Case No. E.1422/97-98 - Appendix A
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Introduction
1. We were asked to advise on Miss Y's complaint that there was insufficient assessment and monitoring of Mr Y's condition by the nursing and medical staff, and that his care was inadequate.
Basis of our report
2. We received and reviewed relevant documents including Miss Y's letter of complaint to the Ombudsman, the Trust's response and Mr Y's medical records. We accompanied the Ombudsman's investigator to most of the staff interviews and referred to interview notes of others.
Complaint
Medical care
Chronology
3. The events which are the subject of this complaint took place following Mr Y's admission via the A and E department in the early hours of the morning of Saturday 15 February 1997. It is necessary, however, to note that Mr Y had been admitted initially on 13 February to the admissions ward under a consultant physician, but had been discharged on the afternoon of 14 February. During this brief stay, the opinion of the specialist registrar on the respiratory firm had been sought and a follow-up appointment was arranged for the next week in the respiratory firm consultant's clinic.
4. During the 13/14 February admission, Mr Y's blood gases showed a raised level of CO2 and a reduced level of oxygen (the values of all blood gas results for the period 13 to 16 February are listed in Appendix C). It is evident from the results on 13/14 February that Mr Y's CO2 level was adversely affected by administering oxygen, though the change was small. Reducing the oxygen brought Mr Y's CO2 to a lower but far from satisfactory level by the time of his discharge, and (breathing air) his oxygen level was low (p02 6.06 kPa, arterial saturation 77%).
5. Mr Y was discharged home during the afternoon of 14 February but remained there for less than 12 hours. During the evening of 14 February he is described by his family as becoming increasingly distressed. He was taken back to the A and E department in the early hours of 15 February where the notes record that he was breathless. Blood gases gave results at 2.00am on 15 February that were not materially different from those obtained 12 hours earlier just before his discharge home.
6. Mr Y was taken from A and E to the admissions ward. There is only a brief entry in the medical notes indicating that he had been re-admitted shortly after discharge. It was decided that he needed oxygen therapy. There is no entry in the notes that he was seen on the post-take ward round on that Saturday morning.
7. During 15 February Mr Y remained on the admissions ward until late afternoon, when he was transferred to the medical ward. Mr Y's family noticed that he was unduly drowsy and spent much of the time asleep. The unresolved conflict of evidence about the possibility of an early evening visit by the locum house officer means that no conclusions can be drawn about that. The locum house officer was then called probably around 8.00pm to 8.30pm on 15 February and finally arrived about 11. 30pm. Unfortunately, during interview with the locum house officer it was not possible to determine exact times or any reason for the delay. The locum house officer was employed through an agency and worked at the Royal London Hospital for only one day during that weekend and could not recall the events relating to a request for medical assessment of Mr Y in the evening of 15 February.
8. The locum house officer did however recall seeing Mr Y and recognised that he was seriously unwell. She determined from blood gas analysis that he had a very high CO2 but an almost normal oxygen level in the blood. She advised reducing the oxygen intake and sought immediate help. The specialist registrar came to her assistance—it was the respiratory team which was by chance on duty that night. This was the same doctor who had seen Mr Y on the afternoon of 14 February. She instituted treatment with an infusion into a vein of the drug doxapram which stimulates breathing. This produced a rapid reversal of Mr Y's blood gas abnormalities, the CO2 falling dramatically. By judicious adjustment of the amount of added oxygen he was breathing, a situation was achieved by the end of 16 February where both O2 and CO2 levels were satisfactory.
Comment
Clerking (ie recording of medical history) at time of re-admission
9. The very brief comment noting that Mr Y had returned to the hospital via the A & E department in the small hours of the morning of Saturday 15 February is an inadequate clerking for a patient who was clinically unstable. The lack of an entry concerning any decisions made on the post-take ward round compounds the issue, but it is not clear whether this arose because no-one recorded decisions made, or because Mr Y was not seen on the post-take ward round. It appears that the re-admission on 15 February was wrongly regarded as a continuation of the admission on 13 and 14 February rather than a new event. The similarity of the blood gas results should have been seen as a warning not a reassurance, as both sets of results are poor, and imply the need for re-appraisal and corrective action.
