The Communiqués Podcasts

Welcome to Episode Thirteen of our podcast series. This features material from our October 2024 print edition of the Future Leaders Communiqué. Our guest editor is Dr Erica Musgrove, a doctor in training at Alice Springs Hospital, who presents a compelling edition highlighting some of the challenges of providing patient care in rural and remote settings.This podcast presents a case from rural Australia where a culmination of missed opportunities and systemic issues resulted in a poor patient outcome during an interhospital transfer.Our expert commentators are Dr Simon Judkins is an Emergency Physician and the Past President of the Australasian College for Emergency Medicine and Dr Bridget Honan who is an emergency physician working in Grafton Hospital (Bundjalong Country), and with the Central Australian Retrieval Service in Mparntwe (Alice Springs).Episode Contents04:08 Guest Editorial by Dr Erica Musgrove08:29 Editorial by Professor Joseph Ibrahim11:04 Case: Midnight in the Outback by Dr Erica Musgrove32:42 Expert Commentary #1: Navigating systems and pathways by Dr Simon Judkins39:12 Expert Commentary #2: A junior doctor's guide to retrieval by Bridget Honan44:41 Comments from our peers

Welcome to Episode Twenty-two of our podcast series. This features material from our November 2024 print edition of the Residential Aged Care Communiqué. This podcast presents two cases highlighting the challenges of facilitating and supervising community access for residential clients. Our expert commentary addresses ‘The influence of the system's design on tragic failures of governance and care’ in this edition is written by Mr Anthony Black.Episode Contents00:58 Editorial by Prof Joseph Ibrahim03:49 Case #1: Always ready to help by Dr Chelsea Baird12:45 Case #2: A Man Who Loved Walking by Dr Supriya Rama Krishnan16:00 Expert Commentary: The influence of the system's design on tragic failures of governance and care. by Mr Anthony Black24:02 Comments from senior nurses31:06 2024 National Mental Health Webinar Series

Welcome to Episode Twenty-one of our podcast series. This features material from our August 2024 print edition of the Residential Aged Care Communiqué. This podcast presents two cases highlighting the poorer outcomes that can occur for older persons following trauma and the how the desired goals of care may influence decision-making in a trauma scenario. Our expert commentary on ‘Trauma Geriatricians’ in this edition is written by Dr Kate Gregorevic.Episode Contents00:40 Editorial by Prof Joseph Ibrahim03:10 Case #1: A small fall but major injuries by Prof Joseph Ibrahim12:19 Case #2: A fall with head strike by Supriya Rama Krishnan17:07 Expert Commentary: Trauma Geriatricians by Dr Kate Gregorevic

Welcome to Episode #12 of the Future Leaders Communiqué podcast. In this episode, we review a coroner’s investigation into the unexpected death in hospital of a complex major trauma patient. As the case unfolds, issues around protocols, junior doctor autonomy, and senior supervision within the treating team arise.Episode Contents01:20 Guest Editorial by Dr Kee Whye Chin05:17 Editorial by Dr Brendan Morrissey07:40 Prescribing a protocol unsupervised by Dr Kee Whye Chin21:46 Expert Commentary #1: The building blocks of solid foundational years—Supervision, safeguards, and structural supports in junior doctor training by Dr Emma Ku30:58 Expert Commentary #2: Empowering our interns—The learning of professionalism, and the attributes and responsibilities that define the role of the junior doctor by Associate Professor Bruce P Waxman39:18 Comments from our peers

Welcome to episode 16 of the Clinical Communiqué, based on the June 2024 edition of the Clinical Communiqué. In this episode we feature two surgical cases that each portray several clinical themes, but at the heart of both is the theme of communication. In their ensuing inquests, the coroners explored how the treating teams communicated with the patient and their family members - where conversations around consent, post-operative complications, and open disclosure were lacking; and how those treating teams communicated with their own colleagues - where missed opportunities in communication hindered timely diagnoses.Episode Contents00:59 Editorial by Associate Professor Nicola Cunningham06:46 Case #1: Closing the loop by Dr Rachel Marr23:30 Case #2: A critical procedure by Dr Kristin Boyle36:52 Expert Commentary: At the Core: communication as a key to patient safety by Dr Mary Dahm48:05 Expert Commentary: The Australian Open Disclosure Framework – past, present and future by Mr Peter McDermott

Welcome to Episode Twenty of our podcast series. This features material from our May 2024 print edition of the Residential Aged Care Communiqué. This podcast examines particularly challenging aspects of palliative care for persons with dementia, for those who have lost decision-making capacity and terminal sedation. We present two clinical cases that provide contrasting narratives. Our expert commentary is written by Dr Kylie Staggard and Dr Aaron Bak Ong Wong drawing on their combined extensive experiences in geriatric medicine and palliative care medicine.Episode Contents01:03 Editorial03:08 Case #1: Live and let die by Dr Huong Nguyen14:38 Case #2: An inconsequential error by Prof Joseph Ibrahim20:22 Expert Commentary: Frontotemporal dementia and terminal sedation by Dr Kylie Staggard and Dr Aaron Bak Ong Wong31:12 Reflections from senior nurses

