Case No. E.1422/97-98
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Case No. E.1422/97-98
Insufficient assessment and monitoring by nursing and medical staff, and inadequate care
Complaint as put by Miss Y
1. The account of the complaint provided by Miss Y was that in the early hours of 15 February 1997 her father, Mr Y, was admitted to the Royal London Hospital (the hospital), which is managed by the Trust, complaining of shortness of breath. He had been discharged from the hospital only hours before. Later that day he was transferred to a general medical ward. Miss Y understood that her father was not given oxygen until late that night. It was only after repeated requests by his family that a doctor eventually saw him at about 11. 45pm. He was discharged on 21 February.
2. On 17 February Miss Y complained to the Trust about aspects of her father's care and treatment. The chief executive replied on 8 April. On 16 April Miss Y wrote to the Trust for further clarification and received a detailed reply on 15 July. She was dissatisfied with the explanations offered and on 22 August asked for an independent review of her complaint. On 15 October the convener wrote to Miss Y refusing her request. Miss Y remained dissatisfied.
3. The matters investigated were that on 15 February 1997 there was insufficient assessment and monitoring of Mr Y's condition by the nursing and medical staff, and his care was inadequate.
Investigation
4. The statement of complaint for the investigation was issued on 24 March 1998. The comments of the Trust were obtained and relevant papers, including Mr Y's medical and nursing notes, were examined. The Ombudsman's investigator took evidence from Miss Y and her parents, Trust staff and former employees of the Trust. Three independent professional assessors were appointed—two nurses and a chest physician— to advise on the clinical aspects of the complaint. A relevant assessor accompanied the investigator at most interviews with Trust staff. The assessors' report is at Appendix A of this report.
Evidence of the family
5. Mr Y said that when he was in the accident and emergency (A and E) department he was given oxygen through a mask. Mrs Y said her husband was admitted to Cambridge ward (an admissions ward) at about 4.00am and that she remained with him until about 5.00am. Mr Y said that he did not have oxygen with him during the transfer to the ward and he was refused oxygen when he asked for it. He had felt very sick and breathless. He did not recall anything else until he woke up on 16 February. Miss Y telephoned the ward between 10.30am and 10.45am and was told that Mr Y was asleep. Mrs Y telephoned about six times between 10.00am and 5.00pm and was told the same thing. At about 5.00pm Mrs Y was told that her husband had been transferred to Currie ward (a medical ward).
6. When Mrs Y visited at about 6.00pm her husband was still asleep. He was not receiving oxygen. She asked a nurse (the first staff nurse) if Mr Y had been sedated. The first staff nurse checked her notes and said that he had not. At about 7.30pm Mrs Y told the first staff nurse that her husband did not seem like himself (he was not usually drowsy even when ill), and asked if a doctor could see him. The first staff nurse told Mrs Y she would call a doctor if Mrs Y was worried. Mrs Y confirmed that she was. When interviewed Mrs Y recollected hearing, at the handover between shifts at about 8.30-9.00pm, another nurse (the third staff nurse) being told that they were waiting for the doctor. Mrs Y asked once or twice more about the doctor. Mrs Y said that she did not recall her husband requesting or taking paracetamol during the evening (see paragraph 43). Miss Y arrived at about 10.00pm. Her father was very drowsy and uncommunicative. When she asked she was told that a doctor would be there soon. She also asked about oxygen and was told that the doctor would decide. She asked on three further occasions before a doctor (the locum house officer) arrived at about 11.45pm.
7. Miss Y said that the locum house officer took some blood and returned with a second doctor (the specialist registrar). At about 2.30am on 16 February the specialist registrar told the family that Mr Y had emphysema, though they had previously thought that his long term chest condition was asthma. The specialist registrar said it was '50:50' whether Mr Y would survive the night. That was a great shock to the family. They felt that the doctors had done a very good job, but that the nurses had not monitored Mr Y properly. They had not taken proper notice of his records, or of the family's concerns. The family believed that Mr Y should have received oxygen and more medication sooner, and were concerned that had they not been there to alert the nurses to his condition, he might have died.
Chief executive's comments
8. In comments to the Ombudsman the chief executive said 'The Trust believes .... that [Mr Y's] assessment, his subsequent monitoring and care was adequate on 15 February 1997.'
Background provided by the assessors
9. The medical background to this case is complex making it necessary in this introductory section to examine in some detail the nature and consequences of the lung condition from which Mr Y suffered. The material in paragraphs 10 to 32 below is based on advice from the Ombudsman's professional assessors.
Terminology
10. The terms used to describe conditions which cause narrowing of the airways in the lungs are, regrettably, confusing. Airways narrowing which occurs from time to time is generally described as asthma, and that which is persistent as chronic airways obstruction (COAD), though the terms chronic obstructive lung disease (COLD) and chronic obstructive pulmonary disease, (COPD), are also in common use.
