Case No. E.1422/97-98 -Appendix B
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Case No. E.1422/97-98
Insufficient assessment and monitoring by nursing and medical staff, and inadequate care
Appendix B: Documentary evidence
A summary of Mr Y's medical records for 15 to 16 February follows.
| Nursing records | Medical records |
|---|---|
|
15 February
1.19am—Admitted to A and E. Admission sheet completed and showed a diagnosis of 'asthma'. Oxygen saturation (paragraph 25) recorded as 97%. |
1.30-2.00am (approximately)—Seen by duty registrar who recorded 'Re-attended [A and E] 6 hours post discharge. Says cannot be without oxygen'. Blood gas test performed which showed a high pressure of carbon dioxide at 9.43kPa. Mr Y to be given oxygen. |
| 4.00am (approximately—untimed)—Admitted to the admissions ward. Oxygen saturation was recorded as 97%. Computerised care plan produced at 4.14am described Mr Y as 'short of breath at rest'. It included: 'Give 24% oxygen as prescribed'; and 'Monitor oxygen [saturation] continuously/4-6 [hourly]. Inform medics if [less than] 85%'. There followed a handwritten entry which said 'Remains a little [short of breath]. Needs encouragement to wear [oxygen] mask'. | |
| About 8.00am—Ward round usually held by admitting team. There is no record of Mr Y being seen at a ward round. | |
|
12.00 noon—Oxygen saturation of 96% recorded on temperature chart. Only other observation about lack of bowel movement. No other record of nursing care.
5.00pm (approximately—untimed) Transferred to the medical ward. (The records show a nurse from the medical ward giving medication at 6.00pm.) A handwritten care plan completed by the first staff nurse said that Mr Y was 'experiencing episodes of breathlessness'. The plan included monitoring 'use of prescribed oxygen'and 'respiratory rate 6 [hourly] and during acute episodes of breathlessness.' Later the nurse noted in an untimed entry, that Mr Y had been asleep most of the evening. 9. 30-10pm—The drug chart showed that Mr Y was given medication, including antibiotics and oral paracetamol. 10.00pm—The temperature chart contained no entry for nursing observations at 10.00pm. The drug chart said that Mr Y was given medication by nebuliser (see paragraph 43). |
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11.30-11.45pm (approximately—untimed)—The locum house officer examined Mr Y and recorded 'Family concerned that [patient] is confused and drowsy. Known COPD [patient].' Blood gas tests showed a very high pressure (13.37kPa) of carbon dioxide. A plan was recorded to reduce oxygen to one litre per minute, repeat the blood gas test, and arrange review by a registrar. (The records contain no earlier record of the locum house officer examining Mr Y.) 11.45pm-12.00 midnight (approximately—untimed)— The specialist registrar examined Mr Y and recorded '.... Known COPD/emphysema .... Very drowsy on the ward. Retaining [carbon dioxide] on [two litres of oxygen]. [Lowered] to [one litre] and gases repeated.' A blood gas test showed the pressure of carbon dioxide was 14.1kPa. Mr Y was prescribed doxapram (a respiratory stimulant), which was given from 1.45am. |
|
| 16 February | 2.48am—Further blood gas test showed the pressure of carbon dioxide of 8.22kPa. Continued on doxapram. Blood gases were noted to be improving. |
| The third staff nurse recorded (in the first entry of the day) that Mr Y had been very 'hypoxic' overnight, with very poor CO2 | 4.28am—Repeat blood gas test result showed pressure of carbon dioxide of 8.55kPa. Mr Y was noted to be much improved: alert and oriented. |
