The first edition of Health Care Insider, Winter 2015, published by Kaden Boriss Legal.

1. * OHO—Working within
policy and the scope of
practice
* Precision is the key to
Permissible
Employment Health
Assessments
* Transcription errors
and the importance of
reviewing care plans
* Meet our Team
Working Within Policy And
The Scope Of Practice
by Hamish Broadbent, Partner
The focus of the complaint by Mrs A was her care in January 2013 while she was between 36 and 39
weeks pregnant. The Health Quality and Complaints Commission (HQCC) investigated and considered
the following factors to be of significance:
 The shared care by midwives and clinicians in different locations;
 Mrs A’s reporting of reduced movement;
 The finding of increased fundal height on examination; and
 The ultrasounds that were ordered and performed.
The following timeline became the focus of the investigation:
 8 January 2013 - At approximately 36 weeks gestation, Mrs A attended a routine antenatal
exam at the Bowen Hospital. The Registered Midwife (RM) raised concerns about the fundal
height with a Registered Midwife (RM1) at THBC. RM1 advised that they would contact Mrs A.
The Bowen RM then discussed the concerns about fundal height with a doctor at Bowen
Hospital, who requested an ultrasound. When the Bowen RM called Mrs A about having an
ultrasound, Mrs A advised that a scan was to be taken by RM1 at THBC.
 12 January 2013 - Mrs A was examined by RM1 at THBC where a physical, “informal or
comfort” ultrasound and CTG examination found no issues.
The Office of the Health Ombudsman (OHO) recently published its investigation report into the
obstetric care of Mrs A by the Townsville Hospital and Health Service (THHS) and the eventual
stillbirth of Baby B on 29 January 2013 at the Townsville Hospital Birth Centre (THBC).
www.kadenboriss.com
In this issue:
WINTER 2015
HealthCareInsider

2. UPCOMING
EVENTS
Medico-Legal
Society of
Queensland
2015
Conference
28-29
August 2015
www.medico-legal.com.au
HealthCare Insider
 23 January 2013 – Mrs A was examined at THBC by her primary care provider, a Registered
Midwife (RM2). RM2 discussed concerns about the fundal height with RM1 and the Director of
Obstetrics, who recommended a formal ultrasound. During the attendance, Mrs A updated her
address with the midwives as she was staying in Townsville until the birth.
 24 January 2013 – Mrs A attended THBC and spoke with RM2, who told Mrs A she would be
advised of the ultrasound appointment time. At this attendance, Mrs A reported concerns about
reduced movement but was told not to be concerned.
 29 January 2013 – Mrs A attended the arranged ultrasound at Townsville Hospital where she was
told that the baby did not have a heartbeat. After an induced labour, Mrs A’s baby was delivered
stillborn at 39 weeks gestation. An autopsy was not performed but a MRI of the baby indicated
polyhydramnios.
In June 2014, the HQCC published the draft investigation report which made a number of preliminary
recommendations. It considered that there were systemic communication issues in communicating
patient information between facilities within the THHS, and highlighted multiple failures on the part of
RM1 and RM2 to adhere to proper policy and procedure.
The HQCC found that some practices of the midwifery model of care affected the ability to identify
potential problems during antenatal care, particularly where a patient is seen a different locations and
there is little to no peer review or oversight. The HQCC pointed to the lack of action in relation to the
increased fundal height on examination as well as the fact that
ultrasounds were used as part of the diagnostic process, but the
results were not recorded.
The practice of undertaking a comfort or informal scan was also
criticised. The HQCC observed that there was a marked difference
in gestational measurements recorded by RM1 during the comfort
ultrasound on 12 January 2013 when compared to measurements
taken before and after that date by other practitioners. The HQCC
recommended that ultrasounds should be undertaken and
reported by suitably trained persons.
The THHS responded to the draft investigation report outlining the
existing policies and procedures and the measures that they had
introduced to ensure compliance. Further, a new guideline “Point
of Care Ultrasound” was developed for when midwives perform
comfort or informal ultrasounds and, importantly, there was no
scope within this guideline for midwives to perform formal
ultrasounds.
The OHO determined that:
1. The actions of the midwives did not amount to serious misconduct but it referred RM1 and RM2
to AHPRA for performance failures associated with standard practice and policy; and
2. The THHS had:
a. Appropriately considered and complied with the recommendations outlined in both the
Root Cause Analysis conducted by THHS and the HQCC’s draft report; and
b. Successfully undertaken suitable measures to enhance quality of care to patients.
If you have a matter which requires the expertise of a multidisciplinary team, please feel free to contact
us to discuss your needs.
A copy of the full report can be found on the website of the Office of the Health Ombudsman at:
www.oho.qld.gov.au/news-updates/closed-investigations/
Working within policy and the scope of practice... cont.
Upcoming
Events
Medico-Legal Society
of Queensland
2015 Conference
28-29 August 2015
medico-legal.com.au