11. Asthma can come on very quickly and will cause attacks of wheezing and breathlessness, but it is usually very responsive to treatment with bronchodilators (drugs which improve airflow to the lungs) and steroids. Chronic airways obstruction progresses slowly over many years, causing increasing breathlessness on exertion. It is usually fairly unresponsive to treatment, though nearly always inhalers, the same as those used in asthma, are prescribed. Response to treatment in chronic airways obstruction can be particularly unrewarding if the destructive process known as emphysema (a condition of the lungs in which there is destruction of the walls of the air sacs across which oxygen passes from the air into the blood) is present. This term is often used rather loosely. The diagnosis should be based on X-ray findings.
12. The distinction between asthma and chronic airways obstruction is often blurred in real life for several reasons. First, the allergic inflammation of the airways in asthma can persist between attacks, so causing chronic narrowing which can give similar exertional breathlessness to that caused by chronic airways obstruction. Secondly, in patients with chronic airways obstruction, an infection can cause additional short term (days or weeks) narrowing of the airways. Such episodes are described as an acute infective exacerbation of COPD (or synonym). And, thirdly, the predominant causes of asthma and chronic airways obstruction, respectively allergy and smoking, are common, and so there are many individuals with both conditions.
13. This complex terminology is evident in the case in question. The family believed that Mr Y had asthma. Various other terms, in addition to asthma, were used in the hospital discharge diagnoses ('exacerbation of COAD', 'chest infection' etc), and he and his family were told on 15 February 1997 that he had emphysema. In this report the abbreviation 'COPD' is used to describe Mr Y's condition.
Monitoring and use of oxygen
14. To understand the issues raised in relation to the monitoring of Mr Y's condition and the use of oxygen, it is necessary to describe how gases are exchanged in the lungs and the consequences for gas exchange of airways obstruction.
15. The bellows action of the chest wall draws air into the lungs: this air contains 21% oxygen. Oxygen passes across to the blood in the lungs and is used as an energy source by the body. The 'waste product' from using oxygen is carbon dioxide (CO2). CO2 rich blood returns to the lungs, and some CO2 passes across into the air spaces and is exhaled as the lungs deflate on breathing out. Exhaled air contains about 5% CO2 and 16% oxygen.
16. Not all the CO2 produced by the body is breathed out. CO2 reacting with water in body fluids forms a dilute acid. It is absolutely crucial for the functioning of the whole body that the level of this acid is kept as constant as possible. The rate and depth of breathing are used by the body as a control mechanism. If the CO2 in the body rises, breathing increases to blow off the excess and vice versa.
17. This automatic control mechanism can be overridden. Deliberate overbreathing reduces body CO2 excessively, producing tingling of the hands and feet, light-headedness and fainting. If the flow of air in and out of the lungs is impeded—as it will be by conditions which narrow the airways—then CO2 can accumulate in the body.
18. In acute episodes of asthma, the regulating mechanism will come into play causing breathing to increase. This will blow off any excess CO2, but at the expense of the effort of breathing excessively through narrowed airways, thus producing breathlessness. In chronic airways obstruction, the CO2 regulating mechanism is often blunted and this allows the CO2 in the body to rise. In severe cases this causes confusion, drowsiness and eventually coma.
19. Any form of airways narrowing can impede the access of air to the surface linings of the deepest parts of the lungs where oxygen passes across into the blood. The consequence of this is that oxygen levels in the blood fall. Oxygen is essential to the proper functioning of all body tissues, but a lack of oxygen causes particular problems to the nervous system (twitching, confusion) and the heart (giving a type of heart failure).
20. In asthma, blood oxygen levels are low in the acute attack. In COPD, the blood oxygen can be low all the time. The state of low blood oxygen is known as hypoxia. Hypoxia drives the brain to increased breathing in an attempt to compensate for the lack of oxygen.
21. A further explanatory note is necessary to understand some crucial aspects of Mr Y's case. He had COPD with blunted sensitivity of his CO2 regulating mechanism. As a consequence of this, his CO2 rose. He also had poor oxygen levels, but much of his drive to keep breathing relied on a lowered oxygen level. Giving oxygen in this setting can therefore reduce the drive to breathing and lead to yet further accumulation of CO2.
