Coroner Case Essay Example

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Coroner Case

Summary of Coroner’s Findings

Mr. Ian Trengove died at the age of 81 at St Andrews Hospital on 30th March 2008. The cause of death, as indicated in the postmortem report carried out by Dr. Gilbert, was retroperitoneal hemorrhage complicating pelvic fractures with contributing warfarin anticoagulation and hypertensive heart disease. Mr. Trengove had a medical history of complete heart block with subsequent pacemaker insertion in 1981, hypertension, congestive cardiac failure, ischemic heart disease with previous coronary artery stenting, atrial fibrillation, and insertion of a pacemaker/defibrillator in 2006 and a transurethral resection of the prostate gland. Due to atrial fibrillation, the patients are at risk of developing blood clots that can block important blood vessel resulting to complication and other conditions such as stroke (Tripodi, et al, 2012). To minimize the risk, he had been placed the anticoagulant drug warfarin that is orally taken.

Anticoagulant drug, however, has other risks as the patient using the drug may experience excessive bleeding in the event of a traumatic injury. This is because the drug reduces the tendency of the blood to clot (Lewis, et al., 2014). The amount of anticoagulant in the blood can be measured using a blood test known as INR. Mr. Trengove had suffered an accidental fall while performing his duties as a verger in St John’s Anglican Church. He was taken to St Andrew Hospital where an x-ray indicated that there were minimally displaced fractures through the superior public ramus and the junction of the pubic body and inferior ramus in the right side. The hip joint showed minor degenerative changes, but no pelvic fracture was seen. Dr Miller, who first examined him, was unable to locate the location of the bleeding as he indicated that no major blood vessel had been affected. The excessive bleeding resulted from the intake of anticoagulants and the failure of Dr. Gilbert to carry out the INR blood test which would have relieved the bleeding.

The administration of the Daily dose of anticoagulant by Dr. Miller was faulted as he had not carried out any blood test. Mr. Trengove was later referred to Dr. Lakshmanan, who was also leaving the hospital at night. The management of the patient during the nigh also contributed to the death. The nurses frequently consulted Dr. Lakshmanan based on the condition of the patient. At one point recommended the administration of stemetil and indocid which also contributed to the problem. The assumption made by Dr. Lakshmanan was not corrected and there was no focus on the injury during the management of the patient. This is even after the nurse in her report made suggestions that could have indicated the patient was bleeding excessively. Regular monitoring through blood tests should be carried out on a patient under the anticoagulants (Bruno, et al, 2015).The death of Mr. Trengove could have been avoided had the doctors carried out proper diagnosis and prescriptions. The Coroner’s report indicates that poor management of the patient contributed to the death. Dr. Lakshmanan was especially focusing on the wrong aspects despite the medical history of the patient.



According to Ignatavicius and Workman (2015), documentation is an important aspect of medical and nursing. It is considered as a tool that supports the continuous and efficient way of understanding the medical history of the patient. Documentation plays an essential role in promoting continuity, safety and good quality of care. The primary purposes of documentation are to facilitate the flow of information in order to support continuity, quality and safety of care (Ignatavicius & Workman, 2015). In the case of Mr. Trengove, the documentation was available and the medical history of the patient was well known. However, it was not utilized. The drugs that were prescribed to the patients had the potential of aggravating the bleeding. This is a consideration that Dr. Miller and Lakshmanan should have utilized. The use of the medical history of the patient can contribute to saving the life of the patient (Walter, et al, 2012). The health record of the patient could have ensured that the doctors put more emphasizes on the aspect of bleeding as a result of the accident. Dr. Lakshmanan also ignored the information that had been documented by the nurses who was monitoring the condition of the patient at night. The use of the information documented by the nurse would have ensured that proper procedures are carried out immediately. The decision-making process by the doctors can be enhanced through the use of the records. The doctors in the case of Mr. Trengove were mainly relying on assumptions as opposed to documentation and hence impacting negatively on the management of the patient (Ignatavicius & Workman, 2015).

Ethical decision making

According to Tripodi et al., (2012), the healthcare environment is experiencing a lot of changes which has led to the question of ethics. The medical personnel have to consider the moral issues in order to make the appropriate decisions. The doctors and nurses have to consider the legal issues and regulatory implications during the decision-making process. This is for the benefits of the patients who are in need of the medical services. The ethical decision-making by the medical personnel requires effective decisions that determines the course of treatment are made (Polit & Beck, 2013). In the case of Mr. Trengove, the ethical decision-making concept was not fully utilized. Mr. Trengove was not admitted in the high dependence unit in order to ensure that the monitoring process is effective. The decision that was made by the doctors in terms of providing medication was not in consideration of the ethical concepts. However, the nurse who was monitoring the condition of Mr. Trengove maintained high levels of ethics. Before making any decision he called Dr. Lakshmanan, for the purposes of consultations. The coroner reports also indicate that the nurses had shown a lot of consideration due to the deteriorating conditions of the patient. All the decisions that the nurse made was for the best interest of the patient. However, the nurse did not have adequate information about the problem that the patient was facing due to the reliance on the information provided by the doctors. Ethical considerations are therefore useful during the decision making process as it promotes the best interest of the patients (Walter, S, et al, 2012).


