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Assessment Review Of Coroners Court Case Assignment Sample

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Introduction : Assessment Review Of Coroners Court Case 

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Written component

  1. Download the Non-inquest findings into the death of JJKD 17/08/2017 from Coroner’s Court of Queensland and develop a timeline of JJKD’s involvement in the mental health service. The timeline should highlight: 500

Where you consider JJKD’s recovery may have been compromised;

According to the case study of JJKD, it has been observed that he has gone through multiple drastic scenarios with respect to his schizophrenic condition. The medication dose has been constantly altered multiple times as per the observation of his mental health condition. However, an irregularity from the side of JJKD was also noticed in terms of appointments, medication and behaviour. Thus, the case was quite complex and it has been also explored in November 2015, 3 November 2015 risk assessment reflects that risk was low in terms of hurting himself or others. However, on the 23rd of December, it has been noted that the deterioration of mental state was quite high. Thus, it can be stated that an issue with medicinal dose intervention can be noticed.

Important milestones where effective clinical nursing interventions would have been appropriate;

The nursing service has a few major milestones with respect to biological and pharmacological treatment approaches. In terms of pharmacological intervention, nurses need to be aware of the rules and rights of pharmacological care intervention. That states care deliverers need to be taught or briefed about the dose and use the perspective of drugs to the patent (de Pinho et al. 2021). Hence, it can be stated that the right time, proper dose and will of the patient need to be considered. In terms of the biological treatment approach, proper assessment through following a standard protocol needed to be performed by the nurses. Along with that a few pieces of documentation or paperwork also need to be affected by the nurses in terms of maintaining and monitoring a proper record of patients (Sommerstad et al. 2021). On the other hand, it comes under the sole responsibility of nurses in terms of delivering adequate health education to concerned patients and their supporters with respect to their condition.

Appropriate nursing interventions for that point in the timeline;

During September 2008, the concerned patient was having a major complex state thus medication was irregular and this patient needs to be handled with emotional care and empathy. From 2009-2013, nursing care needs to be focused on the proper dose of medication and monitoring the patient. Thereafter, standard assessments needed to be performed with proper documentation of interventions and outcomes. From 2013 October to April 2014, the care interventions needed to be performed carefully along with educating the patient on health literacy. In November 2015, both biological and pharmacological interventions need to be addressed by the nursing care deliverer (Carrara et al. 2021). In December 2015, his state was falling with respect to mood thus emotional empathy needed to be delivered to the concerned patient.

How you would have intervened, as a practising mental health nurse?

It has been observed that the core focus of “Mental Health Service” reflects that at first patient rehabilitation then treatment and neurological disorders need to be addressed. Thus, the management of drowning has been performed through an immediate treatment approach. The patient has been taken to the safe side, and the pulse and breathing approach of the patient has been checked. Due to the absence of breath immediate CPR has been given in order to restore the pulse (Bellass et al. 2021). The given compassion rate of CPR was nearly 100-120

Review all prescribed psychotropic medications in this case and identify

The case study deals with the study of the condition of JJKD and it was observed that he was going through some mental health condition and having schizophrenia. Multiple doses of medication have been altered constantly to observe the medical health condition. Some doctors have prescribed the consumption of the medications as per the order of the coroner. The medications are prescribed to remove the addiction to any other drugs and it contains psychotropic drugs for analyzing the quick response in a human being (Deen et al., 2021). Psychotropic drugs affect the thought, perceptions, and behavior of an individual.

 Psychotropic drugs may contain antidepressants and anti-anxiety medications and it is used to make a change in the behavior of an individual. The prescribed psychotropic medication to JJKD helps to improve the functioning of the brain and has an impact on the mood swings of the patient. The psychotropic drug prescribed to the patient shows some positive effect while treating the patient with mental illness (Anis et al., 2022). It helps to reduce the psychotic symptoms and stabilizes the mood of the patient along with anxiety relieving capability. It also decreases the tendency of suicide and produced a calm and relaxing nature in a patient.

  • The metabolic reactions of psychotropic drugs are biologically active in patients via the metabolic pathway helps to uptake selective inhibitors to analyze the effect of the prescribed drugs. The pathway makes a change in the rate of metabolism to characterize different properties of the active metabolites of psychotropic drugs (Ribaudo et al., 2020). The pathway shows a low therapeutic index that contains the interindividual; differences in the rate of metabolism. After completion of the pathway, the drugs are again metabolized and the resulting excretory products are retained by the patient's body and at last excreted through the urine.
  • Psychotropic drugs have various side effects like dizziness, drowsiness, and blurred vision. Psychotropic drugs help to regulate emotions but they also have some adverse effects on emotions. The patients do not use the prescribed drug continuously as it enhances the addiction of the patient to take this type of drug regularly (Dikec et al., 2022). The drug changes the appetite of the patient and elevates the rate of heart to a limit that can cause the immediate cardiac arrest of the patient. The drugs are also responsible for frequent panic attacks, and bleeding of the nose. These are some major concerns related to psychotropic drugs.
  • Psychotropic drugs are very useful in the treatment of different psychotic disorders. The early warning signs are adverse effects that indicate a risk of harm. The warnings can occur due to the discontinuation of the medication after continuous use (Stroup and Gray, 2018). The outcome of the drugs contains some long time risk factors and as a result, dizziness and nausea develop in the patient's body. In the case of JJKD, the early warning sign includes the increasing heart rate that leads to the death of the patient. According to the mother of the patient use of Thorazine was stopped suddenly by the doctor and that phenomenon makes a deep impact on the brain of the patient. 
  • The advance clinical nursing interventions consist of different valid nursing tools to define a rooted scientific-based assessment of the patient to derive a fruitful result (Gedde et al., 2021). These interventions are used in this case for better support of the patient in adverse conditions. It includes
  1. Assessment of data is done after medication and therapy and it helps to identify the adverse effect of the prescribed drugs. The recorded data of the patient allow the doctor to make some changes to the medication. It also allows the nurse to check the patient regularly and monitor the deteriorating condition of JJKD.
  2. Provide Health teaching: It is an important nursing intervention that enhances the encouragement of the patient and the family about the facts and recovery measures. It encourages a patient to actively take part during the treatment.

