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Selected Investigations Completed December 2000March 2001 > Part II, Case no. E.1777/99-00
Complaint against: The Royal Bournemouth and Christchurch Hospitals NHS Trust
Complaint as put by Mr and Mrs M
1. The account of the complaint provided by Mr and Mrs M was that on 24 November 1997 they visited their friend, Miss Q, who was 32 years old and who suffered extensively from eczema. She had been ill for several days and was unable to rise from bed. She was hallucinating and was incontinent.They called a duty general practitioner (GP) who said that he thought Miss Q had probably developed septicaemia, which needed treating with intravenous antibiotics. He called an ambulance and she was taken to the accident and emergency (A&E) department of the Royal Bournemouth Hospital, and then admitted to a ward.
2. When Mrs M visited Miss Q at the hospital on 27 November, Miss Q was in a worse condition. Although her eczema had been noted, there was no evidence that intravenous antibiotics had been given; blood tests and other investigations had not been carried out. Mrs M told a nurse about her concerns but Miss Q died the next day. A post mortem found streptococcal septicaemia to have been the likely cause of her death.
3. Mr and Mrs M complained to the Trust. An independent review (IR) was held on 15 April 1999, but Mr and Mrs M remained dissatisfied.
The complaints subject to investigation were that:
the actions of the Trust’s medical staff were inadequate in that they:
(i) did not take sufficient account of the referring GP’s concerns;
(ii) did not take sufficient account of the clinical findings on presentation at hospital;
(iii) did not investigate and treat Miss Q appropriately; and
failed to ensure appropriate review by the admitting consultant physician;
communication between nurses and medical staff was inadequate; and
(c) the remedies proposed by the Trust, in the light of the IR, were inadequate.
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Investigation
5. The statement of complaint for the investigation was issued on 12 January 2000. The Ombudsman obtained the comments of the Trust. Relevant papers were examined, including Miss Q’s clinical records. The Ombudsman appointed three external professional assessors – a consultant physician in emergency medicine, a consultant dermatologist and a director of nursing – to provide clinical advice. In reaching my findings I have noted their comments: their reports are attached as annexes. The Ombudsman’s staff, accompanied by the assessors, took evidence from Trust staff.
(a) Actions of Trust’s medical staff were inadequate
Mr and Mrs M’s evidence
6. Mrs M explained in her letters of complaint, and at interview with the Ombudsman’s staff, that Miss Q suffered from chronic eczema and had regular admissions to Christchurch Hospital when the eczema was particularly bad. Mr and Mrs M visited Miss Q at home on Sunday 23 November 1997 and were so concerned about her condition that they contacted her GP’s out-of-hours service. No GP visited that night, but one did the following night. By then Miss Q was very ill – her eczema was worse than Mr and Mrs M had ever seen before; Miss Q was also hallucinating and was doubly incontinent. The GP said that Miss Q was hypothermic and should be admitted to hospital. He suspected septicaemia, for which he thought an intravenous infusion of antibiotics should start that night. Christchurch Hospital had no available beds so the GP arranged admission to the Royal Bournemouth Hospital.After calling an ambulance, the GP left, leaving an admission letter for the hospital with Mrs M. As the ambulance crew arrived Miss Q was hallucinating and the crew could see that she was ill. Mrs M gave the crew the GP’s letter and Miss Q was taken to hospital. Mrs M did not go with her.
7. Mrs M visited Miss Q on 25 and 27 November. There was no evidence at either visit of antibiotics being given. On 27 November Mrs M was shocked at Miss Q’s condition – her skin, which could usually be relieved by creams, was very dry and uncomfortably tight. She was immobile, desperately thirsty, and experiencing hallucinations. Mrs M spoke to the ward sister saying that she thought Miss Q was more unwell than she had been on admission, but the ward sister did not seem unduly concerned. Mrs M spoke to other nurses about Miss Q’s condition. One said that the doctors did not think Miss Q had septicaemia; Mrs M assumed that the appropriate tests had been conducted, though she was concerned that Miss Q was in an isolation bed, out of sight of the nursing station.
8. When Mrs M heard on 28 November that Miss Q had died she was shocked, but not surprised. Miss Q had been so obviously very ill. She later found out that throughout Miss Q’s hospitalisation the staff had simply been awaiting transfer to a bed in Christchurch Hospital; in the meantime, no investigations were conducted. The GP’s suspicion of septicaemia was not investigated; nor was Miss Q’s poor fluid intake, her failure to pass urine, or her incoherence. Miss Q’s skin looked extremely unpleasant and that clouded the views of the staff – they assumed her problem was solely an exacerbation of her eczema.
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Evidence of the ambulance crew
9. A paramedic who was one of the team that took Miss Q to hospital on 24 November said that he could not recall whether Mrs M had given him a GP’s letter. However such letters were routine when admitting GP-referred patients to hospital, so he would usually collect them. Otherwise, he would have wanted to know why there was no letter.Similarly, on arriving at the hospital, staff there would usually ask for the GP’s letter.
