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Selected Investigations Completed August 2001November 2001 > Part II, Case no. E.730/99-00

Part II—Full Texts of Selected Investigations

Case No. E. 730/99-00Inadequate medical and nursing care

Complaint against:  Pilgrim Health NHS Trust (the Trust)(now part of United Lincolnshire Hospitals NHS Trust)

Complaint as put by Mrs P 

1. The account of the complaint provided by Mrs P was that on 23 December 1996 her husband, Mr P, was referred for admission to Pilgrim Hospital (the Hospital) by a general practitioner (the GP).  On admission Mr P was extremely short of breath and blood tests indicated that he had suffered a heart attack two or three days previously.  On 27 December Mr P died in the hospital due to myocardial infarction (heart attack) and left ventricular failure.  Mrs P complained to the Trust about several aspects of the medical and nursing care provided to Mr P. 

2. Having considered the Trust’s substantive response to her complaint, on 13 April 1999 the Community Health Council wrote on behalf of Mrs P, requesting an independent review (IR) of her complaint.  On 17 June 1999 the Trust’s convener wrote to Mrs P refusing her request. 

3. The matter investigated was that the Trust failed to provide adequate medical and nursing care to Mr P following his admission to Pilgrim Hospital on 23 December 1996.

Investigation

4.   The statement of complaint for the investigation was issued on 16 December 1999 and the comments of the Trust were obtained.  Relevant papers, including Mr P’s medical records, were examined and evidence was taken from Mrs P and Trust staff, although it was not possible to contact all those who had been involved in Mr P’s care. Two professional assessors, a consultant cardiologist and a nurse, were appointed to advise on the clinical issues.  Their report is attached as an Annex to this report.  I have not included in this report every detail investigated, but I am satisfied that no matter of significance has been overlooked.

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Guidance

5.The Trust’s policy on the mobilisation of patients following uncomplicated myocardial infarction, in use at the time of Mr P’s admission, was as follows:   

6. In 1993 the United Kingdom Central Council for Nursing, Midwifery and Health Visiting (the UKCC) issued a standards paper on records and record keeping.  Section 4 states that the purpose of nursing records is to: 

• provide accurate, current, comprehensive and concise information concerning the condition and care of the patient or client and associated observations; 
• provide a record of any problems that arise and the action taken in response to them; 
• provide evidence of care required, intervention by professional practitioners and patient or client responses; 
• include a record of any factors (physical, psychological or social) that appear to affect the patient or client; 
• record the chronology of events and reasons for any decisions made; 
• support standard setting, quality assessment and audit; and 
• provide a baseline record against which improvement or deterioration may be judged.

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Mrs P’s evidence

7.When Mrs P first complained to the Trust about the care her husband had received she raised a number of concerns, including the following: 

• Why were neither she nor her husband informed of his diagnosis and condition during his in-patient stay? 
• Why, when he had been admitted because the GP thought that he had had a heart attack, was he allowed to mobilise? 
• Why was he not monitored better by nursing staff? 
• Why was he not seen regularly by medical staff? 
• As he had complained of discomfort, why was he not given appropriate medication? 
• Why was he not given oxygen? 
• Why were staff unaware that on the morning of his death, he had been in the bathroom for 1 1/2 hours? 

8.When interviewed by the Ombudsman’s staff, Mrs P said that she had not been present when her husband had been examined or assessed.  She had been told by a nurse that he was suffering from ‘congestion’.  Her husband told her that he was suffering chest pains, but had received no medication.  From the outset he had been very weak.

Trust’s response to the statement of complaint

9. The Trust’s formal response to the Ombudsman included the following: 

‘Gradual Mobilisation is encouraged for such patients, and on the day of [Mr P’s] death, considered from the blood test results to be about 6 days following his infarction, mobilisation would not have been restricted. 

‘As with other NHS organisations routine patient services not required as a matter of urgency (ie blood tests, X-rays, doctor ward rounds/reviews) are not generally provided over weekends or Bank Holiday periods. 

‘During [Mr P’s] admission [over the Christmas period] routine reviews of patients by medical staff were not undertaken unless requested by nursing staff.  There was however a team of doctors ‘on call’ and available if needed for advice or patient review should it be considered necessary. 

‘Our investigation revealed a lack of clear effective communication between medical and nursing staff although there is no evidence to suggest that [Mr P’s] care was adversely affected by this.  His plan of care was based on the symptoms he was experiencing at the time.  Nursing documentation and inter-professional communication were poor but we believe we have taken adequate steps to improve these …. [Note: see paragraph 47.] 

‘From our investigations with staff and reviews we do not feel there is any evidence to support the complaint that the level of nursing or medical care [Mr P] received was inadequate.’

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Clinical background

Mr P’s medical history and the details of the care he received during his hospital stay are set out in the professional assessors’ report.

Doctors’ evidence

11.The consultant said that Mr P had been seen by the first SHO following his admission, and that he had discussed the case with him.  (Note:  It was not possible to contact the first SHO.)  The consultant said that he would normally see patients admitted the previous day on his afternoon ward round, but he did not see Mr P.  He said that the ECG result, which was available for his discussion with the first SHO, suggested that Mr P had suffered a myocardial infarction some 2448 hours before his admission, although subsequent review of the records would be consistent with 2 infarcts, one more recent during a 2448 hour period before admission, and one previous to that.  The consultant said that he believed it was appropriate for Mr P to be mobilising, but activity should have been introduced gradually.  He said that Mr P’s respiration rate should have been recorded.  He did not know why nursing observations had been reduced from 3 times daily to once daily on 26  December. 