22. Mr Y was treated with oxygen. It is crucial to distinguish between two methods of giving oxygen—mask and nasal prongs. The masks are designed to deliver a fixed percentage of oxygen—for example, 24%, 28% or 33%. The mask works at a set flow rate and irrespective of how much the patient is breathing himself, he will always get the prescribed percentage. Nasal prongs are different. Pure oxygen is delivered into the nostrils at a rate that can be varied, but is usually 1 litre or 2 litres per minute. The oxygen being delivered through the nose is then diluted by the air the patient is breathing in through his mouth. At any given flow of oxygen through the nasal prongs, the lungs will always receive a greater amount of oxygen if the patient is breathing shallowly, than if he is diluting the oxygen with large amounts of air by breathing deeply through the mouth. This is therefore not a precise way of giving added oxygen, and is a mode of delivery that is not favoured for acutely ill patients. For them the mask, with a specific percentage of oxygen, is preferred. Prongs are acceptable for long term delivery of oxygen to patients in a stable condition.
23. Reference in the text that follows is made to certain measurements which therefore need defining:
— (a) The pressure of carbon dioxide in the blood: pCO2: normal values 5 to 6 kPa (kilopascals: a unit of pressure);
— (b) The pressure of oxygen in the blood: pO2: normal values 12-14 kPa.
— (c) The blood acidity: pH: normal value 7.40.
The level of acidity is very important to body functions. When CO2 rises quickly the acidity increases quickly. When a raised CO2 is sustained, the body compensates by retaining bicarbonate. This 'buffers' the CO2 acidity and returns the blood acidity (pH) towards normal. In Mr Y's case a pH of 7.35, which was the case on 5 February, represents good compensation. There are then a series of figures less than or equal to 7.30, which indicate increasing acidity. The acute correction of CO2 with doxapram (a respiratory stimulant—see Appendix B) on 16 February led to a normal pH of around 7.4.
24. The above measurements can be made only by sampling arterial blood, a technique which generally only doctors carry out. The collective results are called the 'blood gases'.
25. Oxygen saturation is the percentage to which the blood is saturated with oxygen. Percent saturation does not vary linearly with pO2. Normal saturation is 97%, quite close to the maximum (100%) obtained by breathing pure oxygen. Oxygen saturation is measured by a pulse oximeter, a device placed over the end of the finger. No blood sampling is required; and the test can be done by nurses. If the saturation falls, very little effect is likely to be noticed until the figure reaches 90%. At 90% and below an increased drive to breathing occurs, which is sensed by the patient as an increased shortness of breath. In monitoring oxygen delivery to these patients using a pulse oximeter, the desired level looked for is a saturation above 90%. However, saturation measured at 95% or above, especially in a drowsy patient with COPD, indicates that too much oxygen is being given, and points to the need for blood gas analysis to measure the pCO2.
26. If too much oxygen has been given and the added oxygen is either stopped or the percentage being delivered reduced, then a new saturation level will be established in a patient with COPD in about ten minutes. On the other hand, CO2 is stored in body tissues, and a raised CO2 level will not adjust for several hours unless some positive steps are taken to increase breathing (using drugs or artificial ventilation machines).
27. The nursing care needed for a patient with COPD with actual or potential CO2 retention should include the following interventions:
—to call for medical assistance if oxygen saturation is greater than 95% in a drowsy patient;
—to give prescribed oxygen via a 'ventimask' at 24%.
28. Measuring the respiratory rate (the number of breaths per minute) is part of routine monitoring by nurses. In normal healthy individuals, the respiratory rate is around 14 per minute and will increase on activity. Patients with COPD in hospital often breathe at around 20 per minute. A fast rate of around 30 per minute signifies an excessive drive to breathing, eg fever, low oxygen (hypoxia) or anxiety. A slow rate of about 10 per minute signifies a depressed drive to breathing, eg sedative drug treatment (especially opiates) or excessive use of oxygen. Under these circumstances further accumulation of CO2 in the body will occur and so there will be a raised arterial pCO2 measurement.
The hospital and its staffing
29. The Royal London Hospital is a large teaching hospital with approximately 500 acute beds. Medical care is given by eight medical 'firms'. Each firm takes acute medical emergencies for 24 hours (9.00am-9.00am) on a strict 1 in 8 rota (irrespective of weekdays or weekend days). The average number of medical admissions per 24 hours is 23 with a range of 15 to 30.
30. The medical admitting team consists of two house officers (resident), a senior house officer (resident), one registrar (resident), one registrar (non-resident), and a consultant (non-resident).
31. Acute medical emergencies are all admitted through the A and E department whether they are sent from their GP (approximately 30% of the total), or self refer to A and E. The majority of patients who need to come into hospital are first admitted to an admissions ward (Cambridge). The medical team on duty conducts a ward round at the end of their 24 hour shift on duty (the 'post-take' ward round). At that time the decision is made either to discharge a patient or to admit to one of the general medical wards.