Trust comments
10. In comments to the Ombudsman the chief executive wrote:
‘[Miss Q] …. was admitted to Royal Bournemouth Hospital …. following an emergency referral from …. the GP attending out of hours ….
‘[The GP] spoke to [the on-call senior house officer – the first SHO] by telephone to discuss her admission.Subsequent investigations found that [the SHO] had no recollection of [the GP] saying he suspected septicaemia. [The GP] believed that he did say this and the Trust has no reason not to believe his assurance.
‘…. did not take sufficient account of referring GP’s concerns
'Routine practice would be for the doctor in A&E to pick up the referral letter and take account of its contents. In this case there is uncertainty because:
‘(i) the original [GP] letter cannot be found. However, a copy is in the notes; and
‘(ii) the medical staff involved believed that if the letter had been seen, they would have had increased concern …. [the second SHO] cannot be certain she saw this letter, as …. she would have diagnosed septicaemia had she [done so] ….
‘On the balance of probabilities, it is likely that the admitting medical staff did not see the letter from the GP.
‘…. did not take sufficient account of clinical findings on presentation at hospital
'The clinical findings after [Miss Q] had been assessed in A&E were that she had severe eczema over her entire body but was alert and orientated …. She was not confused or hallucinating. There were no clinical signs of septicaemia at this stage. There was no raised temperature, no raised blood pressure and no tachycardia (elevated heart rate). It is admitted that by the next day her condition was much worse.
‘Given the initial information that was presented to the medical staff, the Trust feels that their actions were not inadequate.
‘…. did not investigate and treat appropriately
The severity of [Miss Q’s] eczema and the contamination of her body due to faecal incontinence were both contributing factors to the lack of any detailed investigations in A&E. Advice was taken by telephone from [Miss Q’s] consultant dermatologist and that was followed.
‘Following admission …. the medical staff did not consider the diagnosis of infection or septicaemia. Instead, the management focused on her skin condition. The possibility, in a case of such severe eczema, that there may have been other medical conditions in need of treatment was not effectively addressed.
‘Given that the treatment of [Miss Q] at Christchurch Hospital on previous admissions had included antibiotics and repeated blood tests, in retrospect a more active approach to her management should have been considered. With hindsight this view is easier to take and must be ameliorated by the other circumstances of the admission, including the persistent lack of the usual signs of septicaemia …. However, the Trust entirely accepts that [Miss Q’s] medical needs were not properly met ….
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‘…. failed to ensure appropriate review by the admitting consultant physician
'The …. consultant in this case …. is also the medical director for the Trust. (He) has accepted that his duties as medical director, without dropping any clinical workload, have made it difficult for him to do a post-take ward round [a visit to patients newly admitted under his care].’
Documentary evidence
11. The GP’s admission letter included:
‘Thanks for seeing this …. [patient] with severe erythrodermic [abnormal reddening, flaking and thickening of the skin] exacerbation of chronic eczema …. last [two days] feverish, intermittently confused and hallucinating. Incontinent of faeces today.
‘[Impression] …. becoming toxic [ie showing symptoms of severe infection] and dehydrated.’
12. The second SHO who clerked Miss Q in A&E on 24 November completed four pages of notes, which included:
‘…. eczema .... from head to foot .... says this comes on [with] stress
‘Plan
[Administer] creams
[Seen by] Reg[istrar]_ Push oral fluids
[Discussed with consultant dermatologist at Christchurch] _ agrees with above
…. Transfer to [Christchurch Hospital] tomorrow ….’
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13. During the next three days in the ward, the entirety of entries in Miss Q’s medical records were:
25 November
‘[Await] Christchurch dermatology
On relevant treatment.’
26 November
‘Still awaiting bed at [Christ]church. [Increase] analgesics.’
27 November
‘Going to Christchurch tomorrow.’
14. Miss Q’s nursing observations during her admission consisted of six temperature readings and three blood pressure readings. No fluid balance records were kept. Entries in the nursing notes include:
25 November
‘Slept very little. [Not complaining of] pain during the night.Appears very confused ….
26 November
‘…. Confused and disorientated at times ….
27 November
‘…. Continues to hallucinate at times ….’
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Evidence of Trust staff
15. The A&E sister said that the GP who had arranged Miss Q’s admission was present in the hospital that evening and spoke to her about Miss Q’s impending arrival. On arrival she was lucid and reasonably mobile. The A&E sister could not recall whether the GP’s letter came with Miss Q, but it was so unusual for patients to arrive without a GP letter that she thought she would have remembered if it had not. Moreover, given that the GP was in the hospital, she would have told the doctors that they could speak to the GP in person if there had been no letter.
