Welcome to Episode Nine of our podcast series. This features material from our August 2021 print edition of the Residential Aged Care Communiqué. This podcast focusses on harm resulting from failures to listen carefully to family concerns. We present two cases where earlier attention and prompt responses to concerns raised by family may have altered the outcomes. Our expert commentary explains the online education and training programs designed for the residential aged care sector in particular learning about recognising imminent dying and preparing for the death of a resident.

Episode Contents

• 01:47 minutes Editorial

• 03:04 minutes Case #1: Ryan's rule and aged care

• 12:42 minutes Case #2: Inappropriate discharge

• 28:24 minutes Expert Commentary: Online education - recognising and responding when a palliative approach to care is needed

This episode of the Future Leaders Communiqué podcast presents the coroner’s case of Mr A, a 53-year-old man admitted to hospital with severe neck pain who was found dead in his hospital bed three days later. The episode examines two topics central to patient safety: iatrogenic injury, and barriers to escalation of care. The content is based on the July 2021 print edition, guest-edited by Dr Kate Charters.

Episode Contents

• 01:27 minutes Introduction

• 02:30 minutes Guest editorial by Kate Charters

• 07:56 minutes Editorial by Dr Brendan Morrissey

• 12:36 minutes Case report: Prioritising closure and disclosure

• 29:30 minutes Expert Commentary: Don't give more if it makes them snore by Dr Anna Korin, Emergency Medicine Physician Alfred Health

• 38:22 minutes Expert Commentary: Time to extend our medication safety net by Anne Leversha, Senior Lecturer, Monash University, Faculty of Medicine, Nursing & Health Sciences

• 45:32 minutes Comments From Our Peers

Welcome to episode six of the Clinical Communiqué podcast, titled 'Access Block'.

This podcast is based on the June 2021 edition of the Clinical Communiqué.

In this podcast episode we look at the problem of access block, a major barrier to delivering safe and timely care to patients in hospitals. We present four cases that demonstrate how the negative consequences of access block are far-reaching and affect every stage of a patient’s journey through the healthcare system.

Our expert commentary is about the lessons learned from the cases in this episode, and looks at the role every clinician can play in addressing such a systemic and pervasive and preventable problem.

Episode Contents

• 04:15 Editorial by Dr Nicola Cunningham

• 10:35 Case #1: Alone in a crowded space

• 20:03 Case #2: The long wait

• 27:44 More on the matter by Dr Nicola Cunningham: Outing the problem

• 34:53 Expert Commentary by Dr Simon Judkins: A system under pressure

Welcome to Episode Eight of our podcast series. This features material from our May 2021 edition of the Residential Aged Care Communiqué. This podcast focuses on harm resulting from resident-on-resident interactions. We present two cases where the deaths occurred and an expert commentary which explains the role of Dementia Support Australia, an organisation that provides clinical support in managing complex behaviours of people with dementia. Our narrator for this episode is Will Thomas.

Episode Contents

• 03:23 minutes Editorial

• 05:34 minutes Case #1: In my room

• 14:09 minutes Case #2: Not so Great Expectations

• 28:24 minutes Expert Commentary #1: Who do I call? DBMAS

• 34:08 minutes Expert Commentary #2: A geriatrician talks to a psychiatrist

This podcast of the Future Leaders Communiqué presents a case based on an inquest into the death of a pregnant woman who presented to an emergency department with ‘rib pain’, only to later die of an undiagnosed pulmonary embolism.

The content of the podcast is based on our April 2021 print edition, with Dr Vincent Wong as guest editor. In this podcast, we have expert commentaries describing what clinicians can do to recognise the limitations of their clinical experience, and how best to utilise the safety net of senior supervision.

Episode Contents

• 01:29 minutes Introduction

• 04:34 minutes Guest editorial by Dr Vincent Wong, editorial by Dr Brendan Morrissey

• 10:50 minutes Case Report: How do you know when you need to ask for help?

• 25:42 minutes Expert Commentary: Be wise and confess to ignorance by Dr Nhi Nguyen

• 34:29 minutes Expert Commentary: Keeping an eye on junior doctors’ clinical blindspots by Associate Professor Julia Harrison

• 41:50 minutes Comments From Our Peers

Welcome to our fifth podcast episode based on the March 2021 edition of the Clinical Communiqué.