Delay in house officer on call seeing Mr Y on the evening of 15 February
10. It is not clear whether one or both of the house officers on call were contacted, or at what time s/he was first bleeped. The use of locums is a regrettable necessity. There is no suggestion of any medical inadequacy in dealing with the situation on the medical ward during the night of 15/16 February, but it should be noted that a locum's lack of knowledge regarding local protocols and practices can lead to delays.
Medical action taken
11. The medical note by the locum house officer in the late evening is excellent, and her appraisal and management decision then were appropriate. However, unfortunately her entry is not dated or timed. The results of the blood gas sample she took were handwritten in the notes. The computer record of that analysis indicates that it was taken on 15 February, but not the time. It is likely to have been around 11. 30pm. The time of the sampling can only be recorded by the doctor who takes the sample. This information is usually hand-written on the result slip from the machine.
Oxygen Therapy
12. The medical staff understood the use of oxygen therapy, the differences between the use of masks and nasal prongs and the dangers of excess oxygen. The specialist registrar's entry on the morning of 16 February (at about 1.00am) indicates that she was fully conversant with the situation and her actions were correct and effective. Once again, however, she did not insert the time of this consultation.
13. When the intake of oxygen was adjusted through the different oxygen delivery devices, it was not always clear from various entries by medical (and nursing) staff that flow rates of oxygen were always appropriate, nor is it at all clear from the records when changes were made or when Mr Y was actually breathing oxygen. The family state that much of the time on 15 February Mr Y was not receiving oxygen. However, the figures for blood gases recorded late that night and in the early hours of 16 February, can only be explained if oxygen therapy was being given. It is certain that at some stage, or for intermittent periods, Mr Y was given oxygen, but for how long and at what flow rate or concentration is not clear. The need for detailed and accurate recording of oxygen therapy, together with a full understanding of the use of different delivery devices is highlighted by this case.
Nursing Care
Documentation
14. The nursing care we would expect to be given to Mr Y would include a full nursing assessment of his needs and problems on admission. We could find no evidence of a comprehensive assessment on either admission to the admissions ward, or transfer to the medical ward. An initial nursing assessment is essential to give a baseline for the 'norm' for individual patients. This would alert the nurses to change in the patient's condition and be used to make judgments regarding the necessary action to take.
15. A nursing care plan was in place for 'shortness of breath'. On both wards this was a non-specific respiratory care plan. There was no evidence of recognition of the specific care needed for a patient with COPD with actual or potential CO2 retention.
16. Evaluation of care should provide a chronological history of events. This should include care given and reasons for inability to carry out prescribed care. In this case that was lacking; we found the documentation of nursing history to be very poor. For instance we were unable to determine whether Mr Y was given oxygen and whether nasal prongs were used or a mask.
17. We also noted that very few entries were timed. This made it almost impossible to identify the sequence of events as they occurred during Mr Y's period of hospitalisation.
Oxygen Therapy
18. There was a general lack of understanding among all of the nursing staff interviewed regarding the significance of the route of administration of oxygen. The care plan drawn up on the medical ward did not specify the percentage of oxygen to be given. The computerised core care plan, which was in place shortly after his admission to the admissions ward, specified correctly 24%. This could be delivered only via a mask with the correct valve. The first staff nurse stated that she drew up the care plan on the medical ward based on knowledge gained in her pre-registration training. Neither care plan indicated that the medical staff should be called if saturation levels were above 95%. None of the nurses interviewed demonstrated an understanding of the significance of a saturation level above 95%. The second staff nurse responded when asked specifically about a saturation level of 95% in a patient with COPD that she 'would be happy and that there was no problem'.
19. There were two recorded occasions when the medical staff should have been alerted: first about 4.00am on arrival in the admissions ward and secondly at midday when the saturations were 96%. The medical staff should have been alerted and in addition more regular recordings should have been made. This should have formed part of the handover between nurses on transfer between the admissions ward and the medical ward. We note that a pulse oximeter was not available on the medical ward. However we believe that if clinical need indicates, as in this case, every effort should be made to obtain one. If this is impossible then that should be clearly documented in the notes.