16. The registrar said that he was in his first year in post at the time of these events. It had been very busy on the night of 24 November when he was asked to review Miss Q. No one had mentioned to him that the GP suspected septicaemia and he did not see the GP’s letter. Nor did he see the A&E sister – who knew that the GP was present in the hospital that night. The registrar said that he briefly examined Miss Q, taking her pulse and temperature. He carried out a brief mental test because the second SHO who clerked Miss Q said that she might have been hallucinating at some point, though the second SHO had not witnessed Miss Q having a hallucination and neither did the registrar. The registrar said that he did not take blood samples as Miss Q had gross eczema which meant that a central cannula (a tube inserted into one of the two main veins near the heart) would have been necessary to take blood. Miss Q needed to be admitted and blood tests could have been conducted in the ward. The registrar telephoned Christchurch Hospital to speak to the consultant who usually treated Miss Q there and told him that she needed care for her skin. The consultant gave advice about that. The registrar acknowledged that he may have been over-confident in talking to the consultant and had possibly influenced the discussion to concentrate on the exacerbation of Miss Q’s eczema. He accepted that he had made a mistaken diagnosis. However the registrar said that he had expected Miss Q to be reviewed by a consultant within 24 hours. After Miss Q’s death the registrar saw a copy of the GP’s letter. It would have caused him to suspect septicaemia had he seen it when Miss Q was first admitted.
17. The consultant physician who led the team, under which Miss Q was admitted, was also theTrust’s medical director. He agreed that Miss Q had not been managed correctly. The Trust had admitted that at the IR and they wanted to prevent recurrences. When Miss Q arrived at hospital on 24 November she was seen by the second SHO and then by a registrar. Miss Q was not confused on presentation, she was not feverish and the doctors concluded that she was suffering an exacerbation of her skin condition. Although the GP said that he told a doctor by telephone that he suspected sepsis (destruction of tissue through disease), that had not been recorded by the doctor who took the call. Nor was it clear what had happened to the GP’s admission letter. Despite symptoms that should have prompted further investigations, including blood tests, Miss Q was ‘compartmentalised’: she arrived with eczema and the staff thought that her problem was solely an exacerbation of that. Transfer to Christchurch Hospital seemed to be in hand and no further investigations then took place.
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18. Newly admitted patients should have been reviewed on the morning following admission. Miss Q should therefore have been seen on 25 November, but on that day he had been engaged on other clinical duties. His responsibilities sometimes made it difficult for him to carry out his post-take ward round. The outcome for Miss Q might have been different had she been seen by a senior doctor at an early stage. Arrangements had now been made for another consultant to conduct his ward rounds (see paragraphs 36 and 39) when he was unavailable, though there would still be occasions, due to staff absences, when post-take rounds could not be undertaken by a consultant.
19. The ward sister said that up to 13 different medical teams had patients in the ward; there were not always sufficient nurses to accompany ward rounds. When junior doctors completed ward rounds alone, they would often write only very briefly in the records and she was not certain that they would always even see the patient.
20. The clinical director, responsible for the medical directorate, said that the Trust had failed Miss Q and she was not surprised that Mr and Mrs M were disappointed with the Trust’s responses to them. She thought it likely that the GP would have fully explained Miss Q’s symptoms and his concerns when he telephoned the hospital, but she suspected that the GP’s letter had not been available to the doctors who first saw Miss Q. The GP had made his concerns perfectly clear in the letter and it would have been strange if the doctors had not acted on those concerns.The clinical director said that despite the unusual presenting symptom of faecal incontinence in a young woman, the second SHO’s clerking was bland and did not mention that particular symptom.The clinical director said that Miss Q was clearly lucid on admission and that had set the scene: the registrar concluded that Miss Q was a patient with an exacerbation of a skin condition and that diagnosis was never reviewed. In the three days that Miss Q remained in hospital junior doctors had made entries in her medical records, but it seemed probable that they had not actually examined her. Transfer to Christchurch Hospital had been arranged and staff seemed to have concluded that nothing further was to be done ahead of that transfer. Miss Q was probably septicaemic on admission, although there were confusing factors such as her unremarkable temperature, stable blood pressure and stable heart rate.
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Findings (a)(i) and (a)(ii)
21. This is a very sad case. Miss Q was a young woman who suffered from chronic excema and who required regular admissions to Christchurch Hospital. Mr and Mrs M were very concerned about her condition when they visited her at home on 23 November and thought she appeared more ill than they had seen her before. They called a GP, who decided to refer Miss Q to hospital. As there were no beds at Christchurch Hospital the GP arranged for Miss Q to be admitted to the Royal Bournemouth Hospital. The junior doctor there, to whom he spoke, did not record that conversation. The GP subsequently explained that he had said that he was concerned that Miss Q was septicaemic; that accords with Mrs M’s evidence of what the GP said. Although the junior doctor does not recall the conversation, the Trust have not sought to refute the GP’s claim. Mrs M says that she gave the GP’s letter to the ambulance crew, one of whom was sure that there would have been a letter – he said that it would have been memorable had that not been the case. A copy, but not the original, is in the records. There is no doubt in my mind that the ambulance crew took the letter to hospital. Mrs M did not travel to hospital with Miss Q: she thought that Miss Q would be in safe hands.Unfortunately it appears that she was not.