12.  The next doctor to see Mr P (the second SHO), in written evidence provided to the Ombudsman’s staff, stated that when he saw Mr P on 24 December he based his treatment plan on the diagnosis made on admissionleft ventricular failure secondary to ischaemic heart disease (reduced blood flow to the heart muscle).  As he had not made the diagnosis himself, he was not in a position to explain the basis on which it had been made.  He decided to give diuretics (Frusemide), Aspirin and Angiotensin-converting enzyme inhibitor (an ACE inhibitor) following a trial.  The objectives were to reduce Mr P’s breathlessness due to left ventricular failure, stabilise his ischaemic heart disease and help to improve cardiac function with an ACE inhibitor.  He documented the treatment plan in the notes, but did not consider it necessary to record the reason for each drug, as those things were normally understood by the medical and nursing professions.  He stated that it would have been his practice in such cases to give verbal instructions to the nursing staff indicating that the patient should receive bed rest and be given oxygen as required; also that any worsening of his condition should be reported to the medical staff. 

13.  The second SHO said that he was aware of one set of test results which showed that Mr P had raised levels of cardiac enzymes.  He said he knew that the raised levels might indicate that Mr P had suffered an acute myocardial infarction, but further cardiac enzyme tests and ECGs were needed to confirm that.  However, he was not on duty between 24 December and Mr P’s death.  He stated that Mr P should have received serial ECG tests over a number of days, under the direction of the on-call team.  

14.  The second SHO said that, had he been certain that Mr P had suffered an acute myocardial infarction, he would have followed the standard UK-wide policy about mobilisation.  However, when he saw Mr P on 24 December he was not sure that that was the case. 

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Nurses’ evidence

15.  A written statement made by a nurse (the first nurse) during the initial investigation of Mrs P’s complaint by the Trust included the following:

‘…. whilst administering [Mr P’s] [medication] [early on 27 December] I asked if he was alright and pain free.  He stated that he was.

‘Later on, at approximately 10.30 a.m.  I was informed by another patient in the same room as [Mr P] that he had not been seen for approximately an hour.  I immediately asked [another member of staff] to look for [Mr P], as I was on my way to answer a call bell.

‘I was then alerted [that] [Mr P] [had been] found …. in a collapsed state.’ 

16.  The former staff nurse (the staff nurse) told the Ombudsman’s staff that she was the nurse who completed the documentation when Mr P was admitted to the ward.  She explained that the ward was short staffed then and very busy, and that consequently there was a great deal of documentation which required completion.  She said that she could not specifically remember Mr P. 

17.  The staff nurse said that while some sections of Mr P’s assessment form were not completed, most were.  When asked why, having identified that Mr P may have had restricted mobility, she had focused on the possibility of pressure sores rather than the specific issue of mobility, she replied that the care plan which she raised was an individual one based on core issues.  When asked how she would manage a patient who suffered from poor mobility, she replied that it could be managed by medication, an aid, or physiotherapy. 

18.  The staff nurse said that entries in the notes suggested that Mr P had a problem with his breathing after exertion.  If he had been unduly short of breath on admission, she would have recorded that in the notes.  The staff nurse said that she had made an entry in the notes of 25 December 1996 which indicated that Mr P could breathe better when he was lying down, suggesting that he might have had breathing problems without exertion.  However, she could not remember any further details. 

19.  The staff nurse said that she could not remember whether or not she had received a telephone call from the laboratory concerning Mr P’s blood test results.  She said that at the time the results were written in a book which was held in the ward. 

20.  The charge nurse said that he thought the initial assessment and care plan for Mr P were satisfactory.  When asked about the entry in Mr P’s notes which suggested that he could breathe better when lying down, the charge nurse said that it was probably ‘just a comment made by the patient’. 

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21.  The charge nurse said that he did not know who had received the results of Mr P’s blood tests, but that a book was kept that was signed and dated by those receiving the results.  He did not believe that it was the nurse’s responsibility to bring abnormal results to the attention of the medical staff.  When questioned on that point, his response was ‘we are not doctors’.  He said that during weekends and bank holidays the wards were visited once a day by on-call staff, whom he believed should review test results during their visit. 

22.  The charge nurse said that there was a monthly audit of documents, but that the workload would obviously influence the quality of documentation.  He was aware of the UKCC standards for the completion of nursing records. 

23.The charge nurse said that at the time of Mr P’s admission to the ward, it was not known that he had suffered a myocardial infarction two days previously.  The protocol for managing patients immediately following myocardial infarction was not therefore used. 

24.  The former senior nurse (the senior nurse) said that after she had completed the investigation into Mrs P’s complaint she concluded that there were problems in relation to record keeping and communications within the Trust.  She said that she felt that the documentation of Mr P’s care was very poor, which had hampered her investigation.  As part of her investigation she had interviewed the charge nurse who had agreed that Mr P’s nursing notes were unsatisfactory due to their brevity.  She said that she implemented a development plan for the ward which had resulted in improvements in assessment and record keeping. 

25.  The head of nursing said that at the time of the events under investigation he was the senior nurse, medicine.  He and other senior nurses were aware that at the time there was widespread criticism of the amount of unnecessary information recorded by nurses.  It was a desire to improve the quality of the information collected which prompted the exception reporting scheme.  Meetings were held with senior nurses at directorate level, ward managers who would be involved with the pilot, and the senior tutor for in-service training.  As a result exception reporting was introduced as a pilot scheme on a few wards, with the intention that only information necessary for the care of the patient would be recorded in the clinical records.  The scheme was supported by training from the planning group members and the senior tutor.  Initially things seemed to be proceeding satisfactorily, but the group became aware of a drop in the quality of records over a period of a few months.  The pilot was then abandoned. 

26.  The head of nursing said that the project management of the exception reporting scheme could have been better.  He accepted that there was no formal project plan and that monitoring could have been better.  He acknowledged the absence of any formal written record of monitoring or evaluation, although he maintained that monitoring had been good throughout the project.  He believed that the scheme met the UKCC guidelines.  The in-service tutor had been involved to ensure that was the case.  He felt that criticism of the monitoring and evaluation might be justified, but not the scheme itself. 

27.  With regard to Mr P’s nursing records, the head of nursing considered that there were gaps in the information recorded and that they did not meet the level intended by the project.  The guidelines for exception reporting were ‘write what you need to write’, and there were clearly aspects of Mr P’s care which were not adequately recorded. 