32. On the medical wards a patient's medical care is undertaken by the medical team that admitted them, unless they have been under the care of a different team within the past year in which case care is handed back from the admitting team to the patient's previous team. The medical team responsible for that patient attend to all medical matters during normal working hours. At night and at weekends medical patients are looked after by two resident duty house officers, supported by the second medical registrar but also with access to the medical admitting team. These doctors are on call for all the patients on the general medical wards and some on specialist medical wards. They care for more than 200 patients. Their duties include on-going medical input to sick patients specifically notified to them by other teams, and coping with unexpected medical events notified to them by the nurses on duty.
Guidance
33. In April 1993, the United Kingdom Central Council for Nursing, Midwifery and Health Visiting (the UKCC), the body which regulates the standards and conduct of those professions, issued a document entitled 'Standards for Records and Record Keeping'. It states that 'record keeping is an essential part of care' and goes on to say that records must be 'written legibly and indelibly, clear and unambiguous, accurate in each entry as to date and time .... In summary, the record .... will demonstrate the chronology of events and all significant consultations, assessments, observations, decisions, interventions and outcomes.' The Trust's local standard stated that a 'nursing assessment [should be] completed within 12 hours .... and .... reassessment [carried out] when necessary'.
Key events and documentary evidence
34. A summary of key events relating to Mr Y's hospital admission follows. Documentary evidence from his medical records is summarised at Appendix B.
Previous hospital admission
Mr Y was admitted on 13 February and discharged on 14 February. During that time he was seen by a specialist registrar from the team dealing with chest problems, and an outpatient appointment was made to see the consultant the following week.
Admission including period covered by this report
15 February
1.19am—Mr Y was readmitted to A and E, and seen by a doctor.
4.00am (approximately)—He was admitted to the admissions ward.
8.00am (approximately)—A ward round was usually held in the admissions ward. There is no record of Mr Y being seen by the doctors.
5.00pm (approximately)—Mr Y transferred to the medical ward.
6.00pm (approximately)—Mrs Y arrived to see him.
7.30pm (approximately)—Mrs Y raised concerns about her husband's condition.
8.15pm to 9.00pm—Handover between late and night shifts of nurses.
10.00pm (approximately)—Miss Y arrived in the medical ward.
11.30pm to midnight—The locum house officer examined Mr Y, and found he had a very high carbon dioxide level. She called the registrar and a respiratory stimulant was prescribed.
16 February
4.28am—Mr Y was noted to be much improved.
Evidence of Trust staff
35. The duty registrar who saw Mr Y in the A and E department said that, since he had been discharged about six hours before, she did not consider it necessary to record all the details of his previous medical history; intervals between visits by a doctor when a patient was in hospital were often up to eight hours. She re-assessed Mr Y and found his condition unchanged. That was confirmed by a blood gas test. As Mr Y had a low oxygen saturation, she prescribed oxygen; this was at the lowest concentration of 24% as his carbon dioxide level was high. It was important to consider carbon dioxide levels in a patient with COPD. Mr Y's condition was not unstable, and there were no new problems. At that time of the morning she would not have talked to nurses about a care plan for Mr Y; he would not have continued to be her patient. She said that a post-take ward round (paragraph 31) always took place on a Saturday morning, but she could not remember this particular one. She would have been there and would have handed over to the consultant. Mr Y's condition would have been reviewed then. It would have been a house officer's responsibility to record it.
36. A health care support worker in the admissions ward remembered Mr Y being given oxygen from his arrival in the ward, and thought that he might have been receiving it when he arrived. Mr Y became panicky at one point and tried to take his oxygen mask off. A record the healthcare support worker had made of an oxygen saturation of 97% (Appendix B) indicated that that was the figure on admission to the ward.
37. A nurse in the admissions ward said that the health care support worker entered her as the 'named nurse' on Mr Y's care plan, but she did not believe she was. Mr Y's care plan was standard for a patient with COPD, although she would have planned more frequent observations. If oxygen saturations fell below 90% she would consider informing a doctor, and she would have been concerned if Mr Y's fell from 97% on admission to 90%. Mr Y was continuously observed and staff did not rely on saturation measurements alone to indicate that a doctor should be informed. She usually considered a patient's colour, condition, respiratory rates, pulse and signs that they were drowsy as indicators that they were not getting enough oxygen, were retaining carbon dioxide, or both. She considered the entry made by the medical staff on Mr Y's admission was inadequate as there was no clear assessment or plan of care.
38. The second nurse in the admissions ward who entered details of the oxygen saturation (96%) at midday, said she thought she had done that to assist a colleague, since she did not think that Mr Y had been her patient. Had she been taking observations on one of her own patients she would have recorded more detail. Although the care plan said that a doctor should be informed if saturation fell below 85%, in practice nurses would take action if it fell below 90%. A saturation of 96% would not, taken in isolation, indicate any problem: she would always take into account other symptoms. She was confident she would have recognised if Mr Y had been more drowsy than could be accounted for by his lack of sleep the previous night. She had recorded that Mr Y had not moved his bowels. He must have been awake to tell her that.
