The following scenario is a real-life story, which may be distressing to some students.

The Scenario: Ryan Saunders was a two-year-old boy who died in Rockhampton hospital in 2007 from a misdiagnosed infection which had culminated in toxic shock.

The circumstances surrounding Ryan's death prompted many changes within Queensland Health

The Task. Discuss the case of Ryan Saunders. Your essay should include discussion of the following points:
- The human factors focusing on communication, that led to the adverse outcomes in this case.
- The coroner's findings in relation to systems improvement and communication errors and how these errors became a catalyst for change.
- The role of the RN in the detection and reporting of clinical deterioration.
- The contributing factors in Ryan's death, focusing on the Coroner's findings and the recommendations that resulted from the Coroner's Inquest and the subsequent reports.

Support your discussion with particular focus on the academic literature surrounding the contributory factors of communication, patient safety, clinical handover and medication safety. You are not required to critique the medical care given but to focus on the contributing factors surrounding Ryan's death. Incorporate the Registered Nurse standards for practice in your discussion.

An academic paper uses the following features: This paper requires you to read the associated literature surrounding Ryan Saunders death, identify key contributing factors as highlighted by the coroner and support your findings with information from the academic literature in relation to these findings.

- An introduction (approximately 10% of the suggested word)
- A body (approximately 80% of the suggested word count
- A conclusion (approximately 10%of the suggested word count)

Read the question carefully and identify the main areas that you will be required to research.
- Read the reports and associative literature regarding the circumstances surrounding Ryan's death.
- Identify the coroner's recommendations. Identify the recommendations from the HQCC(Health Quality and Complaints Commission)
- Research the areas the coroner highlighted and base your academic research on these areas.