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Findings

28.  In reaching conclusions about this complaint I have taken account of the report provided by the professional assessors.  There are number of aspects of Mr P’s care which are open to question, and I will deal with each in turn. 

Diagnosis  

29.  When Mr P was assessed on admission, a provisional diagnosis of  left ventricular failure and ischaemic heart disease was made.  In the opinion of the medical assessor, that was consistent with his symptoms, especially his shortness of breath.  However, with hindsight, sufficient consideration was not given to the cause of Mr P’s heart failure, especially in the light of his history of pain radiating into his left arm five days previously.  Some appropriate tests were ordered, although it would have been prudent to have arranged at that stage for serial ECGs to be taken.  It has not been possible to establish why these were not arranged by the first SHO.  However, while the SHO did not appear to do the ideal thing, he did arrange the cardiac enzyme tests, and I am advised that he did take the first step in establishing the diagnosis.

30.  When Mr P’s care was reviewed by the consultant, the ECG was available but not the results of the blood tests.  The diagnosis was not modified, and a treatment plan was formulated on that basis, with the emphasis on reducing Mr P’s shortness of breath by the use of diuretics to remove excess fluid from his lungs.  I find it surprising that no formal diagnosis of a recent myocardial infarction was made at this stage, especially in the light of the consultant’s statement that the ECG results suggested that one had occurred during the previous 2448 hours.  I understand that the information available at that stage was not sufficient to form a definitive diagnosis, but I am of the view that there was sufficient information to influence the management of Mr P, especially in relation to further tests and restriction of his mobility.   It is the view of the medical assessor that a more rigorous assessment of Mr P’s breathlessness should have been undertaken, to determine whether the administration of oxygen would have been beneficial.  The assessor also notes that there is no evidence that the medical staff were aware of the outcome of a chest X-ray taken on Mr P’s admission.

31.  The next day the second SHO noted the abnormal cardiac enzyme test results. The medical assessor is critical of the fact that no contemporaneous interpretation of the test results was recorded in the clinical notes.  The second SHO told the Ombudsman’s staff that he had considered the possibility of an acute myocardial infarction but required further tests to establish a firm diagnosis. It was, therefore, reasonable to defer a decision.  Serial cardiac enzyme tests [CARD] were already underway.  However, I am critical of the second SHO for not taking any steps to obtain further  ECGs.  None of the three doctors who were involved in Mr P’s care, including the consultant who might have been expected to have considerable experience, realised that serial ECGs were not being undertaken, and I am critical of that oversight.

32.  Mr P was not seen by medical staff on the next day, which was Christmas Day, or on the following morning prior to his collapse.  Blood tests results were available on 23, 25 and 26 December, all of which showed abnormalities.  However, there are no further entries in the medical records until Mr P’s collapse, and therefore no evidence in the medical notes to show that medical staff were made aware of them.  It seems reasonable to conclude that they were not.  I have received evidence from nursing staff that the system in place at the time was for the laboratory to telephone the ward with test results, which were recorded in a book kept for the purpose.  I have been told that it was the doctors’ responsibility to collect that information from the ward.  It is the view of the nurse assessor that the failure of nurses routinely to take responsibility for reporting abnormal test results is unacceptable.  I agree.  There is no reference to the results in the medical notes and I have, therefore, to conclude that they did not do so.  The situation was further complicated by the fact that routine ward rounds were not being undertaken because it was a holiday period; the wards were visited daily by a member of the on-call team.  Any results not reviewed by the on-call doctor on that visit would not be acted upon until an unspecified time the following day, with potentially critical consequences.  There was clearly a breakdown in communication which resulted in no action being taken in response to abnormal blood tests.

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Communication

33.  There is no evidence in the nursing or medical records to indicate that any explanation of his illness was given to either Mr P or his wife.  Mrs P recalls being told that her husband was suffering from ‘congestion’.  In the absence of any other evidence, I must conclude that they were not given any detailed information about his diagnosis, and that is not acceptable.

34.  There is repeated evidence that communication with Mr and Mrs P, and among staff, was inadequate.  The nursing assessor has cited several examples including the fact that nursing staff did not know that Mr P had had a myocardial infarction; nor were they aware of the reasons for his admission to hospital.  Furthermore, the medical assessor has commented that there is no record that medical staff informed the nurses of Mr P’s diagnosis and intended management.  I strongly criticise the Trust for those failures.

Management

35.  Mrs P expressed great concern that her husband had been allowed to mobilise, and I share that concern.  The second SHO recognised that an acute myocardial infarction was one possible diagnosis and indicated that he would have directed the nursing staff to give bed rest, but there are no written records in either the medical or nursing notes to indicate Mr P’s proposed management.  In my view this is a serious inadequacy in record keeping.  The Trust had a policy for mobilisation following uncomplicated acute myocardial infarctions, but there is no evidence that this was used in planning Mr P’s care, although the Trust implied in their response to Mrs P that it had been.  In any case it would have been inappropriate for a number of reasons.  First, his heart attack was not without complications; he was considered to have left ventricular failure on admission.  Secondly, there was no certainty as to when Mr P had suffered his heart attack.  The only results available to the second SHO, who was the last doctor who saw Mr P, were not sufficient to draw a firm conclusion.  The assessor, in his report, offers a number of possible scenarios, one of which includes a second myocardial infarction on the day of his admission.  The diagnosis recorded in the Trust’s formal responsethat Mr P had suffered a heart attack two days before his admissionis made retrospectively with the advantage of more clinical test results than were available to the doctors at the time.  The nursing staff were not, at the time, aware that Mr P had suffered a heart attack.  It seems reasonable to conclude that a cautious approach to mobilisation would have been more appropriate.

36.  There is no reference in either the medical or nursing notes to the possibility of giving Mr P oxygen.  The second SHO indicated that he would have advised the nursing staff to do so if necessary, but again there is no record.  The results of the chest X-ray were not available to ward staff and observations of respiratory rate and fluid balance do not appear to have been carried out.  Therefore, no proper assessment was made of whether Mr P would have benefited from supplemental oxygen.