39. The manager of the admissions ward (the first ward manager) was not on duty when Mr Y was a patient. She said that an 'activities of daily living' assessment sheet should have been completed. (Note: the Trust have not been able to provide that document.) Mr Y would have been seen at the Saturday ward round. Written evaluation of patients was usually done at the end of a shift. As Mr Y transferred before then, a written evaluation might not have been done, but should have been completed. She said that the standard of record keeping at that time could have been better. The Trust audited nursing records generally; and she had audited records in her own ward on two occasions in the past year.
40. If a patient with COPD was drowsy she would expect the nurses to check oxygen saturation levels, carbon dioxide retention, and to carry out general observations. Guidance and text books on caring for patients with COPD were now held in the ward. She said that nurses would have noticed if there had been any problems during Mr Y's stay in the ward; they knew him (from previous admissions) and would have recognised any changes. If a COPD patient deteriorated the change would be quite dramatic. Nursing involved continuous assessment and observations, and it was difficult to draw any conclusion from a saturation figure of, say, 97%—in a patient like Mr Y that could be fine. The saturation result alone would not determine whether a doctor should be called.
41. The staff nurse who admitted Mr Y to the medical ward (the first staff nurse) said that this was her first job since qualifying. There had been an oral handover when Mr Y was transferred to her ward. She had not met Mr Y before then and considered that his condition was stable. She completed the care plan. She said that she had also recorded on a communication sheet that he had been receiving oxygen. (Note: the communication sheet cannot be found.) There was no guidance in the ward about patients with respiratory problems, but she had some knowledge from her training. She knew that depletion of oxygen or an increase in carbon dioxide could cause patients with COPD to become breathless, confused and increasingly distressed. She did not remember Mr Y showing those signs. She believed that drowsiness in a COPD patient was significant as it showed a lack of oxygen. She thought that Mrs Y had told her that Mr Y was not usually so drowsy. She bleeped a doctor but could not remember when, or whether the doctor answered. She knew she should have documented the call. She did not remember whether she spoke to the more senior staff nurse on duty (the second staff nurse) before calling the doctor, though she would usually have done so. She did tell the third staff nurse, at the shift handover, that she had called a doctor. At interview, she recognised that she should have been more careful in her documentation.
42. The second staff nurse did not remember Mr Y or when he was admitted to the ward. She was not aware of any guidance within the ward for the management of patients with respiratory problems, although it was not uncommon to have such patients in the ward. If oxygen was prescribed it would routinely be given to the patient through a mask. It was important to regulate the oxygen to a patient with COPD. If patients with COPD received too much oxygen they could become drowsy or confused. To check on that she would take oxygen saturation levels using a pulse oximeter (paragraph 25), though at the time the ward did not have one of its own. She would call the doctor if she was concerned. An oxygen saturation level of 95% would not in itself cause her concern. It was also important to take account of other information about a patient's condition including that from their relatives. She thought that the first staff nurse would have spoken to her if she had had any concerns.
43. The staff nurse who cared for Mr Y on the night shift, which began at 8.15pm, (the third staff nurse) said that she did not remember him. Mr Y's condition, the diagnosis and the nursing care planned would have been discussed with her at the shift handover. She thought that Mr Y would have been receiving oxygen from a mask. If she did not know a patient it would be harder to tell his condition. She would rely on her own clinical observations and any comments from the family. Although there was no guidance in the ward on the management of patients with respiratory problems, she knew the signs to look for. With a COPD patient she would have checked the rate of his breathing and whether the patient was clammy, agitated or confused. If the patient was on a monitor she would check if oxygen saturation was falling. Also too much oxygen could result in retention of carbon dioxide in COPD patients, which she understood could result in hyperventilation or respiratory arrest. Referring to the drug chart, she said that at around 9.30pm she gave Mr Y paracetamol orally and maxolon (a drug to relieve nausea) by injection. She also administered the first dose of an antibiotic. The drug chart showed that Mr Y was given ventolin by inhaler and atrovent (a bronchodilator) by his nebuliser at 10.00pm. (Note: this was the first time some of these drugs had been administered to Mr Y. The prescription for the additional drugs was signed by the locum house officer. They appear to have been prescribed after the usual 6pm drug round.) The third staff nurse did not remember calling the doctor. She said that, if she had, she should have recorded doing so. She would not have given the drugs unless the doctor had come to the ward to authorise the prescription on the drug chart. Drugs were not authorised by phone.
