1.  Analyse the Coroner’s case to identify the issues (what happened and why it happened) in care delivery that contributed to a failure to recognise and respond to clinical deterioration. Discuss how the issues identified, in conjunction with the patient presentation, medical history, and underlying pathophysiological processes led to the clinical deterioration. 
2. Based on contemporary evidence, analyse the clinical actions of the registered nurse(s), how the actions contributed to the patient’s clinical deterioration, and discuss what action(s) should have been undertaken to potentially prevent the clinical deterioration.
3. Based on issues identified in the Coroner’s report, apply contemporary research to discuss the communication barriers in the escalation of care and how these may be addressed to improve future care.
4. References:
You must use current and relevant peer-reviewed literature to support your arguments in addressing these tasks. 
Integrate contemporary literature in the form of published articles within journals, no older than 7 years.
Your textbooks may be used as references, however, textbooks should not comprise more than 25% of your overall sources.
If using web pages, they must be evidence-based. Sponsored sites and review sites such as StatPearls are NOT to be used.
Demonstrate your knowledge and understanding related to:
1. Anatomy, physiology, and pathophysiology of the primary diagnosis, medical history, and associated clinical data identified within the coroner’s report.
2. The physiological assessments relevant to the features within the case study.