22. On arrival at hospital Miss Q was clerked by a different junior doctor, who had not spoken to the GP. Her notes indicate that at that stage Miss Q was lucid. The admitting doctor asked a registrar to review Miss Q and his evidence to the Ombudsman’s staff was that he had assumed that Miss Q only needed treatment for an exacerbation of her eczema. He contacted Miss Q’s consultant at Christchurch Hospital for advice about that. He said, when he later saw a copy of the GP’s letter, that the information therein would have caused him to suspect septicaemia. We do not know what happened to the letter, between Miss Q’s arrival in hospital and her review by the registrar, but it is obvious that there was a significant breakdown in communication. It is even more unfortunate, given that the GP who had visited Miss Q was present at the hospital that evening and had spoken to the A&E sister about Miss Q’s impending arrival. Yet the GP’s warnings went unheeded. This is not just a case of poor communication. Given the lengths to which the GP had gone to spell out his concerns, by writing a letter and then repeating his concerns orally to staff at the hospital, the failure to take account of his worries seems perverse.
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23. I acknowledge that the Trust have recognised the need to introduce systems to help prevent a recurrence of the obvious failures in communication which occurred in Miss Q’s case. It is intended that a particular identified nurse will take telephone calls from GPs wishing to admit a patient. That should ensure that the details of such calls will be available to staff when patients are admitted. The Trust’s new unitary record will contain a section where GPs letters will be affixed. Though, in principle, I welcome these changes I am concerned that they should be assessed in practice. I recommend that the Trust implement these measures urgently and then audit their effectiveness.I uphold both aspects of this complaint.
Findings (a)(iii) and (a)(iv)
24. The registrar has admitted that he reached a mistaken diagnosis when he examined Miss Q on the day of her admission, but he also thought that she would be seen by a consultant within the next 24 hours. That did not happen. On each of the following three days entries were made in Miss Q’s medical records. Those entries were made by junior doctors: all indicated merely that the plan was for Miss Q to be transferred to Christchurch Hospital. It seems that no thought was given to undertaking any investigations in the meantime. The ward sister and clinical director both suspected that the junior doctors made their entries without physically examining Miss Q, and the sparsity of those entries would lead me to concur with that view. Like the registrar, who expected a review by a consultant within 24 hours of admission, the Trust did, indeed, expect their consultants to complete daily post-take ward rounds. The exception to that arrangement was that the medical director’s responsibilities sometimes meant that he was unable to carry out his rounds. The Trust were aware of that, but had not made proper contingency plans. Both the clinical director and the medical director thought that the latter would have correctly diagnosed Miss Q’s problem if he had seen her. That will be of little consolation to Mr and Mrs M.
25. There was a lamentable lack of care entailing a complete failure to make an adequate assessment or plan for Miss Q’s medical management.Staff seem to have made no real attempt to look beyond Miss Q’s eczema and question why she had other worrying symptoms. I note the Ombudsman’s assessors’ comments and am surprised by the Trust’s apparent failure to date to appreciate the severity of their failings. The clinical director, the medical director, and the assessors all think it likely that a follow-up consultant visit after admission would have led to the identification of septicaemia. I agree. The septicaemia could then have been treated and while it is not possible to be sure about the outcome, Miss Q might then have survived. I conclude that the Trust’s failure to have a safe system in place put Miss Q’s life in jeopardy. The Trust now have an arrangement in place to ensure that, when the medical director is unable to carry out a post-take ward round, another consultant will cover for him. I recommend that the Trust audit the completion of post-take ward rounds in respect of the medical director’s patients. In view of the assessors’ comments about reconciling the medical director’s role with his clinical responsibilities, I also recommend that the Trust review the role of medical director and report formally to their own Board the results, together with any resultant recommendations. I uphold both of these aspects of the complaint.
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(b) Communication between nurses and medical staff was inadequate
Mrs M’s evidence
26. Mrs M said that Miss Q had been placed in a ward away from the admitting consultant’s ward: such patients are often referred to by NHS staff as outliers. She thought that that affected the quality of Miss Q’s care. Nor did it help that Miss Q was in an isolation bed at a distance from the nursing station. Noting that the medical staff had subsequently said that they were unaware of Miss Q’s hallucinations, Mrs M said that there seemed to be very little communication between the doctors and nurses. She and her husband were appalled that the consultant had not reviewed Miss Q; they also thought that the registrar had not reviewed Miss Q very often.Mr M acknowledged that diagnostic mistakes could be made, even after appropriate investigations, but no effort had been made to diagnose Miss Q’s condition.