Utilizing appropriate literature, examine issues relating to the concurrent use of the medications prescribed

Continuous use of psychotropic drugs can lead to the deteriorating mental condition of a patient. Concurrent use of psychotropic drugs assesses the prevalence of patients to identify the combined frequency of the drugs. Long-term medication of such types of drugs increases the rate of attacks in the patient and enhances the addiction. The study of the case discusses the cause to lead a patient to death. The case study also reveals the interaction of drugs with alcohol worsens the condition of the patient. According to Zhu et al., 2019, a proper plan to review the case management is required for analyzing the main reason behind the death of the patient.

Five major ‘take home’ lessons that have been evident from engagement with the report

The five major take-home lessons that are evident are as follows:

  1. i) It helps to experience the use of certain psychotropic drugs in a patient to enhance the condition of his health.
  2. ii) It provides a rigid strategy to prove the inadequacy of healthcare by connecting the critical events during treatment.

iii) It helps to maintain various record sheets of the patient including all his previous medical history and prescribed drugs. This helps the doctors to change the medicine during any deterioration.

  1. iv) It helps to plan some strategy for the cure of the patients by proving all the necessary needs. It gives an effective result for maintaining the system regulations.
  2. v) It is mandatory to take consent from the family members of the patient for a smooth medical procedure.


The case study expresses some lack of concern for healthcare professionals. It suggests the management make a record of the prescribed medications for better treatment. Voluntary maintenance should be done to ensure the participation of the patient without any interruption in therapy (Shafiekhani et al., 2018). It also suggests including counseling to state the benefits and efficiency of the treatment to manage the declining condition of the patient.


According to the case study, it has been observed that non-compliance was issued by the mother of JJKD in terms of lack of care. JJKD was mentally distorted thus proper maintenance of appointments and medication was not taken. The nurses need to have a deep exploration and serious concern over his case in terms of meditational delivery and health education to the patient. The findings of RAC are accurate and HHS recommendations have major value in terms of effective compliance. Hence, it can be stated care delivery staffs need to follow the proper code of ethics and conduct in terms of effective care delivery to the patients.

 Slide 1: An overview of the Coroner’s report

  • JJKD has not committed suicide
  • He has a deteriorating mental state and activity
  • RAC found a pivotal role in CCT.
  • Dose of clozapine was inaccurate (Lin et al. 2022).

It has been observed that JJKD died due to drowning no such evidence has been found that he committed suicide. The JJKD have been going surfing in his deteriorating mental state thus it can be considered poor judgment by him. The claim of the concerned patient's mother reflects dose of clozapine was inaccurate and not effectively prescribed by CCT. the RCA has found that a few deficiencies from the side of “Public mental health service” have been noticed. A pivotal role has been noticed from the side of CCT staff capability in terms of delivering proper attention to the case of JJKD.

Slide 2: The timeline



Managed by




“public mental health system”

depressive and maniac

2009 May

2013 August


Deterioration over behaviour

October 2013

April 2014


Less schizophrenia

May 2014

June 2015


Irregular activity or behaviour

JJKD was 1st admitted in September of 2008 with a depressive and maniac state then from 2009 May to 2013 August he was managed by CCT. Then 2013 October to 2014 April he was under the supervision of CMHC and from then till June 2015 he was again under the supervision of CCT. On 29 November 2015, concerning unfortunate event happened at McDonald’s.

Slide 3: What, in your opinion, went wrong

  • JJKD was not stable
  • Mood and behaviour frequently changes
  • Medication was not precisely effective (Todorova et al. 2021)
  • JJKD decision-making ability was poor

According to the case studies, it has been observed that during this entire timeline JJKD was having complex issues and a diversified behaviour approach. The mood and behaviour approach of the patient was different at every time period and he had irregularities in terms of appointment and treatment aspects. It can be stated that CTT has tried to manage as per their capability despite that medication dose inappropriateness has been noticed. The decision of surfing was too poor in terms of decision making and a lack of attention by the family side towards his condition also has noticed.

Slide 4: Cont..

  • CCT need to be more functional
  • Poor attention to JJKD.
  • HHS recommendations (Koschorke et al. 2021)

It has been observed that the workload of CCT was too heavy despite that protocols and responsibilities must need to be considered. It has been observed that the patent was having several issues with medication and appointments. Thus, special attention in terms of medicinal care delivery needs to be given in the case of JJKD. Along with that as per exploration of the case concerned event of JJKD’s death can be considered as an accident. The recommendations made by HHS have major relevance in terms of the transformation of the health framework system thus implementation of those recommendations has major value.

Slide 5: Learnings that support the mental health nurses to manage these risk factors in the future

  • Community skill improvement
  • Regular community work (Tasijawa et al. 2021)
  • Proper medication rule following

The nurses need to strengthen their community skills and need to perform community work properly in terms of eliminating gaps and errors over service. The patent care in terms of redactional intervention needed to be performed accordingly to the report and given a prescription with documentation.

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