Advocacy is mainly concerned with the rights of the patients. The doctors and nurses are supposed to advocate for the rights of the patients by providing them with adequate information about their health as well as supporting and educating the patients. The nurses and doctors are supposed to provide high quality care to the patients in order to promote their recovery. Advocacy also requires the nurses and doctors to engage in activities that saves the lives of the patients (Hamric, 2013). In the case of Mr. Trengove, the nurse monitoring him at night played an important role in terms of advocacy. This was through putting in place measures to ensure that the pain and distress and the patient was facing was eliminated. Calls were made to the doctor any time the patient was in pain. High level of monitoring was carried out by the nurse in order to ensure that the condition of the patient is improved. The nurse monitoring the patient also consulted another nurse in order to ensure that the needs of the patient are met. The high levels of advocacy by the nurse led to the close monitoring of the condition of the patient throughout the night. However, the doctors did not play much role in terms of advocacy. The doctor did not critically analyze the problem that was facing the patient. This led to poor management of the condition of the patient which was also a contributing factor to his death. The quality of care of the patients can be improved through advocacy by the nurses and doctors (Ibrahim, et al, 2013).

Leadership/ Management

In terms of leadership and management, the nurses have an obligation to their clients to demand practice environment that have human as well as organizational support that promotes the well being of the patients (Hamric, 2013). Williams and Hopper (2015) argue that leadership also involves shared responsibilities among the medical personnel. Leadership also requires the nurses and other medical personnel to be advocates of quality care, collaborators, communicators, mentors, role models, risk takers and visionary (Williams & Hopper, 2015). The two doctors at St Andrews did not show proper leadership and management during the treatment of Mr. Trengove. This is because of the poor patient management strategies. The doctors failed to consider the critical issues related to the health of the patient and hence contributing to the death. However, strong leadership and management skills were portrayed by the nurse who was monitoring the patient at night. This is despite the low levels of experience that she had. Constant communication with the patient and the doctor when monitoring the condition of the patient is an indication of good leadership and management style (Huber, 2013). Consultations with the doctor and the other nurses are also an indication of good leadership and management skills on the part of the nurse. All the efforts were mainly for the purposes of benefiting the patient which is vital when providing care to the patients. Advocacy for the needs of the patients is also an indication that the nurse had strong leadership and management skills. The presence of strong leadership and management skills can lead to enhance care for the patients (Williams & Hopper, 2015).

Organizational culture

Organizational culture involves the values and behaviours that contribute to the unique social and psychological environment of the organization. The organizational culture also represents the collective values, beliefs and principles of the members of the organization. According to Huber (2013), organizational culture influences the delivery of services to the customers. How an organization handles a certain situation is greatly affected by the organizational culture of the organization (Polit & Beck, 2013). The organizational culture of St Andrews indicates that the level of interaction between the patients and the doctors is not high. However, the personnel at the hospital work closely with each other. The doctors and the nurses strictly rely on the information that has been provided to them by their colleague. The decision making process is however not collective. The doctors are responsible for making the final decisions with regards to the conditions of the patients (Huber, 2013). It is for this reason that the nurses was only relying on the instructions provided by the doctor. The organizational culture of the company therefore affects the quality of healthcare services provided to patients. It is for this reason that the coroner’s report recommended some changes with regards to the procedures at the hospital. The organizational culture of the company however allows for some levels of consultations between the staff members. It is due to this reason that the nurse kept consulting the doctor throughout the night. The doctor was available for consultations during the night despite not being on duty. This is an indication that the organizational culture promoted the needs of the patients (Huber, 2013).

How the deceased death may be prevented

The death of the patients could have been prevented if proper management plans would have been put in place. The medical history of the patient is an important factor that the doctors have to consider (Ibrahim, et al, 2013). Dr. Miller who was the first to analyze the conditions of the patient did not focus on the medical history of the patient. Based on the injury of the patient, hemorrhage was expected. Since Mr. Trengove was on anticoagulants any form of bleeding could have endangered his life. Focus on identifying the exact site of the bleeding would have saved the life of the patient. A blood test was not carried out at the emergency department to establish the levels of anticoagulants in the blood. This process could have identified the risk that Mr. Trengove could face in terms of bleeding. The failure of Dr. Miller to order INR test was a major mistake in the management plan of the patient. This test alone can influence the treatment plan as well as the diagnosis of the patient (Moore & Jones, 2015). The test could have prevented the doctor from administering the normal dosage of anticoagulants. The failure of Dr. Miller to carry out the blood test influenced the decision making process of Dr. Lakshmanan. The coroner’s report also indicated that Dr. Lakshmanan wondered why no blood test was carried out as it is a common practice at the emergency department. The death of the patients was a result of assumptions that were made by the doctor regarding the conditions of the patient.