37.  Mr P’s observations were recorded three times daily from his admission until 26 December, when the frequency was reduced to once daily.  There is no rationale for these decisions recorded in the nursing notes.  Indeed, it is surprising to find that the frequency of observation was reduced when blood pressure and temperature were both low.  This a further inadequacy in the nursing care, with inadequate rationale for this in the nursing records.

38.  Mr P had been away from his room for a period of at least an hour before a patient drew this to the attention of nursing staff.  The nursing assessor is quite clear in her view that nursing staff have an implicit responsibility to be aware of the whereabouts of patients within their care.  In this regard the care offered to Mr P fell below an acceptable standard.

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Medication

39.  Mrs P questions why her husband was not given anything to relieve his pain.  On examining him, both the first and second SHO recorded that he was free of pain.  It is therefore reasonable to conclude that on 23 and 24 December no analgesics (painkillers) were required.  It is impossible to assess, in the absence of any records, whether Mr P reported any pain after that.  There is no record of analgesics being prescribed. (Note: the aspirin which he received was for a different purpose.)  

40.  On 24 December the second SHO prescribed three drugs, and I am critical of the way nursing staff administered each of them.  A trial dose of Lisinopril was requested, but the form has only been earmarked with a tick and not the required signature.  I consider this to be unacceptable practice.  Two other drugs were requested on a daily basis, but they were not given until the following day, which in my view represents an unacceptable interruption in treatment.  There is no explanation for this in the nursing notes.  

Nursing records

41.  In the view of the nursing assessor, the practice of exception reporting in place at the time of Mr P’s admission falls below the standard set by the UKCC.  She is also critical of the way the scheme was implemented without the involvement of the Trust Board, and the absence of formal monitoring and evaluation, and I share those concerns. 

42.In summary, is it my view that Mr P’s care fell below an acceptable standard because:  

• despite a reported discussion with the consultant, no senior doctor or consultant physician saw Mr P during his admission;  
• no serial ECG recordings were done; 
• there was no contemporaneous interpretation of the abnormal cardiac enzyme results recorded;  
• there was no contemporaneous diagnosis of an acute or recent myocardial infarction made during his admission;  
• the system of exception record keeping in use by the nurses was wholly unacceptable;  
• there was no plan for his mobilisation, or restriction to his mobilisation; 
• there was an inadequate assessment of his breathlessness, and clinical observations were too infrequent; 
• the medical treatment, which was indicated and planned for him, was not given consistently; 
• there was a marked lack of communication both between doctor and doctor, and doctor and nurse, with regard to Mr P’s clinical observations, treatment and appropriate degree of mobilisation;  
• there was a lack of communication between ward staff resulting in medical staff apparently being unaware of abnormal test results;  
• it was unreasonable that a member of the medical staff appeared to visit the ward but did not check the test results;  
• there was inadequate observation of Mr P, resulting in his being absent from his room for a long period before nursing staff were aware of his absence; and  
• there was a lack of communication between both medical and nursing staff and Mr and Mrs P, resulting in neither being advised of Mr P’s condition.  
   

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Recommendations

43.  I am extremely critical of the unacceptably poor standard of nursing records  current at the time of Mr P’s admission, which clearly fail to meet UKCC standards.  I accept that better systems are now in place, but it is questionable whether such an experimental system should ever have been introduced, even on a trial basis.  I recommend that no changes should be made to nursing documentation or practice without the full involvement of the director of nursing services.  A full and careful evaluation of any revised procedures should also be undertaken.  I look to the Trust to consider the recommendations of the nursing assessor in paragraph 10 of the assessors’ report.

44.  I am critical of the lack of communication between laboratory staff, medical and nursing staff, which was inadequate for many aspects of Mr P’s care.  I recommend that the Trust review their procedures for notifying ward staff and medical staff of relevant test results. 

45.  I also criticise the inadequate communication among staff and with Mr and Mrs P.  I recommend that the Trust review their practice to ensure that all clinical staff are not only aware of the importance of effective communication both among themselves and with patients and relatives, but also take responsibility for practising it. 

46.I am critical of the evident lack of a co-ordinated approach to the care of patients who had suffered myocardial infarctions.  I would normally recommend that the Trust develop and implement a policy embodying the best clinical practice.  However, I have seen documentation which demonstrates that this development has already taken place within the Trust.  

47.  There are a number of other issues which would normally lead me to make recommendations to the Trust.  However, in his formal response to the Ombudsman, the chief executive indicated a number of steps which had already been taken to improve the service provided.  I list those actions here, whilst formally noting that the absence of these improvements would have attracted my criticism:  

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Admissions

‘…. [Nursing practice] has …. been enhanced by the use of Core Care Plans and the practice of more detailed recording of information on nursing assessment forms.  (Note: Examples of Core Care Plans were provided for my inspection.) 

‘In December 1997 the Trust opened its Medical Admissions Unit which has recently been expanded to a 15-bedded area with dedicated staffing. All emergency medical patients are initially admitted to this unit for thorough nursing and medical assessment with relevant investigations prior to transfer to an appropriate Ward. The staffing rota provides for two senior house officers and a registrar, a senior member of the medical staff, to be allocated to emergency admission patients between the hours of 9am to 5pm.  These doctors are based mainly on the unit.  After 5pm the registrar is on call.  An additional senior post of staff grade is based on the unit on Monday, Wednesday and Fridays between 5pm and 9pm to cover busy periods.  These arrangements allow a senior member of the medical team to review all patients admitted and assessed by the on-duty junior doctor.  Additionally the senior doctor is available to provide immediate advice or intervention if considered necessary by staff on the unit. 

‘The nursing team is supported by a senior grade nurse allocated to each shift between 7am and 10pm.  Their role has expanded under the scope of professional practice to be multi-skilled which, supported by senior health care support workers who have received additional diagnostic training, facilitates speedy  investigations for emergency patients. 