National guidance
27. In their ‘Code of Professional Conduct’, issued in 1992, the United Kingdom Central Council for Nursing, Midwifery and Health Visiting (UKCC), the body responsible for overseeing the professional practice of nurses, set guidelines about working with other professionals:
‘As a registered nurse, midwife or health visitor, you are personally accountable for your practice and, in the exercise of your professional accountability, must:
‘work in a collaborative and co-operative manner with health care professionals and others involved in providing care, and recognise and respect their particular contributions within the care team;’
On record keeping, the UKCC stated, in ‘Standards for Records and Record Keeping’, issued in 1993, that records made by nurses should, among other things, be accurate and comprehensive, and should provide evidence of the care and intervention needed by patients.
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Trust comments
28. Comments to the Ombudsman from the chief executive included:
‘The Trust agrees that communication between nurses and medical staff was inadequate in this case ….’
Evidence of Trust staff
29. Nursing staff said that Miss Q was memorable. They recalled that she had an extremely severe skin condition. Most recalled that Miss Q had little if any hair on her head or body, that she drank very little and passed little urine, but that she said that that was normal for her.
30. The named nurse, allocated to take overall responsibility for Miss Q, said that Miss Q was distressed about her appearance and needed help in applying creams to her body. The nurse did not witness Miss Q having hallucinations, although a colleague had done so: colleagues thought that the cause was the pain Miss Q was suffering. The junior doctors were told that Miss Q was intermittently confused, but they were not particularly concerned about that. Communication between doctors and nurses could have been better. The problem was that the patients in the ward belonged to many different medical teams and different teams would complete their ward rounds at, or around, the same time. She would try to speak to the doctors about her patients but it was not always easy to do that.The problem in this case was that no one had realised that Miss Q was very ill.
31. The staff nurse said that Miss Q had been a difficult patient to nurse: she sometimes refused pain-killers, but shortly after would complain that she had not had them. There were times when she would indicate that her skin was troubling her, and she would ask for antiseptic cream to be applied even when it was not due; at other times her skin did not really seem to bother her. There were times when she could walk unassisted, and other times when she needed to be taken to the toilet. Sometimes she was confused, and at other times, not. The staff nurse did not understand the reason for those contradictions. She thought communication between doctors and nurses was reasonable although that was sometimes compromised because of the number of different medical teams that could be involved with patients in the ward. Staff had possibly been a little casual due to Miss Q’s impending transfer to Christchurch Hospital.
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32. The ward sister said that Miss Q was a pleasant, uncomplaining patient. Staff noted that Miss Q had had hallucinations, which they attributed to her skin condition and the medication she was receiving. There were no problems in the relationship between doctors and nurses.
33. The director of nursing said that she had not had any involvement in the case until just before the IR. On reviewing the papers she was concerned initially that there had been communication problems. However after speaking to staff she concluded that they had been genuinely deceived by the fact that Miss Q was uncomplaining and reasonably mobile. She had said that she felt all right and that it was normal for her not to pass urine. The planned transfer to Christchurch Hospital had also clouded the picture.There was a general belief among the nursing staff that the doctors had been told about Miss Q’s hallucinations. Despite the establishment of a new admissions ward (see paragraphs 36 and 39), general wards still held many patients belonging to different medical teams – that was caused by the volume of medical admissions. One of the IR panel’s recommendations was about communication between doctors and nurses:the director said that she had great faith in a system of unified clinical records which the Trust were due to introduce.
34. The medical director thought that communication between staff could have been better. Miss Q’s records showed that the nurses were concerned that she was confused at times and was not passing urine, but the doctors did not seem to be aware of that. Miss Q had been reviewed by junior doctors on 25, 26 and 27 November, but the medical director would have expected them to have written more in her notes than was the case. Doctors have since been told that they should write more about their examinations of patients. The Trust were also due to introduce combined nursing and medical notes which would help in communication between doctors and nurses. He could not say whether junior doctors would sometimes make entries in patients’ notes without having actually seen them.
Findings (b)
35. Mrs M has said that she told nursing staff of her concerns about Miss Q. In their interviews with the Ombudsman’s staff some of the nurses said that they had observed Miss Q having hallucinations. There was a consensus, though none were specific, that doctors had been told about that symptom. The nurses said that doctors from different medical teams could complete their ward rounds at about the same times. That made it difficult sometimes for the nurses to speak to doctors about their patients.I note that the Trust have accepted that communication between their nursing and medical staff was inadequate.Although I recognise that unitary records should lead to an improvement, I should be concerned if they were seen as the single solution to the problems experienced in this case. It remains important that records kept by nurses are of the standards required by the UKCC. The Ombudsman’s nursing assessor has commented on the management of the ward, though I note the apparent improvement since the events complained about. I recommend that the Trust take steps to ensure that nurses provide information and advice about patients to doctors during ward rounds, and that the Trust remind nursing staff of UKCC guidance about record-keeping and on working with other health care professionals. I uphold this aspect of the complaint.
