff on the floor, she did not bother to ensure there was sufficient staff in the unit, and there was little knowledge or information about Patient A’s status (Dobrowolska, Wrońska, Fidecki, & Wysokiński, 2017). The NSQH has a set standard for Identifying and Replying to Acute Worsening. The said standard aims to ensure that a person’s acute deterioration is recognized promptly and appropriate action is taken. Acute deterioration includes physical changes, as well as acute changes in reasoning and mental state (Ritchie, Gaca, Siemensma, Taylor & Gilbert, 2018). The Bungarribee House policies and procedures provided that two nursing staff would be unceasingly existing to offer regulation to acute patients (Boyd & Sheen, 2014). The strategy also stated that it was the obligation of the particular nursing worker to organize with the team leader for the delivery of relief for the periods of absenteeism before those periods of absence occur (Dobrowolska, Wrońska, Fidecki, & Wysokiński, 2017).

Thirdly, when RN Prasad went to look for Patient A, she exercised poor judgment in not searching the bathroom attached to his room (Dobrowolska, Wrońska, Fidecki, & Wysokiński, 2017). The time she took leaving the room before finding another nurse to help look for the patient would have been what it took to save the patient, her assumption that the patient would be where she had left him was a misjudgment on her part (Meyer et al., 2017).


            To avoid similar incidences in the future, this paper recommends that hospital management staff should put in place systems to monitor when staff and patients are within the health facility and when they live. The system would keep a record of the number of patients and staff at the facility at any one given time and the exact location of their jurisdiction.

            Strict and stringent policies on who should make entries on patients’ behavioral records should also be put in place. No healthcare giver will be allowed to sign or make entries on behalf of another. This will ensure consistency in patients’ records by ensuring only those who make the observation fill and sign on the patient’s documents and records.

            Health institutions should also consider ensuring that when scheduling shifts, they consider times when health practitioners have to change shifts for another in another facility, this will ensure a smooth transition between shifts while allowing enough time for transition.


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Annandale, E. (2015). Working on the front-line: risk culture and nursing in the new NHS. The       Sociological Review, 44(3), 416-451.

Bryce, J., Foley, E., & Reeves, J. (2017). Conduct most becoming. Australian Nursing and Midwifery                 Journal, 25(6), 25.

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Flanigan, K. (2016). NSQHS standard-patient identification. ACORN: The Journal of Perioperative Nursing in Australia, 29(1), 23.

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Meyer, G.J., Finn, S.E., Eyde, L.D., Kay, G.G., Moreland, K.L., Dies, R.R., Eisman, E.J., 2017.                Psychological testing and psychological assessment: A review of evidence and                issues. American psychologist, 56(2), p.128.

Pryzwansky, W. B., & Wendt, R. N. (2019). Professional and ethical issues in psychology: Foundations of practice. WW Norton & Co.

Roughead E, Semple S. (2019) Medication safety in acute care in Australia: where are we now? Part 1: a review of the extent and causes of medication problems 2002–2008.      Aust New Zealand Health Policy, 6(1):18.

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