‘These arrangements have contributed to providing a more stable and comfortable environment for the patients and relatives and have allowed speedier access to medical staff who are specifically allocated to the unit. 

‘The close working relationships that are in place as a result of these arrangements have improved communication between medical and nursing staff.

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Ward Rounds

‘Due to the increasing number of emergency medical admissions, a number of consultant physicians are cancelling outpatient clinic sessions that clash with the morning following their [night] ‘on call’ in order that a full and comprehensive ward round can be undertaken. 

Cardiac Rehabilitation Nurse

‘A new senior grade nursing post, in the role of cardiac rehabilitation nurse, has recently been appointed to supplement the service provided to cardiac patients.  This nurse reviews the regime of all patients admitted with cardiac problems and patients can be referred by medical or nursing staff.

Documentation

‘On transfer from the Medical Admissions Unit to a Ward, the Medical and Nursing plan of care has already been initiated and this documentation is audited monthly to ensure and maintain standards. 

Bank Holiday Cover

‘The Trust recognises the impact that Bank Holidays can have on patients continuing care and as a result Ward Rounds are now undertaken on Bank Holidays to ensure that patients are reviewed by a consultant on a regular basis.’

Conclusion

48.  I have set out my findings in paragraphs 2847.  The Trust has agreed to implement my recommendations in paragraphs 4345 and has asked me to convey to Mrs Pas I do through this reportits apologies for the shortcomings I have identified.

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Annex to E.730/99-00

Report of the Professional Assessors to the Ombudsman

1. Matters considered

That the Trust failed to provide adequate medical and nursing care to Mr P after his admission to hospital on 23 December 1996. 

2.   Basis of report

This report is based on medical and nursing notes of Mr P’s in-patient stay at the Pilgrim Hospital and other documentary evidence, interviews with Trust staff and complaints correspondence.  Only the consultant involved in the case was available for interview as both SHOs had left the Trust and one was abroad and could not be contacted.  Furthermore, staff interviews and a series of written questions to one SHO were conducted 3-4 years after the events, and they were understandably unable to recall details of specific issues.  Much of this report is therefore based on the documentary evidence. 

3.   Background and history of events

3.1  In 1996, Mr P was a 58 year old man and apparently healthy, with no relevant previous personal medical history.  He had smoked tobacco since the age of 20 years.  There was a family history of hypertrophic cardiomyopathy in his son Thomas, who died in 1994 aged 31 years.  There is no suggestion in the medical records I have seen that Mr P had been advised that he (and his family) should have undergone, or that he had undergone, cardiac screening for hypertrophic cardiomyopathy. 

3.2  Mr P’s General Practitioner was called to his home on 23 December 1996, and was seen at approximately 13:00; the diagnosis made was “D CCF ?2° to Myoc Infⁿ, ?AS, ?cardiomyopathy” [Diagnosis: Congestive Cardiac Failure query secondary to myocardial infarction; query aortic stenosis; query cardiomyopathy]. He referred Mr P in to the Hospital by ambulance for admission.  Mr P was admitted to ward 8A, an acute general medical ward. 

3.3  Mr P was admitted to the hospital and seen by the first Senior House Officer (SHO), at about 14:00 on 23 December 1996.  The SHO diagnosed “SOB on exertion, ?cause, ?LVF – IHD” [Short of Breath on exertion,  query cause, query Left Ventricular Failure – Ischaemic Heart Disease].  He indicated that various blood tests were to be arranged, including “CARD” [cardiac enzyme series, or specific blood enzyme tests to diagnose myocardial infarction repeated daily over 3 days], an ECG [electrocardiograph] and a CXR [chest X-ray].  The ECG was recorded at 14:10, and the SHO recorded the findings as “NSR, RBBB. Tall P waves. Q waves ant leads. ST­ V₁-V₆” [Normal Sinus Rhythm, Right Bundle Branch Block, Tall P waves, Q waves anterior leads, ST-segment elevation in leads V₁-V₆].  There is no record of any request or arrangement having been made for serial ECG recordings to be done over subsequent days. 

3.4  It is recorded that the SHO discussed Mr P’s case with the consultant general physician (the consultant), probably later on 23 December 1996.  It is recorded that the consultant diagnosed an old infero-lateral (myocardial) infarction. He noted that Mr P was not to receive thrombolytic treatment, and was to have diuretic treatment.  It would appear from the medical records that the consultant did not actually see Mr P on 23 December 1996. Frusemide (a diuretic) was prescribed and administered as a single intravenous dose at 17:35 on 23 December 1996. 

3.5  The consultant did a ward round on the morning of 24 December 1996 to assess those patients who had been admitted as emergencies the previous day. There is no record in the medical notes that he saw Mr P. It is evident that Mr P was not actually seen by a senior doctor or consultant during his admission. 

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3.6  The results of some of the blood tests are written in the medical record, but it is not evident when these were entered.  It appears that these results are written in the same style as the next entry made on 24 December 1996 by another SHO (the second SHO);  it seems likely that these results were entered by the second SHO on 24 December.  The abnormal results of CK and LDH (Cardiac enzymes) have been indicated by a ­ symbol adjacent to them, but no deduction or conclusion has been made of these abnormalities in the records. 

3.7  An untimed entry confirms Mr P was seen and reviewed by the second SHO, on 24 December 1996.  The records indicate that Mr P was free of pain but was breathless on exertion, and treatment with Aspirin, Frusemide and a trial of Lisinopril was planned.  Oral aspirin was prescribed on 24 December, but was not administered until 25 December and subsequently.  Similarly, oral Frusemide was prescribed on 24 December, but was not administered until 25 December and subsequently.  A trial of a single dose of oral Lisinopril was prescribed on 24 December to be given at 18:00, and a tick has been entered into the prescription chart, but in the absence of a signature it is not possible to be certain that it was given.  No blood pressure observations have been entered from 18:00 on 24 December until 10:00 on 25 December to monitor the effect of this trial of Lisinopril on Mr P’s blood pressure.  No further prescription or administration of Lisinopril has been made. 

