This module was adapted from an actual clinical case in which a serious clinical error occurred and this resulted in a person’s death. The coroner’s report following the inquest identified communication between staff and during handover, documentation and clear identification of decisions, and use of appropriate guidelines and protocols as key areas for improvement.

Mark Green is a 65 year old man who presents to the Emergency Department of a large hospital with a pelvic fracture following a motor vehicle accident. A series of errors and oversights through his care, including examples of poor interprofessional communication and a reluctance to speak up about potential errors led to a near miss, with Mr Green narrowly escaping serious venous thromboembolism. We urge viewers to reflect upon the points through Mr Green’s clinical journey in which communication – good or bad, changed the course of events.

Supporting documents

  1. Venous Thromboembolism Risk Assessment (PDF)
  2. Coroners Report (PDF)
  3. Critical Thinking Questions (PDF)
  4. Guideline Prevention Venous Thromboembolism (PDF)

Japanese version of this module

This video was developed by Mieko Omura as part of a BNursing Honours project at the University of Newcastle. The video was directed by Scott Davis.