44. The staff nurse in charge of the night shift (the fourth staff nurse) did not remember Mr Y. She knew that COPD patients needed oxygen but that too much resulted in a build up of carbon dioxide, and confusion. She said that she would expect to have been told if the third staff nurse had contacted a doctor.
45. The manager of the medical ward (the second ward manager) had not been on duty at the time of Mr Y's admission. There were difficulties covering rotas then, and they relied on bank and agency staff to cover. The usual staffing on the late shift was two trained nurses, two untrained nurses and often another untrained nurse, who worked between 5.00pm and 11.00pm. On this evening there was one trained nurse (the second staff nurse) and the first staff nurse, who was trained but had not yet received her UKCC registration number and two untrained nurses. (Note: the UKCC registration number is a personal index number which is given to every trained nurse, and is necessary in order to practise.) The second ward manager said that the first staff nurse had been expected to carry out all the duties of a staff nurse, except administering drugs. The ward did not have any guidance about the management of patients with respiratory problems, but various text books were available. New staff were now given more information, including formal teaching at the bedside. She thought that the first staff nurse's care plan was good. It did not include any record of oxygen saturation levels because there was no pulse oximeter in the ward then. The ward now had one so she would expect nurses to check oxygen saturation levels.
46. The second ward manager said that the records in this case were not as good as they should have been. Now documentation was audited twice a year. She did not consider that Mr Y's nursing care was inadequate. In a statement made on 28 February 1997, the second ward manager said that the doctor was called at 8.00pm. Although she could not now remember where she obtained that information, and no record could be found, she was sure that she would not have specified the time if she had not been satisfied that it was accurate. Mr Y had been well cared for and a doctor had been called.
47. The nurse who oversaw nursing standards in the medical directorate (the lead nurse) said that qualified nurses should know the basic care required by patients with respiratory problems. She was concerned that the nurses interviewed did not fully understand the significance of the oxygen percentage in COPD patients, and consequently that they might not be able to distinguish between drowsiness and respiratory failure. She thought that Mr Y must have deteriorated rapidly that evening. It appeared that he had been given paracetamol orally at about 9.30pm, and so must have been conscious then. A nurse should have recognised if Mr Y had deteriorated between 9.30pm and 11. 00pm. There were serious deficiencies in the record keeping which were inexcusable. The communication between the nurses and Mr Y and his family, and between the nurses and the doctors, was not good enough. Vacancies were high at that time, and there had been little formal support for newly qualified nurses. Recruitment procedures were much better now and the professional development of nurses was now being addressed.
48. The operations manager said that the standard of record keeping was monitored by ward managers. It was also regularly audited by the quality department. She would be notified of the results and would deal with any issues involving the directorate; ward matters were the responsibility of the individual ward manager. They were trying to improve their record keeping. It appeared that a communication sheet which was completed was now missing from Mr Y's records. The standards of record keeping in the medical ward were no worse than in any other ward at that time. She questioned why a newly qualified nurse had been rostered on the late shift as the second trained nurse, though that nurse should still have been able to recognise if a patient was comatose. In later comments, about when Mr Y's condition deteriorated, she said that she did not believe that his condition had been critical in the afternoon and early evening.
49. The locum house officer who saw Mr Y in the medical ward worked at the hospital for one day only. She thought that she was on duty from 5.00pm. She could not remember when or how often she was bleeped about Mr Y. She did not know exactly when she saw him. The locum house officer confirmed that she had written prescriptions for some of the medication given to Mr Y at 9.30-10.00pm. She was certain that she would have come to the ward to do that. She was surprised that she had not noted this visit in the medical records as was her usual practice. His blood gases result later in the evening indicated to her that he had been receiving oxygen and she reduced his oxygen flow to one litre per minute instead of two, in case that was causing his carbon dioxide retention. However, his breathing did not improve so she gave him medication. She knew that she should have timed her entries in the records.
50. The specialist registrar remembered Mr Y. She had reviewed him at the request of his consultant on 14 February. She was surprised that Mr Y's medical history was not taken again in the admissions ward, and wondered if this admission had been considered as a continuation of the previous one. When she was called by the locum house officer, who had taken the appropriate action, she reviewed Mr Y's condition. He was drowsy and confused. She took two further blood gas tests, after allowing for the effect of the reduction in oxygen prescribed by the locum house officer. The second blood gas test showed that at some time Mr Y had been receiving oxygen. She did not know how much oxygen he had received or for how long. It was possible that having been diagnosed as suffering from asthma, rather than COPD, Mr Y might have been given too much oxygen. That would have caused a problem. She said it was a mystery to her why things had happened so suddenly. Mr Y had been quite sick, but she did not know why his condition deteriorated. The family's being there had been very important as the nurses might not have been able to recognise how much his condition had differed from usual.
