Part 1 - Complaint about Basildon and Thurrock University Hospitals NHS Foundation Trust (the Trust) and the Healthcare Commission (the Commission)
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Complaint about the care and treatment of a critically ill child admitted with breathing problems, and complaint about the Commission’s subsequent review
Background to the complaint
Miss A, aged 17, suffered from multiple and severe health problems from birth and her parents were her full-time carers. As she required frequent hospital contact, she had direct access to the paediatric unit. In August 2003 she was admitted to the paediatric unit with shortness of breath and coughing, on the advice of the Paediatric Triage Team, which her parents had contacted. Some hours later, when her condition failed to improve, she was transferred to the Intensive Care Unit; however, sadly, she died an hour later.
The complaint to the Trust and the Commission
In January 2004 Mr and Mrs A complained to the Trust about Miss A’s care and treatment and in particular her delayed admittance to the Intensive Care Unit, the failure to call the duty consultant when Miss A was admitted and the fact that the consultant was not on the hospital site. They believed that there had been a failure in care and that Miss A had not been adequately reviewed by a senior doctor. They also believed that, had she been transferred to the Intensive Care Unit more quickly, she would have survived.
The Trust’s response to the complaint encompassed three letters and two meetings with Mr and Mrs A between February and August 2004. The Trust acknowledged some shortcomings, apologised and highlighted actions arising from the case including the introduction of individualised illness management plans for children with complex conditions; a system of flagging children with special needs on the patient administration system; and developing summary history sheets at the front of patients’ notes. The Trust also subsequently reported improved staffing levels.
In November 2004 Mr and Mrs A complained to the Commission, which reviewed the case having taken clinical advice. In February 2006 it concluded that the Trust had taken steps to reduce the risk of similar problems occurring in the future and that there was no scope to take the complaint further.
What we investigated
Mr and Mrs A complained to the Ombudsman in April 2006 and we investigated the complaint as put to the Trust as well as the Commission’s subsequent handling. We had access to Miss A’s medical records for the last five years of her life and copies of all complaints correspondence. We also took clinical advice from a Senior Nurse with paediatric experience and obtained a full report from a Consultant Paediatrician.
What our investigation found
Our investigation found the following significant failings during Miss A’s admission:
- Inadequate monitoring.
- Poor record keeping in terms of both nursing and medical notes.
- Failure to recognise the seriousness of Miss A’s condition.
- Delays in seeking and obtaining reviews by senior doctors.
- Delay in contacting the on-call consultant.
- Delay in transferring Miss A to a High Dependency or Intensive Care Unit despite clear indications that she needed more intensive care than was available on the paediatric ward.
We found that the standard of care provided to Miss A during her last illness fell below a reasonable standard. This amounted to service failure on the part of the Trust. We concluded that, while it would never have been possible to say for certain whether Miss A would have survived her illness had she been transferred to the Intensive Care Unit at an earlier stage, there seemed little doubt that her chances would have been improved.
We also found that the Trust had not acknowledged or apologised in relation to several key issues from Mr and Mrs A’s original complaint.
We also concluded that the Commission’s review was seriously flawed because it was not clear that sufficient clinical advice had been taken from a properly qualified adviser and the clinical advice had not been recorded properly on file (the Commission’s files contained only a brief note of a discussion with an adviser which gave no indication of the adviser’s qualification and did not make clear if the adviser had seen the relevant clinical records). The investigation, which concluded in September 2006, upheld the complaints against the Trust and the Commission.
Outcome
As a result of our recommendations the Trust wrote to Mr and Mrs A to apologise for the shortcomings identified in our report. The Trust also drew up a comprehensive action plan in response to our recommendations which included:
- the commissioning of a designated paediatric high dependency facility;
- the implementation of a paediatric early warning system, which has been integrated with an updated monitoring chart for critically ill children;
- staff induction and training programmes, which include the recognition and resuscitation of critically ill children;
- the regular auditing of new joint medical and nursing notes;
- the appointment of a paediatric clinical practice facilitator; and
- the establishment of professional liaison with the regional paediatric intensive care consortium as a resource for advice, training and service strategy.
The Commission wrote to Mr and Mrs A to apologise for the shortcomings in its review and for any distress or frustration that this had caused. The Commission also explained that its policy now required that clinical advice be recorded in appropriate detail (either the adviser’s report or a signed record of a detailed discussion).