Welcome to Episode 15 of the Clinical Communiqué Podcast, based on the March 2024 print edition of the Clinical Communiqué. In this podcast episode the two cases demonstrate two main risk profiles in older drivers – the driving risks when a patient is bodily capable but easily disorientated, and the driving risks when a patient is mentally sharp but physically slow.Episode Contents01:20 Editorial by Associate Professor Nicola Cunningham06:20 Case #1: A determined risk18:39 Case #2: Lost and confused25:27 Expert Commentary: Driving in older age: A complex challenge

Welcome to Episode Nineteen of our podcast series. This features material from our February 2024 print edition of the Residential Aged Care Communiqué. In this episode we examine the case of a resident who died due to being administered a medication to which he had a known allergy. The case highlights lessons about how we gather and evaluation information. Our expert commentator is Dr Natali Jokanovic, a practising pharmacist with a research background.Episode Contents01:21 Editorial03:58 Case #1: Credible but not reliable17:32 Expert Commentary: Medication allergies and challenges in residential aged care23:33 Reflections from senior nurses25:58 Obituary: Vale Maree Amanda Cameron PSM

Welcome to Episode Fourteen of our podcast series. This features material from our December 2023 print edition of the Clinical Communiqué. This podcast presents key learnings from the coroner’s inquest into the 2016 thunderstorm asthma event in Melbourne in which ten patients tragically lost their lives. We reflect on the terrifying rapidity with which their conditions changed from mildly short of breath to being in extremis, highlighting that it can be a matter of minutes between life and death in thunderstorm asthma. Episode Contents01:13 Editorial by Associate Professor Nicola Cunningham05:37 Case #1: Something in the air by Dr Kristin Boyle20:06 More on the Matter: In the blink of an eye by Associate Professor Nicola Cunningham34:30 Expert Commentary by Associate Professor Matthew Conron and Associate Professor Eve Denton: Thunderstorm asthma: what causes the "perfect storm"?

Welcome to Episode Thirteen of our podcast series. This features material from our September 2023 print edition of the Clinical Communiqué. This podcast presents the lessons to be learned by examining the failure to hear the concerns of those that should be at the centre of every health care interaction. We present two cases where the patient's families told the coroners that they had not been listened to by the nurses and doctors caring for their loved ones.Episode Contents01:25 Editorial by Associate Professor Nicola Cunningham08:14 Case #1: Missing the moments by Dr Angela Sungaila19:12 Case #2: "I told them but no one came" by Associate Professor Nicola Cunningham27:36 Expert Commentary by Ms Belinda MacLeod-Smith: Stolen moments and lost lives38:39 Expert Commentary by Ms Elizabeth Deveny: Engaging patients (and their families) to improve safety

Welcome to Episode Eighteen of our podcast series. This features material from our November 2023 print edition of the Residential Aged Care Communiqué. This podcast presents the lessons to be learned by examining pre-existing circumstances that contributed to two patients’ falls that caused their deaths. A common underlying factor was timeliness of care.Episode Contents00:45 Editorial06:22 Case #1 A fatal fall unwitnessed and unchecked19:41 Case #2 Solving one problem creates another27:58 Reflections of senior nurses

Welcome to Episode Seventeen of our podcast series. This features material from our August 2023 print edition of the Residential Aged Care Communiqué. This podcast presents the lessons to be learned from the premature deaths of residents due to suboptimal management of diabetes mellitus.Episode Contents01:10 Editorial03:51 Case #1 I am fine14:34 Case #2 An old drug and a known complication21:41 Reflections of senior nurses24:04 Commentary: Views of a Diabetes Educator32:31 Commentary: The Contribution of Pharmacists to the Management of Diabetes in the Aged Care Setting

This podcast episode presents the results of the investigation into the premature death of a resident who had a fall from a runaway wheelchair. The three commentaries draw on clinical and research experts to address how to balance improving mobility with a wheelchair while mitigating potential harm. We also welcome a new narrator Ashleigh Redmond who is a practising registered nurse and actor. This is Episode Sixteen of our podcast series and features material from our May 2023 print edition of the Residential Aged Care Communiqué.Episode Contents01:22 Editorial05:15 Case A fatal downhill slope15:11 Commentary: Falls of wheelchair users: what do we know?19:18 Commentary: Call an OT26:00 Commentary: Looking deeper27:49 Reflections of senior nurses