51. The clinical director said that if a patient had been out of the hospital for only a short time, as was Mr Y, full history-taking was not necessary; a management plan would be sufficient. A 'post take' ward round took place in the admissions ward on Saturday mornings, usually at about 8.00am. As Mr Y had very recently been readmitted and the staff knew him, they might not have considered it necessary to review his condition at the ward round. It was the responsibility of nurses to follow the treatment plan and alert medical staff if there were any problems. The house officers on call covered a large number of patients and had to establish priorities. The clinical director described the record keeping by the medical staff as average: some entries were very good, but the initial entry was too brief and entries should have been timed. Lack of timing of entries was a difficult problem to solve.
52. An audit of documentation in the admissions ward in February 1998 (a year after the events complained of) showed that of the eight sample records examined, only one gave the time of admission or transfer and only two had all entries timed. An audit of the medical ward in March 1998 showed that of the sample of eight records examined, five gave the time of admission or transfer. All the entries were timed.
53. In comments on 11 March 1999, the chief executive said that:
'as part of the process of Kings Fund Accreditation, an audit of medical records content took place in June 97, and in June and September 98. As a result, the Standards Committee agreed that one of the Trust's key quality targets for this year is "Improving the Content and Format of Clinical Record Content". Directorates have been advised that it is mandatory to include "Content of medical records" as part of their clinical effectiveness program. Work is in progress, to develop an appropriate audit tool, to monitor standards and to ensure remedial actions take place.
'the Trust has introduced a generic nursing orientation program for all new staff which includes nursing documentation [Note: a copy was attached for information]. Biannual audits of nursing documentation are carried out and reported through the nursing policy board to the Trust Board. Standards are also set and performance evaluated on system compliance of the computerised nursing information system.
'the Trust's "Strategy for Nursing" defines a number of nursing standards and these are audited annually. One of the standard statements is "There will be a safe and appropriate skill mix for the Ward/Department". Over 72% of wards/departments had undertaken a review of the nursing skill mix required for their clinical areas, within the last year of the last audit report (June 1998). The Trust plans to introduce a computerised system which will determine the assessment of staffing requirements .... The format and content of the Audit of the Strategy for Nursing is under review by the Clinical Effectiveness and Quality Nursing Team, who have responsibility to produce an audit tool which can effectively review the nursing service.'
Findings
54. In arriving at my findings, I have taken into account the advice of the Ombudsman's assessors (Appendix A). Miss Y and her family were concerned that despite his breathing problems, Mr Y did not appear to have been given adequate oxygen on 15 February and, after initial assessment on admission, did not see a doctor again until late that night. Investigation of this case has been severely hampered by poor record keeping by medical and nursing staff. That poor record keeping must have affected the ability of other staff subsequently to assess changes in his condition. Nursing records were scanty and too often untimed. In particular, no record was made of when or why the doctor was called and there seemed to be no system for recording what oxygen was given. Record keeping by the doctors was also weak. It has not been possible to find out why there is no record of Mr Y being reviewed at the ward round. If the locum house officer examined him before prescribing the additional drugs which were given between 9.30 and 10.00pm (paragraphs 43 and 49) she made no record of that. Crucial records were untimed. All this has made it difficult to piece together exactly what happened.
55. Mr Y was initially seen in the A and E department by the duty registrar, who knew that he had been discharged the previous day. She did not record as detailed a history as usual, because he had been readmitted so soon after his discharge. Having tested his blood gases she prescribed oxygen. She did not give any instructions about how that oxygen should be given or about Mr Y's future care. She said that that was because he would not have continued to be her patient and she expected him to be reviewed at the Saturday morning ward round. Were her actions reasonable? The Ombudsman's assessors consider that a fuller assessment and record should have been made, and that more attention should have been paid to the medical notes of Mr Y's condition on discharge. That might have given the nurses more guidance about Mr Y's special needs as a COPD patient. The ward round would have been another opportunity to review his needs and give adequate instructions to the nurses. There is no record that Mr Y was seen.
56. When Mr Y was transferred to the admissions ward a computerised care plan was made out. It said that he was to be given oxygen and that his saturation level was to be monitored. It failed to recognise that a high saturation level did not necessarily mean that all was well, and in fact should be cause for concern in a known COPD patient. There is no record of what oxygen was given. The nursing records show that an oxygen saturation level measurement of 96% was taken at midday, following one of 97% on arrival in the admissions ward at 4am. The assessors have said that the level of 96% in a drowsy COPD patient indicated a need for blood gas levels to be checked. While a level of 96% or 97% would be reasonable for most people, to achieve that level in a COPD patient so much oxygen must have been given that the drive to breathe would be reduced, leading to a risk of carbon dioxide retention. That in turn would upset the acid level of the body and affect body functions (paragraphs 21 and 23). Checking the blood gases would have meant calling a doctor. There is no evidence that that was done despite the high oxygen saturation levels.