3.8  The medical records also contain 4 sets of clinical chemistry results, marked as being reported on 23, 25 and 26 December, and one set of haematology test results reported on 24 December.  All show varying degrees of abnormality. 

3.9  The next entry in the medical record is made on 27 December 1996 at 10:45 documenting a cardiac arrest call to Mr P, who had been found collapsed in the toilet, and could not be resuscitated. 

3.10  There is a radiological report of the chest X-ray in the medical record.  This examination was done on 23/12/96, was reported on 23/12/96, and apparently typed on 23/12/96; there is also a date of 30/12/96 on the report, perhaps the date of printing.  However, it is written on this report that this is a copy printed on 18/01/97 for the complaint folder.  Therefore, it would seem that the original clinical report of the chest X-ray was not available to medical staff before Mr P’s death.

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4.  Deductions and opinions

Family history

4.1  Mr P’s acute illness is consistent with a diagnosis of recent or acute myocardial infarction, and with the fact that he was apparently healthy when he suddenly became unwell, and with his sudden death shortly afterwards as a consequence of his illness. 

4.2  Opinion:  I consider that the family history of hypertrophic cardiomyopathy in his son was unrelated to Mr P’s illness and death. 

Seen by senior doctor

4.3   Mr P was not actually seen by a senior doctor or consultant physician during his admission to the Hospital.  This seems to have been a fault of omission rather than commission, as the consultant had intended to see all the medical patients on 24 December 1996 who had been acutely admitted during the previous 24 hours.  I understand that Mr P was due to be seen and reviewed by the consultant on a ward round on 27 December 1996. 

4.4 Opinion: Mr P was not seen by a senior doctor or consultant physician during his admission. 

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Diagnosis

4.5  No definitive diagnosis of the cause of Mr P’s symptoms was made before his death.  The admitting doctor diagnosed query left ventricular failure from ischaemic heart disease, and the consultant diagnosed an old infero-lateral myocardial infarction.  The second SHO recorded no update to these diagnoses, or further diagnosis, when he reviewed Mr P on 24 December 1996. 

4.6  No contemporaneous interpretation was made of the abnormal cardiac enzyme results during Mr P’s admission. These abnormal cardiac enzyme results have been interpreted, retrospectively in the complaints file, that Mr P had a myocardial infarction two or three days before admission. 

4.7  The single ECG done on Mr P on admission shows a large Q-wave antero-lateral myocardial infarction.  This would be consistent with a myocardial infarction of two or three days old, or five days old or older, or five days old with re-infarction on the day of presentation.  Interpretation of both serial ECGs and cardiac enzyme results are required to accurately time the onset of a recent myocardial infarction. 

4.8  Opinion: It is also plausible to interpret the abnormal cardiac enzyme results that Mr P could have had a myocardial infarction five days before admission, particularly with the history of increasing breathlessness over five days, and with abdominal pain radiating to his left arm at five days, before presentation.  And that Mr P had re-infarction on the day of admission, with the history of increasingly severe breathlessness on the day of presentation.  On the balance of probabilities from the information analyzed in retrospect of Mr P’s history of symptoms, the results of the cardiac enzyme blood tests and the single ECG recording, it is my opinion that it was most likely that Mr P had a myocardial infarction five days before presentation, on 18 December 1996, and a myocardial re-infarction on the day of presentation, on 23 December 1996.  I acknowledge that there are other possible interpretations of this information, however. Differences in these various interpretations would affect the recommended timing and degree of mobilisation appropriate for Mr P. 

4.9   It would be usual medical practice to do serial ECG recordings, typically at least once daily for three days, over the first few days after admission in a patient with a suspected acute or recent myocardial infarction. I understand at the time of Mr P’s admission that it was Trust policy that medical staff were responsible for doing out-of-hours ECG recordings on in-patients. Mr P was admitted over the Christmas holiday period, but it would be expected that staffing, diagnostic services and treatment should have been the same during this time as would be the case during usual week-end working. Similarly, medical staff would be expected to have reviewed any abnormal results, such as raised cardiac enzymes, during this period. 

4.10  Opinion: The lack of further ECG recordings, particularly with the first set of abnormal raised cardiac enzyme results, which were reviewed on 24 December 1996, and the lack of contemporaneous interpretation of the abnormal cardiac enzyme results, in my opinion falls below a clinical standard which Mr P could reasonably have expected. 

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Timing of myocardial infarction

4.11  There is no statement in the medical records that Mr P had a recent or acute myocardial infarction; there is no statement in the nursing records that Mr P had had a myocardial infarction at any time.  But various references in the correspondence in the complaint file indicate that, in retrospect, it was thought Mr P had had a myocardial infarction about two days before admission. 

4.12  Opinion: These responses to the complaints have made retrospective analyses of the clinical information, whereas the contemporaneous medical record, diagnosis and treatment of Mr P made no reference to recent or acute myocardial infarction.  I have considered above that there are alternative interpretations of the time of onset of myocardial infarction. 

Mobilisation

4.13  There is no documentation in the medical or nursing records that refers to any necessary restriction in Mr P’s mobilisation.  Various references in the correspondence in the complaint file indicate that it was thought Mr P had had a myocardial infarction about two days before admission, in turn retrospectively justifying the unrestricted mobilisation at the time of his death. At the time, the Trust had guidelines on “Mobilisation Regimen following Uncomplicated Myocardial Infarction”. 

4.14   The Trust guideline indicates that, if he had had a myocardial infarction two days before admission, Mr P should have been allowed up on the day of his admission for one hour am + pm in a chair (on day 3 after uncomplicated myocardial infarction).  Mr P was considered to have left ventricular failure on admission, and thus a complicated myocardial infarction, and perhaps should have been allowed to mobilise even more cautiously than the standard Trust guideline on mobilisation. 

