please read the case study Nursing and Midwifery Board of Australia v Sanger (Review and Regulation) (Corrected) [2020] VCAT 201 (20 February 2020) (the link is provided on the attached file) and answer these questions.

1. What actions/omissions on the part of the Registered Nurse(s) contributed to the adverse outcome for the patient.

2. Were there any other factors (e.g. systems-based) that contributed to the adverse outcome for this patient?

3. With reference to the evidence based literature (including relevant NSW policies) outline the actions that should have been taken by the Registered Nurse(s) to prevent adverse outcome for this patient.