The lack of proper analysis of the conditions of the patient is a factor that may contribute to their death (Neate, et al, 2013). The two doctors who attended to the patient did not carry out their duties effectively and it is as a result of their actions and inactions that the patient died. The x-ray results was not well analyzed by Dr. Miller and hence leading to the false assumption. Based on the expertise and experience of the doctor they would have done more to save the life of the patient. The doctors could have ensured that the patient is admitted on the high dependency unit after the tests are carried out. This would have ensured that his condition is closely monitored and appropriate action taken. A medical examination during the night was not carried out despite the deteriorating conditions of the patient. The medical test would have contributed to saving the life of the patient. Dr. Waters who was giving his expert view also indicated that the patient should not have been administered with indocid as it contributes to the bleeding of the patient. It was not clear why the two doctors who attended to the patient did not put more focus on the medical history of the patient that would have resulted to proper medication and care. The patient was not a risk of death until when the medication was administered. The doctors should, therefore, be held responsible for the death of the patient as it was a result of their wrong assumptions and failing to carry out the required tests on the patient. It is the responsibility of the doctors to ensure high levels of professionalism is observed when treating the patients (Bruno, et al, 2015).

Practicality of implementing the recommended changes

Based on the death of the patient, the coroner made several recommendations that the hospital is required to implement. The coroner recommended that the patients with pelvic fractures who present in anticoagulated or over-coagulated state be subjected to the closest observation. This recommendation can be implemented by the hospital, and it only requires the provision of adequate information to the staff members. This recommendation can be practically implemented by the hospital as it only requires changes in procedures at the hospital. The hospital is also required to make changes in its organizational culture. The recommendation is practical, and it will be useful in saving the lives of the patients and preventing unnecessary deaths. The recommendations involve monitoring the patient of any vital signs. This requires medical examinations to be carried out on the patients to ensure that their conditions do not deteriorate further (Williams & Hopper, 2015). This will also require the hospital to ensure that a doctor is available at the hospital throughout the day including at night. The condition of Mr. Trengove deteriorates due to the lack of medical examination at night. This is despite the efforts that were put in place by the nurses to ensure that the condition of the patient improves (Moore & Jones, 2015).

The recommendations of the coroner also indicate that the hospital should ensure that regular observations of a person’s renal function should be carried out. This is can be achieved in the presence of close monitoring as well as medical tests. The recommendations of the coroner include fluid balance observation and recording. This can be carried out by the nurses monitoring the conditions of the patient (Williams & Hopper, 2015). Regular testing for hemoglobin and state of anticoagulation is also part of the recommendation. This is practical although it will require the hospital to make some changes with regards to its procedures. The recommendations of the coroner will play an important role in ensuring that lives are not lost due to poor management of the patient. The staff members, however, require some training and information about the changes as a result of the recommendations that have been made by the coroner. The hospital will however, incur some costs as a result of the frequent test that have to be carried out.

List of References

Lewis, S, et al, 2014, Medical-Surgical Nursing: Assessment and Management of Clinical Problems, Single Volume, Elsevier Health Sciences.

Ignatavicius, D, D, & Workman, M, L, 2015, Medical-Surgical Nursing: Patient-Centered Collaborative Care, Elsevier Health Sciences.

Polit, D, F, & Beck, C, T, 2013, Essentials of nursing research: Appraising evidence for nursing practice, Lippincott Williams & Wilkins.

Hamric, A, B, 2013, Advanced practice nursing: An integrative approach, Elsevier Health Sciences.

Williams, L, S, & Hopper, P, D, 2015, Understanding medical surgical nursing, FA Davis.

Moore, C, & Jones, R, 2015, The use of coroner’s autopsy reports to validate the use of targeted swabbing rather than tissue collection for rapid confirmation of virological causes of sudden death in the community, Journal of Clinical Virology, 63, 59-62.

Neate, S, L, et al, 2013, Non-reporting of reportable deaths to the coroner: when in doubt, report, The Medical journal of Australia, 199(6), 402-405.

Walter, S, et al, 2012, Geographic Variation in inquest rates in Australia, Health & Place, 18(6), 1430-1435.

Ibrahim, J, E, et al, 2013, Nature and Extent of External-Cause Deaths of Nursing Home Residents in Victoria, Australia, Journal of the American Geriatrics Society,
63(5), 954-962.

Huber, D, 2013, Leadership and nursing care management, Elsevier Health Sciences.

Tripodi, A, et al, 2012, New Anticoagulant drugs for treatment of venous thromboembolism and stroke prevention in atrial fibrillation, Journal of Internal Medicine, 271(6), 554-565.

Bruno, M, et al, 2015, Antiplatelet and anticoagulant drugs management before gastrointestinal endoscopy: Do clinicians adhere to guidelines? Digestive and liver Disease, 47(1), 45-49.