57. On transfer to the medical ward a new care plan was made out by the first staff nurse. She must have been hampered by the lack of adequate records from A and E and the admissions ward. The plan was very general. Any further information she may have entered on a separate document cannot be found. Again there is no record of what oxygen Mr Y might have received, though his family say he received none. The first staff nurse did note that Mr Y slept for most of the evening, but no further oxygen saturation levels were recorded or blood gas tests carried out.
58. No record was made of attempts to contact a doctor after the family expressed concern. The family are quite clear that no doctor arrived to see Mr Y until about 11. 30-11. 45pm when the locum house officer tested his blood gases and found he had very high carbon dioxide levels. The notes do not record any visit by the locum house officer earlier in the evening. They do show, however, that between 9.30 and 10.00pm Mr Y was given drugs which had been prescribed by the locum house officer: she came on duty at 5.00pm and the drugs appear to have been prescribed after the usual 6.00pm drug round. The locum house officer and the third staff nurse say that the prescription would not have been given unless the doctor had come to the ward: but it is open to doubt whether she actually saw Mr Y, when the family who were there from about 6.00pm, clearly did not see her. If she did see Mr Y, I can only assume that it was either just before the family arrived or briefly later if they left the ward for a short period. Furthermore if the nurses had seen the visit by the locum house officer, then surely they would have told the family about that visit when they enquired about calling a doctor. It has not been possible to resolve this conflict of evidence. What is clear is that, if the locum house officer saw Mr Y in the early evening, she did not record that.
59. When the locum house officer came in the late evening she took a blood gas test which showed that Mr Y had a very high level of carbon dioxide. The doctors who treated Mr Y conclude that that must have arisen as a result of being given oxygen and the Ombudsman's assessors agree. It is not possible to be sure exactly when Mr Y's condition deteriorated: the family's and staff's accounts differ significantly, and the records are poor. It is possible that, even if the family are correct and no oxygen was given after they arrived in the evening, the problem could have begun to develop during the morning and afternoon (on the admissions ward, when oxygen does seem to have been given) and then progressed without correction on the medical ward (paragraph 26). In simple terms, while Mr Y's family feared that lack of oxygen contributed to his deterioration, this investigation indicates that it happened because of an excess of oxygen at some point during the day. But that is just as much a matter for concern.
60. Other factors may lie behind some of the failings described above. The OWhy did the situation arise and should it have been detected sooner? At interview all the nurses said that they knew the signs to look out for in a COPD patient. I am not convinced, however, that all had an adequate understanding of the significance of oxygen levels in such a patient. Some of the explanations they gave at interview were incomplete or confused. This is a very complex subject. However, I am advised, and the Trust's lead nurse agrees, that all qualified nurses should have a basic understanding of the risks of oxygen therapy in COPD patients and the monitoring required. That did not seem to be the case here, and had potentially serious consequences for Mr Y. Nursing staff did not plan and monitor his care adequately.
61. Other factors may lie behind some of the failings described above. The Ombudsman's assessors have said that the usual nurse staffing (two qualified and two unqualified nurses) on the late shift and night shift on 15 February would have been average for the size and type of ward. However, the first staff nurse had just completed her training and was not yet registered with the UKCC. Such nurses would usually be considered untrained. In effect, therefore, the ward was running with one trained and three untrained nurses. I agree with the assessors' view that the rostering for that shift was inappropriate as it did not allow for the required level of supervision for such an inexperienced nurse.
62. I note that the Trust now audit their documentation and recommend that that should be continued on a regular basis, and should be multidisciplinary. I also recommend that medical staff are reminded of the need to date, time and sign all entries made in patients' notes; that nursing staff are trained in record keeping; and that records continue to be audited. I recommend that the staffing and skill mix of all acute wards should be reviewed regularly, and that newly qualified nurses awaiting formal UKCC registration should be rostered as an unqualified nurse rather than as the second qualified nurse. I also recommend that the structured induction programme which has been introduced in the admissions ward is evaluated and adapted as necessary, and that comprehensive induction should be available for all new nurses, particularly those newly qualified. I recommend that the Trust assess the need for further in-service training of nursing staff regarding administration of oxygen, particularly to patients with COPD. I uphold the complaint.
Conclusion
63. I have set out my findings in paragraphs 54-62. The Royal Hospitals NHS Trust have asked me to convey through my report—as I do—their apologies for the shortcomings identified and have agreed to implement my recommendations in paragraph 62.
Appendix A to E.1422/97-98 Report by external professional advisers
Appendix B to E.1422/97-98 Documentary evidence
Appendix C to E.1422/97-98 Information on Mr Y's blood gases from the medical records