In this episode we feature two cases of worsening upper airway swelling leading to fatal airway obstruction following routine extubation of patients after surgery. Despite many advances in airway management, extubation-related incidents have not reduced. The cases highlight the actions leading to the loss of airway protection, a failure to recognise the severity of the situation, and an inability to salvage the situation.We also welcome a new narrator Ashleigh Redmond who is a practising registered nurse and actor. This is Episode Twelve of our podcast series and features material from our June 2023 print edition of the Clinical Communiqué.Episode Contents01:48 Editorial by Associate Professor Nicola Cunningham06:15 Case #1: A fatal toothache by Suzanne Doherty19:54 Case #2: Pulling teeth and tubes - a cautionary tale by Dr Jack D'Arcy36:28 Expert Commentary by Dr Louise Ellard: Extubation: An assessment of risk and strategy

Escaping, absconding, unexplained absences lead to death. The investigation into a resident’s unexplained absence determined the cause of death as hypothermia secondary to becoming lost in surrounding bushlands. The inquest findings are presented along with expert commentary around how to prevent unexplained absences.This is Episode Fifteen of our podcast series and features material from our February 2023 print edition of the Residential Aged Care Communiqué. Episode Contents01:33 Editorial04:05 Case Cold, wet, in the dark, and alone18:42 Commentary: Preventing unexplained absences25:55 What do senior nurses think?

In partnership with First Nations Peoples from clinical, education, design, and consumer advocacy backgrounds, this critical edition of the Clinical Communique presents two coroners' cases where a lack of cultural safety in the health care system led to preventable and tragic consequences. Special thanks to Mr Olli Wynyard Gonfond who narrated this episode, and Dr Jordana Stanford for her guest apperance.This is Episode Eleven of our podcast series and features material from our March 2023 print edition of the Clinical Communiqué.Episode Contents01:07 Editorial by Associate Professor Nicola Cunningham07:46 Guest Editorial by Ms Belinda Gibb18:33 Case #1: A culture of care by Dr Glenn Harrison28:42 Case #2: Seen but not heard by Dr Jordana Stanford40:11 Expert Commentary by Dr Olli Wynyard Gonfond: Developing cultural safety behaviours and capabilities in health care46:41 Expert Commentary by Ms Jacqui Gibson: Why cultural safety improves patient safety

Welcome to Episode #11 of the Future Leaders Communiqué podcast. In this episode, we present a thought-provoking summary of the events leading to the tragic death of JL, a 69-year-old woman recovering from an elective neurosurgical operation. We reflect on the challenges faced by junior doctors engaging in locum work and the chain of communication in medical imaging reports.Episode Contents01:05 Guest Editorial by Dr Tony Pham04:22 Editorial by Dr Brendan Morrissey07:38 Case: An obstruction in an unfamiliar place by Dr Tony Pham20:07 Expert Commentary #1: Technological solutions: A remedy for human error? By Ms Nicole Mair26:17 Expert Commentary #2: Ready, Set, Go: safe orientation of locum doctors by Dr Brendan Morrissey32:41 Comments from our peers

The investigations into the deaths of two residents from choking on food are described. Two experts address the challenges of managing the impact of dementia on residents’ ability to eat, as well as, staff managing ethical decision about cardiopulmonary resuscitation. This is Episode Fourteen of our podcast series and features material from our November 2022 print edition of the Residential Aged Care Communiqué.Episode Contents01:53 Editorial04:47 Case #1 Unknown, unknowable and cannot be known17:07 Case #2 We did our best: revisited19:35 Commentary #1: Impact of dementia on eating24:33 Commentary #2: Resuscitation: lessons involving persons with dementia, guardianship and choking32:21 Views from our nursing colleagues

Two deaths due to head trauma related to use of a mechanical hoist and a lift chair could happen in any aged care home. The lessons for improving practice go beyond the actual cases as illustrated by the accompanying reflective exercises. Commentaries provide insights into recall bias, quality improvement rounds, cognitive testing and parallels with motorised mobility scooters.Episode Contents01:08 Editorial06:00 Case #1 Four tales13:32 Brainstorming about the case: views from our nursing colleagues (Case #1)16:05 Commentary #1: A literal approach—recall bias20:06 Commentary #2: Contemplating care—quality improvement rounds23:51 Case #2 Falling off the chair30:06 Brainstorming about the case: views from our nursing colleagues (Case #2)31:48 Commentary #3: See an aside—cognitive testing35:09 Commentary #4: Drawing parallels—beyond the case

This episode draws on the September 2022 edition of the Clinical Communiqué and features two cases that describe alarm fatigue and the failure to escalate care. We look at technology and decision-making tools and explore how while they can be used to support clinical processes, there are inherent risks with the loss of critical thinking.Episode Contents01:32 Editorial by Associate Professor Nicola Cunningham05:18 Case #1: An alarming error18:37 Case #2: Deteriorating or not?29:27 Expert Commentary by Dr David Bramley: Perspectives on risk mitigation and alert fatigue