4.15  The nursing response to the issues raised in the complaints file was that Mr P had had an old myocardial infarction, and thus was free to fully mobilise on and from the day of admission.  This is consistent with the contemporaneous medical documentation in the medical records, but contradicts the conclusion of a recent myocardial infarction made in the medical responses given to the complaints made. 

4.16   Opinion: There is no evidence from the medical or nursing records that Mr P was advised to restrict his mobilisation during his admission. I consider that Mr P should have been advised to be restricted in his mobilisation, at least during the first few days after his admission to the Hospital. 

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Clinical monitoring

4.17   Mr P did not have ECG monitoring during his admission. Continuous ECG monitoring should be done during the first 24 hours of an uncomplicated acute myocardial infarction, and for 48 hours or longer for an acute myocardial infarction with complications.  

4.18  Opinion: With the admission diagnosis of an old myocardial infarction, I consider that it was reasonable practice that Mr P did not initially have continuous ECG monitoring performed.  But with the abnormal cardiac enzyme results, specifically a raised CK of 458 IU/l [creatine kinase, normal range 10-200 IU/l] on the day of admission, I consider that Mr P could reasonably have expected to have had some ECG monitoring done, perhaps as a minimum for the first 24 hours after the elevated CK enzyme result was available.

Assessment of breathlessness

4.19   Mr P complained of breathlessness.  There is no record in the medical notes that the ward medical staff reviewed the chest X-ray performed on 23 December 1996; and the written radiological report of the chest X-ray was not made available until after Mr P’s death. Nursing observations of respiration rate, urinary output, and fluid balance were not done. The clerking notes include “cy^o” [no cyanosis (blueness)] but there is no documentation on whether Mr P was hypoxic or had arterial oxygen desaturation (short of oxygen), and thus whether Mr P would have benefited from supplemental oxygen.  There are no records in the medical or nursing notes to indicate whether Mr P had supplemental oxygen, and it is presumed that he did not receive this. 

4.20  I would expect that a patient presenting with cardiac breathlessness due to a cardiac cause should have had a chest X-ray and that this should be reviewed shortly after admission by the admitting medical staff.  Medical staff should request nursing observations of respiration rate, daily 24 hour urinary output,  fluid balance, and arterial oxygen saturation; and consider taking arterial blood for measuring arterial oxygen pressure.  If blood arterial oxygen pressure or saturation were low, the medical staff should consider the administration of supplemental oxygen treatment.  Thus, it cannot be determined here, whether Mr P would have benefited from or should have received supplemental oxygen treatment. 

4.21 Opinion: I consider that there was an inadequate assessment of the cause of Mr P’s breathlessness. 

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Medical treatment

4.22  Mr P should have had aspirin administered on 23 December 1996, but the records indicate that he did not.  Mr P should have had aspirin and Frusemide administered on 24 December 1996, but the records indicate that he did not.  Mr P should have had Lisinopril administered on 24 December 1996, but the records are unclear whether he did; there is a tick mark placed in the drug chart column “given time/sig.”, but there is no time or initial or signature entered by the staff, and thus it cannot be confirmed and must be uncertain whether the Lisinopril was given to Mr P. (Furthermore, no blood pressure observations have been done over the subsequent hours, which should have been done if Lisinopril had been administered).  If the Lisinopril trial had been satisfactory, Mr P should have had Lisinopril continued after 24 December 1996, but the records indicate that he did not. 

4.23  Opinion: Mr P did not consistently receive the medical treatment that was indicated and planned for him in the medical records. 

Blood pressure

4.24  Mr P had persistently low blood pressure recorded in the nursing observation chart.  No blood pressure observations have been entered from 18:00 on 24 December until 10:00 on 25 December, or from 06:00 on 26 December until his death. The frequency of nursing observations of temperature, pulse and blood pressure were changed from three times daily to once daily on 26 December 1996. 

4.25  Opinion: This reduction in frequency of nursing observations was inappropriate in a patient complaining of breathlessness, who had persistently low blood pressure, and with a diagnosis of left ventricular failure. 

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Lack of communication

4.26  There is no record that the medical staff informed the nursing staff of Mr P’s diagnosis and intended management. 

4.27  Opinion: There seems to have been a lack of communication between medical and nursing staff.  The medical staff should have informed the nursing staff of the diagnosis of left ventricular failure, caused by a suspected recent or old myocardial infarction, and that Mr P’s mobilisation should be slow and gradual according to Trust guidelines.  Medical staff should also have advised the nursing staff with regard to appropriate clinical observations, their frequency, and the need to include monitoring of arterial oxygen saturations. 

5.  Conclusions

5.1  Opinion: It is my opinion that Mr P’s care fell below a standard to which he could have been reasonably entitled because: 

a)   no senior doctor or consultant physician saw Mr P during his admission; 

b)   no serial ECG recordings were done; 

c)   there was no contemporaneous interpretation of the abnormal cardiac enzyme results; 

d)   there was no contemporaneous diagnosis of an acute or recent myocardial infarction made during his admission; 

e)   there was no plan for his mobilisation, or restriction to his mobilisation; 

f) there was an inadequate assessment of his breathlessness, and clinical observations of blood pressure were too infrequent; 

g)   the medical treatment, which was indicated and planned for him, was not given consistently; in particular the trial of Lisinopril was probably not given or, if it was, there was no proper monitoring of it;

h)   there was a marked lack of communication between medical and nursing staff with regard to his clinical observations, treatment and appropriate degree of mobilisation. 

I believe that the facts that I have stated in this report are true and that the opinions I have expressed are correct. 

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6. Nursing care

6.1  The key issues concerning the nursing care that Mrs P wished to be examined were: 

• Mr P was found collapsed after an absence from the ward of 1½ hours; 
• Mrs P was not made aware of the serious nature of her husband’s condition; and 
• the Trust failed to provide adequate nursing care to Mr P following his admission. 

In addition the responses written to the complainant about nursing issues will be addressed. 