(c) Remedies proposed by Trust were inadequate
Documentary evidence
36. On 19 August 1999 the Trust wrote to Mr and Mrs M following a Trust Board meeting at which the IR panel’s recommendations had been considered.That letter included:
(about GP referral letters)
‘The view of the medical staff …. is that referrals are normally firmly inserted in the medical records and this is seen as an unfortunate one-off occurrence.
‘However, the GP referral letter will be clipped into our new unitary medical record ….
(about communication)
‘Unitary records will be introduced in the next 2-3 months ….
[Note: see paragraph 34. However, at the time of the issue of this report, the unitary record was still to be introduced.]
‘The need for [nurses to record significant discussions with medical teams] is already emphasised at induction for all new staff …. The subject will also be raised again at the medical sister's meeting.
‘…. A joint letter from the medical director and the chief executive …. will be sent to all wards and medical staff. This will reiterate the need to record significant discussions.
(about outliers)
‘A daily [analysis of each consultant’s in-patients by …. location] is made available ….
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(the consultant’s conflicting duties as medical director)
‘It has been agreed …. that in view of [the medical director’s duties, the consultant responsible for the acute admissions unit (AAU)] will cover his post-take round when he is unavailable ….
‘The Trust will aim [for a consultant physician to review all emergency admissions within the next working day] but in practice, it will not always be possible ….
(about clinical supervision and review of clinical incidents)
‘All medical wards are now participating in the introduction of clinical supervision. The model used by most wards is reflective practice [standing back to reflect on an incident] either [one to one] or in a group. Critical incident reporting system is in place ….’
Mr and Mrs M’s evidence
37. In their letter of complaint to the Ombudsman, dated 10 December 1999, Mr and Mrs M expressed their dissatisfaction with some of the actions taken by the Trust. These included:
‘there has been no explanation for the loss of the GP referral letter ….
‘the explanation for the breakdown in communication between nursing and medical staff is inadequate;
‘…. arrangements …. to address the problem of ‘outliers’ are not reassuring;
‘…. action in response to the problem caused by the conflict between the duties of the consultant and those he has as medical director is inadequate.’
Trust’s response
38. The Trust’s formal response to the Ombudsman included:
‘The Trust does not accept that its proposed remedies were inadequate. The death of [Miss Q] was a great shock …. Understanding how it came about and how to prevent similar events recurring has been of great concern to senior …. staff within the Trust. The changes made will be of great benefit in preventing any recurrence.
‘There are continual efforts to improve the management of emergency admissions …. changes …. concern the development of an Acute Admissions Unit, with daily consultant or staff grade led rounds and a developing unitary patient record in medicine.’
39. The clinical director said that the Trust had taken steps to help prevent recurrences of the failures that occurred in Miss Q’s case. The Trust were to introduce a system where a senior nurse would take GPs’ calls and log that information directly onto the computer system. The Trust had also produced a GP referral form. The Trust’s proposed unified clinical record form had a section where GPs’ letters were to be affixed. There was now an AAU led by a consultant and a permanent staff-grade doctor. Whenever patients were transferred from the AAU to an outlying ward, bed managers were under strict instructions to transfer patients to the appropriate ward as soon as possible. The arrangement by which the AAU consultant would cover the medical director’s ward rounds was a robust one. In general, the Trust would rather cancel clinics than miss post-take rounds. Also, as a result of the introduction of clinical governance, the Trust now had a committee whose role was to examine critical incidents and which would criticise practice where necessary.
40. The chief executive, who had recently taken up post at the time of this investigation, agreed that there had been failings in Miss Q’s care. However the Trust were committed to putting matters right. A multi-disciplinary group, led by the clinical director, were to look into the whole process of hospital admissions. If the AAU had been established then, it would probably have prevented what had happened in this case. The Trust now intended to appoint a second A&E consultant to the AAU.The chief executive said that he would have expected Miss Q to have been examined on each day of her hospitalisation. The appointment of nurse consultants would help to resolve that problem in future. Other changes were the proposed introduction of the unitary clinical record and the use of a dedicated nurse to take GP calls about patient admissions.
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Findings (c)
41. Mr and Mrs M were concerned about what they saw as inadequate responses to some of the recommendations of the IR. Some of their concerns overlap, and are therefore reflected in, other parts of this report. They were not reassured by the Trust’s response to the IR. In particular, an important recommendation made by the IR panel was for post-take review of newly admitted patients. The Trust’s initial response to that recommendation, in respect of patients under the medical director’s care, was a cause for concern.The recommendation was that the medical director should review all of his emergency admissions within the next working day following admission. In their letter to Mr and Mrs M, dated 19 August 1999, the Trust said that they would aim to meet that standard, although they also could not guarantee that that would always happen. That was an inadequate answer, I have no doubt. There have, however, been developments since then. An AAU has been established and the consultant in charge of that unit will complete post-take ward rounds for the medical director whenever he is unable. I am now satisfied that that there has been an adequate response to that particular problem.This case demonstrates why a post-take review by a consultant physician at an early stage is necessary.
