Summary of Case No. E.1422/97-98
Jump to
Case No. E.1422/97-98
Insufficient assessment and monitoring by nursing and medical staff, and inadequate care
Matters considered:
Whether the patient's condition was properly monitored and assessed, and the care was adequate.
Complaint against: The Royal Hospitals NHS Trust, London.
Summary of case
Mr Y, who suffered from chronic obstructive pulmonary disease (COPD), was admitted to hospital through the accident and emergency department in the early hours of 15 February 1997. He had been discharged only hours before. His daughter complained that, although her father was short of breath, he was not given sufficient oxygen. The family expressed concern about his condition during the evening. When a doctor eventually came, Mr Y was found to be seriously unwell. The family were concerned that his condition had not been adequately monitored and that his care had been inadequate.
Findings
The Ombudsman was advised by two nurses and a chest physician. Investigation of this case was severely hampered by poor record keeping by nursing and medical staff. No record had been made of when or why a doctor was called, and there was no system for recording what oxygen had been given to Mr Y. Some nursing records were scanty and untimed. There was no record of Mr Y having been seen by a doctor between his initial examination and the late evening, though a ward round was usually held in the morning and additional drugs appeared to have been prescribed in the early evening. The doctor who readmitted Mr Y should have carried out a fuller assessment, and paid more attention to the medical notes of his condition on discharge. That might have given the nurses more guidance about Mr Y's needs. The doctor who saw Mr Y in the late evening found that he had very high levels of carbon dioxide in his blood, which must have been due to his being given too much oxygen, not too little. In patients with Mr Y's condition, giving too much oxygen can reduce the drive to breathe and lead to accumulation of carbon dioxide in the blood. In severe cases that can cause confusion and drowsiness and eventually coma. It is therefore important to monitor the condition of such patients. The Ombudsman was not convinced that all the nurses had an adequate understanding of the significance of oxygen levels in a patient such as Mr Y, and found that they had not planned or monitored his care adequately. The Ombudsman was also concerned about the staffing in the ward that evening. He upheld the complaint.
Remedy
The Trust apologised and agreed to continue regular multidisciplinary audits of documentation, and to remind medical staff about the need for entries in patients' notes to be dated, timed and signed. Nursing staff were to be trained in record keeping and records would continue to be audited. The Trust agreed to review the staffing and skill mix of all acute wards. A structured induction programme was to be extended to all new nurses, and the Trust agreed to assess the need for further in-service training of nursing staff about the administration of oxygen to COPD patients.