In this podcast episode we will hear about deaths due to carbon monoxide poisoning – a gas produced by the incomplete combustion of carbon-based compounds. Carbon monoxide is often referred to as the ‘silent killer’ because it is colourless, odourless, tasteless, non-irritating, and extremely toxic. Carbon monoxide poisoning is an entirely preventable illness, and if identified early enough, is wholly reversible.

Episode Contents

• 05:28 minutes Editorial

• 10:20 minutes Case #1: A poisonous adventure

• 16:35 minutes Case #2: The paradox of negative pressure

• 23:08 minutes More on the matter: Outing the problem

• 30:21 minutes Expert Commentary: Carbon monoxide toxicity: a concise and practical overview of the pathophysiology, clinical features, and treatment of patients with carbon monoxide toxicity by Dr. Matthew Spotswood

Welcome to Episode Seven of this podcast series which features material from our February 2021 edition of the Residential Aged Care Communiqué.

This podcast focuses on medication safety in aged care homes. We present two cases where the deaths of aged care facility residents were investigated by the Coroners Court. Dr. Huong Nguyen gives us a case precis of a death involving missed doses of anticonvulsant medication. This is followed by Dr. Supriya Rama Krishnan’s case precis of a death involving inadvertent administration of the wrong medication.

The podcast concludes with a commentary on a systems approach to improve medication management by two experts from Safer Care Victoria, Dr. Raphaela Schnittker, a Human Factors Specialist, and Ms. Jen Morris.

Episode Contents

• 02:29 minutes Editorial

• 04:48 minutes Case #1: The fax of the matter

• 14:51 minutes Case #2: An interrupted drug round

• 22:58 minutes Expert Commentary: Human Factors and Medication Safety

This podcast of the Future Leaders Communiqué presents a case based on an inquest into the death of a young woman from suicide who had present on multiple occasion to different health services seeking help. All to no avail.

The content of the podcast is based on our January 2021 print edition which was with Dr Daniel Grose as guest editor. In this podcast we have a contribution from the family and expert commentaries describing what clinicians could do to mitigate the risk of error in assessing and managing patients presenting with mental health issues.

Episode Contents

• 01:29 minutes Introduction

• 04:34 minutes Guest editorial by Dr Daniel Grose, editorial by Dr Brendan Morrissey and guest commentary by Violet Tregonning

• 10:50 minutes Case Report Dr Daniel Grosse “Who cares?”

• 25:42 minutes Expert Commentary by Associate Professor Jonathan Knott “The system is broken”

• 34:29 minutes Expert Commentary by Dr Evan Symons “Care of the acutely suicidal patient”

• 41:50 minutes Comments From Our Peers

This podcast of the Clinical Communiqué features the important issue of clinical handover of patients to primary care. We present two cases where the multiple steps required to safely discharge the patient from hospital to home were inadequate or incomplete, leading to fatal consequences.

The content of the podcast is based on our December 2020 print edition of the Clinical Communiqué and includes an expert commentary by an Australian group of clinicians leading the way in improving clinical handover to primary care.

Episode Contents

• 03:21 minutes Editorial

• 09:46 minutes Case #1: Don’t ask, don’t tell

• 23:54 minutes Case #2: An incomplete picture

• 35:27 minutes Expert Commentary: Clinical handover to primary care – Why reframing ‘discharge summaries’ as ‘clinical handovers’ matters by Dr Katrina McLean, Dr Michael Rice, Dr Tim Leeuwenburg, and Dr Nick Tellis

This first part of this podcast of the Residential Aged Care Communiqué Dr Chelsea Baird describes several case reports of COVID19 in older persons highlighting the atypical presentations and challenges of management.

The second part of the podcast provides brief summaries of recent important inquiries into the management of COVID-19 outbreaks in aged care.

Episode Contents

• 03:21 minutes Editorial

• 06:49 minutes Case #1 “That’s not COVID-19”

• 11:42 minutes Case #2 “Challenges of isolation and environment”

• 17:26 minutes Case #3 “COVID-19 and mental health”

• 19:02 minutes Report into Newmarch House COVID-19 Outbreak

• 27:28 minutes Amnesty International’s report “As If Expendable”

• 33:20 minutes Royal Commission’s “Aged care and COVID-19: a special report”

• 36:12 minutes Ontario’s “Long-Term Care COVID-19 Commission”

• 38:19 minutes Clinical Screening Tool for COVID-19 in Residential Aged Care Facilities