42. The Ombudsman’s medical assessors have commented on the Trust’s apparent failure to recognise the urgency of the need to change their record-keeping system. Indeed, at the time of writing this report, the Trust have still not introduced the new medical and nursing unitary record. That is the subject of a recommendation elsewhere in this report. Written and oral instruction has been issued to staff about the importance of good communication; introduction of the unitary record will be an important tangible demonstration of a commitment to that principle. I note too the comments of the nursing assessor about the importance of the Trust fully implementing their new practices in respect of clinical supervision and critical incident review. I recommend that the Trust formally audit the implementation of both.
43. Although it has not been possible to discover what happened to the original GP’s letter in this case, the proposed unitary record contains a section where GPs’ letters will be affixed. That will not prevent all possibility of any future loss and I recognise that an absolute guarantee not to lose or misplace a document is not feasible.However, I am satisfied that the Trust’s proposal for a dedicated nurse to take calls from GPs should add to consistency in this area. Thus I conclude that the Trust’s response was initially inadequate on the issue of the medical director’s post-take ward rounds, and also inadequate in that the introduction of the unitary record has been delayed. To that extent, I uphold this aspect of the complaint.
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Conclusion
44. I have set out my findings in paragraphs 21 to 25, 35 and 41 to 43.The Trust have asked me to convey through my report – as I do – their apologies to Mr and Mrs M for the shortcomings I have identified and have agreed to implement my recommendations in paragraphs 23, 25, 35 and 42.
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Annex A
Report of the Professional Assessors to the Ombudsman
(a)(i) The Trust’s medical staff did not take sufficient account of the referring GP’s concerns.
1. The evidence does suggest inadequate recording of the GP’s opinion regarding Miss Q’s clinical condition when requesting admission. The on-call SHO was not the SHO who saw Miss Q on admission and we have read that the on-call SHO had no recollection of the GP stating that he suspected the patient of being septicaemic.
2. We have also heard and read that the admission letter from the GP did not find its way into the case records immediately and was not available for the admitting SHO when Miss Q was initially seen in the A&E department.
3. We are quite clear that a more efficient and reliable system for recording the reasons for admission requests from GPs is required. This system should record relevant clinical details and the referral letter should be filed in the patient’s case records.
4. Following our interviews with Trust staff, we consider that this aspect of the complaint has been recognised by the Trust and that appropriate steps have now been taken to minimise the possibility of recurrence of this problem.
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(a)(ii),(iii) and (iv) Trust’s medical staff did not take sufficient account of the clinical findings on presentation at hospital; did not investigate and treat appropriately; and failed to ensure appropriate review by the admitting consultant physician.
5. Following our interviews with the junior medical staff involved in Miss Q’s care, it is quite clear that there was a failure to recognise how ill the patient was on her admission to hospital.
6. Borderline tachycardia, abnormally low blood pressure and a history of faecal incontinence in a young woman with the background medical problems suffered by Miss Q should have alerted the admitting doctors to the likelihood of severe systemic disease. Moreover, the failure to take blood tests, including blood cultures, was a striking omission as was a failure to obtain adequate venous access with comprehensive assessment (and subsequent correction) of fluid balance.
7. The mistakes in initial appraisal and early management were freely recognised by the registrar who was extremely busy at the time of Miss Q’s admission. We can empathise with the pressures he was under and recognise that he had a short time only to assess the patient. The registrar was impressive in his recognition of the deficiencies of assessment and in his genuine concern at the tragic outcome. He made the comment that at the time he saw Miss Q he felt confident that a consultant would review the patient within the first 24 hours of her admission. In our view the failure of such formal senior medical review was one of the main factors responsible for the subsequent inadequate clinical care received by Miss Q. Miss Q was not seen by a consultant physician at any stage during her admission.
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(b) Communication between nurses and medical staff was inadequate
8. We endorse this view and in particular the daily assessment of Miss Q’s clinical condition by junior doctors conducting ward rounds seemed totally inadequate. In addition, nursing staff appear to have failed to communicate their concerns regarding the patient’s clinical condition to junior medical staff.
(c) The remedies proposed by the Trust in the light of the independent review were inadequate
9. We agree with this aspect of the complaint. The summary of medical recommendations and agreed action following the independent review accepted the need to:
- ensure incorporation of GP information in the case record; and
- take forward the unitary medical record promptly; and
- ensure proper communication between nursing and medical staff. (Although, one of the IR panel’s recommendations was that junior doctors responsible for receiving telephone calls from GPs about patient admissions would carry a book to note key points which could then be referred to by the clerking doctor. That was not considered to be practicable by the Trust and we share in that view.)