6.2  The nurse assessor would like to state for the record, the difficulties in addressing some of the above issues due to the fact that staff interviews were conducted some years after the events.  Many staff interviewed were unable to recall details of Mr P’s episode of care. For this reason much of the report is based on documentation.

7.  Background

7.1  Mr P was admitted as an emergency to Ward 8A of the Pilgrim Hospital Trust on 23 December 1996 at the request of his General Practitioner. 

7.2  Ward 8A is a mixed sex acute general medical ward, which accepted patients with a range of medical conditions. The ward comprises a series of bays and Mr P was allocated to a bed in the bay nearest to the nurse’s station. 

7.3  Evaluation of care given

(i)  The Trust at that time had commenced on a trial of variance reporting in order to reduce the amount of time the nurse spent completing records. Variance reporting is more commonly applied to care pathways where an anticipated recovery path is identified usually by diagnosis e.g. myocardial infarction, any variance from the anticipated progress by the patient will be reported.  Depending on the nature of the variance, the patient will either be transferred to a more appropriate care pathway or a care plan for the problem, which will be developed to operate alongside the care pathway. 

(ii)  Variance reporting should be subject to vigorous audit by the multidisciplinary team and if appropriate the care pathway will be adjusted accordingly. 

(iii)  The Trust has developed a care pathway for the management of myocardial infarction since Mr P was admitted. 

(iv)  The evaluation of Mr P’s care consists of two entries in the 4 day period that he remained on Ward 8A, one on  24 December and the next on the 25^th.  Both refer to his shortness of breath but neither represents a detailed assessment. 

(v)  Review dates on the care plans for mobility and respiration have been crossed out, which the ward manager said meant a review had been completed. However, there had been no changes made to plans, which would reflect the condition of the patient as described in the evaluation form. 

(vi)  It is noted that the nursing documentation does not ask nursing staff to record significant past medical history.  When interviewed, the ward manager said that the nursing staff did not know that Mr P had had a myocardial infarction.  The care was planned and executed on this basis. 

(vii)  The ward also used a communication sheet intended to keep a record of events not considered to be a variance to the care plan.  There are two entries, the first of which states that Mr P was admitted with shortness of breath and that he would require a start dose of Frusemide 50mgs.  There is no reference to the fact that the cause of Mr P’s breathlessness was thought to be cardiac in origin or that he had had a myocardial infarction referred to in the medical records as an ‘old infarction’. 

(viii)  There is no evidence that the nursing staff had any knowledge of the medical rationale for an admission to hospital, which would involve the patient remaining in hospital over the Christmas period, traditionally a time when every effort is made to ensure only those patients who must be in hospital remain there. 

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7.4  Communication

(i)  There is no evidence that the medical notes had been read by the nursing staff or that there was any communication between medical and nursing staff concerning the patient’s condition.  The medical records contain the following significant information about the patient, none of which appears to have been known by the nursing staff: 

a) Mr P had had a myocardial infarction at some time in the past in the opinion of the consultant;

b) there were raised cardiac enzymes;

c) the admitting doctor believed the cause of Mr P’s breathlessness to be cardiac in origin;

d) Mr P had a very low temperature on admission; and

e) Mr P’s ECG had significant changes. 

(ii)  The second entry on the communication sheet is for the 27 December 1996 and refers to the fact that nursing staff were alerted by another patient that Mr P had been missing for a ‘while’ and describes his collapse. 

7.5  General observation of patient

The fact that nursing staff were unaware of Mr P’s whereabouts until informed by another patient demonstrates their belief that he was self-caring with no limitation on his mobility and that they had no responsibilities towards him.  There is an implicit clinical responsibility for ward nursing staff always to be aware of the whereabouts of the patients under their care.  In Mr P’s case this responsibility was not discharged.  

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7.6  Blood Profile

(i)  Mr P had samples of blood taken on the 23, 25 and 26 December, the results of which show a deteriorating picture in terms of raised cardiac enzymes and increasing levels of urea as well as a raised white cell count.  The charge nurse explained that the results would have arrived on the ward on days which were bank holidays and that the wards were covered by on-call medical staff. The ward was visited each day by a member of the ‘on-call’ medical team. 

(ii)  The laboratory would routinely telephone the ward with abnormal blood results and these would be recorded in a book kept especially for this purpose. The laboratory results would be placed in an envelope in the ward office to be reviewed by medical staff. 

(iii)  The ward manager was asked if blood results, such as Mr P’s, should have been brought to the attention of medical staff. The ward manager clearly believed that it was the responsibility of the on-call doctor to review the results and act accordingly.  The ward manager indicated that the book would be available, so that the person who recorded the abnormal blood results could be identified. 

7.7  It was usual practice in 1996 for patients with an abnormal ECG in whom a myocardial infarction is suspected to have repeat recordings on three consecutive days.  The medical records contain only one ECG. 

7.8   Vital recordings

Mr P’s observations were recorded three times daily from admission until the 26 December 1996.  There is no rationale for this decision recorded on the nursing documentation. 

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7.9  Temperature

Mr P’s temperature was 35 – 36 º C on admission and the SHO had advised the use of a space blanket to raise his body temperature. However, by 18:00 hours that day Mr P’s temperature was within normal limits. It must be noted that on the 26 December 1996 Mr P’s temperature is recorded at 35 º C; despite this fact a decision was made to reduce the frequency of his observations, which would mean his temperature would not have been checked for a further 24 hours.  No rationale for the decision to reduce the frequency of the observations is recorded. 

7.10  Blood Pressure

Throughout his admission Mr P’s blood pressure was low. The nursing staff did not feel unduly concerned and said that they did not feel that it should have been brought to the attention of medical staff. 

7.11  Medication

(i)  The initial medical assessment recommends the use of diuretics. An initial dose of intravenous Frusemide was prescribed by the admitting doctor. The medication was administered at 17:35 hours that day.  A review was undertaken by the Senior House Officer on the 24 December 1996.  Frusemide tablets 40mg, