The Vanessa Anderson Case

The Garling Report (2008) highlighted, amongst others, details the critical incident and death of a 16-year-old girl, Vanessa Anderson in 2005.  Watch the ABC video and read the coroners’ report found on the Interprofessional Education for Quality Use of Medicines (IPEQUM) website below.


Part 1

After watching the video read the following questions and post them into the forum (150 words)

  1. What are the key clinical governance issues that surfaced here?
  2. Why are these issues significant?

(Please disregard Part1 as you have already helped me with this part of the assessment)

Part 2

Respond to this student’s response (100 words)

  1. Consider the Registered Nurse Standards for Practice. How should an RN have responded in such a situation to promote safe patient outcomes?


Student Response


Lack of communication between Neurosurgical Registrar and treating Neurosurgeon meant that there was a delay in Vanessa being assessed and scheduled for appropriate treatment when she was first admitted to the hospital. The treating neurosurgeon not being advised of prescribed drugs being withheld or different medication being prescribed. Advising the treating Neurosurgeon may have stopped Vanessa being prescribed and administered more than the recommended dose of both codeine and endone by two different doctors. It may also have meant these medications were not prescribed at all, as the treating Neurosurgeon stated these medications may not have been appropriate. It may also have meant that Vanessa was either administered the original or alternative anti-convulsive medication, which may have stopped Vanessa having a seizure. The nurse in charge not recording the concerns made by Vanessa, notify any other staff of these concerns or further investigate these concerns. The nurse in charge also didn’t advise the treating Neurosurgeon of possible complications Vanessa was experiencing. Further investigation of Vanessa’s concerns may have led to the nurse or another nurse recognising that Vanessa required an immediate medical review by the treating Neurosurgeon and this review may have resulted in Vanessa receiving life-saving treatment.

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