3. HealthCare Insider
Mr McDonnell was an 80 year old gentleman with a history of mental illness. He was admitted to The
Prince Charles Hospital (TPCH) on 28 June 2012 on an Involuntary Treatment Order (ITO) after reporting to
his GP increasing suicidal thoughts and deterioration in his self care.
Over the next 20 days Mr McDonnell remained an inpatient at TPCH. He underwent electroconvulsive
therapy (ECT) and it was recognised by clinical staff that Mr McDonnell was at risk of both self-harm and
harm due to misadventure if he absconded. In fact he had left the ward on one occasion on 4 July and was
found on the hospital grounds, he said that he
wanted to go home and kill himself. At times
during his admission, Mr McDonnell was
managed in a locked ward. After a weekend
where his delirium resolved and he was not
agitated or suicidal, he was moved to the open
ward on 15 minute observations.
During the observation rounds on 19 July 2012
at 9.00am Mr McDonnell could not be located.
After an extensive search by hospital staff and
reporting to the Queensland Police Service
(QPS), Mr McDonnell's body was located in a
creek near TPCH on 20 July 2012.
The Coroner concluded that an error by
nursing staff in the transcribing of observation
orders led to observations being changed (at
some time on 18 July 2012) to 30 minute
intervals. The significance of this was that the
Coroner considered that "more restricted
observations may have made a difference in
this case". While 15 minute observations would
not have prevented Mr McDonnell from
wandering or absconding, it would have
ensured his status would have been noticed
earlier. Due to the frailty and age of Mr
McDonnell and the proximity to TCPH in which
his body was later found, the Coroner found
the error could not be simply dismissed.
To the credit of the staff at TCPH, the policy and procedure for locating missing patients was said to have
been enacted and escalated to the QPS. Further, it was acknowledged that following the incident, TCPH
conducted a thorough Root Cause Analysis and discovered a number of lessons to be learnt. A number of
policies have since been put in place to encourage better documentation of significant events (such as the
earlier absconding event), ensure appropriate medical review, and improve the process of visual
observations.
Transcription Errors And
The Importance Of
Reviewing The Care Plan
The Käden Boriss Legal Health and
Aged Care team currently acts for
public and private hospitals in
defence of medico-legal claims. Our
lawyers have represented medical
defence organisations and self
insured healthcare practitioners in
regulatory and disciplinary
matters. We also act for other
primary and allied health service
providers, as well as disability and
aged care agencies, in the provision
of risk management advice,
employment and industrial relations
issues, licensing and other disputes.
In addition, we bring a broad skill
set to our health and aged care
practice. We have significant
experience and expertise acting for
statutory authorities and
government departments, which
has enabled our Partners to build
practices which are flexible to their
needs and demands, and alive to
the policy imperatives.
By Jennifer Davis, Solicitor
Käden Boriss’ Health and Aged Care Services
Our Areas of Practice
 Medical negligence
 Professional indemnity
 Risk management
 Product liability
(pharmaceutical and medical
devices)
 Public health issues
 Aged care
 Primary allied and community
help/disability support
 Coronial inquests
 Employment and industrial
relations
 Licensing and accreditation
 Regulatory compliance
 Bioethics, research and medical
issues
Contact one of our Health and Aged
Care Partners, Hamish Broadbent or
Damien van Brunschot, to discuss your
specific needs.
“ more restricted
observations may
have made a
difference in
this case".
- Mr John Lock
Queensland Deputy
State Coroner
Simple errors by busy staff can lead to very unfortunate outcomes. It is important to ensure
patient records are sufficiently detailed and the original orders are frequently reviewed.
Mr John Lock, Queensland Deputy State Coroner, recently delivered his Findings of the
Inquest into the death of Mr Kevin McDonnell.

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www.kadenboriss.com
Hamish Broadbent, Partner
T 07 3013 2708
E Hamish@kadenborissbrisbane.com.au
Meet ourTeam
Jamie McPherson, Partner
T 07 3013 2701
E Jamie@kadenborissbrisbane.com.au
Mark Curran, Partner
T 07 3013 2751
E Mark@kadenborissbrisbane.com.au
Damien Van Brunschot, Partner
T 07 3013 2702
E Damien@kadenborissbrisbane.com.au
Damian Hegarty, Snr Associate
T 07 3013 2731
E Damian@kadenborissbrisbane.com.au
Olga Sashko, Snr Associate
T 07 3013 2747
E Olga@kadenborissbrisbane.com.au
Andrew Bautovich, Snr Associate
T 07 3013 2704
E Andrew@kadenborissbrisbane.com.au
Jennifer Davis, Solicitor
T 07 3013 2738
E Jennifer@kadenborissbrisbane.com.au
Insurance & Health, Workplace Health & Safety, and Employment.
HealthCare Insider
Andre Wyman, Solicitor
T 07 3013 2749
E Andre@kadenborissbrisbane.com.au