Significance of drowsiness in patient with COPD
20. Mr Y's relatives were obviously anxious about his condition. Mrs Y asked if he had been given sleeping tablets. The first staff nurse wrote in the notes on 15 February that 'Mr Y has been asleep most of the evening since being transferred from Cambridge Ward'. At interview the first staff nurse said that she thought that Mrs Y had said that her husband was not normally that drowsy. This should have alerted any nurse with experience of nursing patients with COPD that medical assistance should be requested in order to check blood gas levels. We accept that it may be difficult to distinguish between a sleepy and a drowsy patient, especially when the patient is not known to the nursing staff. It may have been assumed that Mr Y was very tired following his disturbed night. However Mrs Y appeared to be insistent that her husband was unusually sleepy. This should have alerted the nurses to the fact that this may have been drowsiness related to carbon dioxide retention. Both the locum house officer and the specialist registrar documented that Mr Y was drowsy.
Transfer of patients
21. We could find no evidence of the evaluation of care given on the admissions ward or a nursing history of Mr Y's condition. The first ward manager informed us that evaluation usually took place at the end of the shift and if a patient was transferred before then, a written evaluation might not have been done, but it was expected to have been completed. There was no evidence that it was on this occasion. She told us that there would be an oral handover. This is not acceptable practice and fails to comply with the UKCC standard of recording a chronological history of events.
Communication within the ward team
22. We are concerned that given the first staff nurse's inexperience, and the fact that she was working as an untrained nurse (as she had no UKCC registration number), there did not appear to be any communication between the second staff nurse and herself. Neither the first staff nurse nor the second staff nurse could recall discussing Mr Y or the family's concerns prior to the doctor being called. In our experience a junior nurse will usually at least discuss the fact that she intends to call the doctor or inform the nurse in overall charge of the ward that the doctor has been called.
Conclusion
23. The nursing care given to Mr Y fell below the standard which we would reasonably expect in the following areas.
24. The initial nursing assessment was poor and incompletely documented. This made subsequent reviews and nursing actions inappropriate. The nursing staff failed to recognise that Mr Y was not usually drowsy or prone to sleeping during the day. Mr Y was in fact retaining carbon dioxide and had become respiratorily compromised.
25. The nursing staff appeared to have a lack of general awareness of the potential risks of oxygen therapy in a patient with COPD.
26. The level of communication between Mr Y, his family and the ward staff was unsatisfactory. It took too long before a doctor was called to review Mr Y and the family's concern was appropriately recognised.
27. The standard of communication was suboptimal between the nurses on the medical ward. This led to fragmented consultation with the medical staff, and in particular led to a delay in calling the doctor.
28. The outcome may have been very different in this case if the family had not been present on the ward. Their insistence that the doctor be called alerted the medical staff to a seriously ill patient, requiring immediate urgent action.
29. In addition, in our opinion, the level of supervision and development of newly qualified staff was inadequate. The medical ward is not a specialist respiratory ward. We would therefore have expected that protocols or guidelines for nursing specific conditions should be available on the ward. It is unrealistic to expect a nurse to be proficient in the care of every condition. This is particularly the case for newly qualified nurses.
Recommendations
30. A regular review should be carried out of staffing and skill mix on all acute wards.
31. Newly qualified nurses awaiting their PIN number should be rostered as an untrained nurse and should never be rostered as the second trained nurse on a shift.
32. The Preceptorship/Mentorship programme which has since been introduced on the medical ward should be formally evaluated and adapted as necessary.
33. A comprehensive induction programme should be available for all new members of nursing staff, particularly newly qualified nurses.
34. All nursing staff should receive training on the administration of oxygen therapy. This should include the provision of formal guidelines/procedures across the Directorate.
35. All nursing staff should receive training in record keeping in line with the UKCC guidelines, 'Standards for Records and Record Keeping'.
36. Medical staff should be reminded of their obligation to date, time and sign all entries made in patients' notes.
37. The audit of documentation which was recently introduced should be continued on a regular basis and should be multidisciplinary. Action plans should be drawn up where indicated and reviewed by the lead nurse.
38. A protocol should be in place outlining actions to be taken when requesting medical staff on call to review patients. This should include documenting the following: to whom the request was made, at what time, by whom.
39. The medical staff on-call rota should clearly state which medical staff are providing cover, for which areas, to enable nursing staff to contact them efficiently thus avoiding any unnecessary delays.
40. A thorough clerking must be carried out for all patients including those re-admitted shortly after discharge.
41. Decisions made on post-take ward rounds must be recorded in the patient's notes.
42. The Trust should consider ways of alleviating the excessive workload and responsibility placed on junior doctors in their first year following qualification ie being on-call for approximately 100 patients on the medical wards.