10. The arrangements for post-take ward rounds have now been addressed adequately, but the Trust’s initial response to the IR would have been less than reassuring for the complainants. In particular, the failure of consultant review of an acutely sick patient was not admitted by the Trust and appropriate safeguards to ensure senior clinical review in future had not been convincingly introduced.
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11. Our overriding impression from the summary of medical recommendations published by the Trust in response to the IR recommendations was not convincing in:
a. recognising or admitting the gravity of the errors and omissions relating to this case.
b. recognising the urgency for change in record-keeping, communication and senior medical review of acutely ill patients.
Additional Point /p>
12. The clinical director and the junior medical staff interviewed by us showed insight into the complaint, recognised that mistakes had been made and gave every impression of having learnt from this tragic experience.
13. On the contrary, at interview, the medical director was less than reassuring. He explained that this event had been due to compartmentalisation and he seemed unwilling, to us, to accept that he should have seen the patient during the first 24 hours of her admission. In addition, his continuing belief that he can reconcile his clinical responsibilities with his duties as medical director causes us concern.
14. If the medical director created the same impression with the complainants during his interviews with them, then we can understand the reasons for this complaint not being settled at an earlier stage.
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In summary:
15. It is the opinion of the medical assessors that the Trust’s medical staff were at fault in not taking sufficient account of the referring GP’s concern, in not assessing the severity of illness of the deceased correctly and in failing to ensure prompt senior medical review of this acutely-ill medical patient. Communication between nurses and medical staff was undoubtedly inadequate and the remedies proposed by the Trust in the light of the IR were made rather begrudgingly.
16. However, we consider that objective developments to improve patient assessment, senior review and communication have now been put in place by the Trust and are much reassured by what they were told at interview with the clinical director and the current chief executive.
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Annex B
Report of the Ombudsman’s Independent Nursing Assessor
(b) Communication between nurses and medical staff was inadequate.
1. Following the interviews with six nursing staff, it seemed to me that there had been a problem with communication between the nursing and medical teams.
2. The nurses interviewed were, in the main, very sure not only that they had documented Miss Q’s condition, but had also discussed the changes with the medical team. Certainly the lack of urinary output and her mood changes when at times she was confused and agitated and seemed to be having hallucinations, had been discussed among the nurses, but no medical action had been forthcoming, as she was to be transferred to Christchurch Hospital.
3. The nurses did not see it as unusual that the consultants and medical teams would often see patients and change treatment but that, if a nurse was not present at the time, the change in care would not be discussed with the nursing team.
4. My impression was that the ward sister did not seem to have total control of the ward and I was concerned about the resolution of these inter-professional problems. However we understood that there had since been staffing changes.
5. For instance no member of the nursing staff could understand why Miss Q had not been seen by a doctor on the ward. This seemed a very weak area of communication. I believe this questions the sort of discipline that the ward was run under. I would have expected the nurses to have contacted the next-in-line nursing manager, stated the problem and asked that it be resolved quicklywhich it should have been.
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6. Miss Q’s death was obviously a great shock to the ward teamwhich they will remember for years to come. When asked would they have done anything differently, most of the nurses said they would make the medical staff listen to them in future and this has been a very hard lesson for them to learn.
7. The A&E sister was sure that if a letter had not accompanied Miss Q she would have alerted the GP as the GP on-call scheme is run from A&E and the GP was on duty that night. I would therefore have to assume that the letter was presented on admission and went missing following Miss Q’s admission to the ward.
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(c) Remedies proposed by the Trust.
Unitary Record
8. At the time of our interviews this system had still not been implemented. We were shown a record in draft form but this document did not have space for the nursing staff to report any areas of concern or the patient’s clinical changes to the medical staff. It did have an area for nursing and medical reports, but nothing joint. The staff we interviewed had not been directly involved with the development of the form so farthis seemed a missed opportunity and could perhaps be pursued.
Clinical Supervision
9. Clinical supervision is a superb tool for supporting staff and there are many ways of delivering this. We heard that ‘reflective practice’ is being developed but it seemed very much in its infancy and the Trust need to develop this further.
Clinical Incident Review
10. This needs to be embedded into the organisation of the Trust. The staff knew there was a system and said that the ‘red box’ (a way of reporting incidents anonymously) was a means of reporting incidents. They all said it was anonymous reporting but no one had used it. They knew the medical director managed the system but were unaware of any feedback system to areas who had reported incidents. The Trust needs to ensure this happens, otherwise no one can learn from mistakes. The system should also be audited and reported to the risk management committee and, ultimately, to the clinical governance committee.
Acute Admissions Unit (AAU)
11. The development of this unit has obviously helped streamline the admission and assessment of patients. The Trust should be congratulated on this change.
Conclusion
12. I hope that the lessons learned by the Trust will prevent a recurrence of these events.
Short report of this investigation
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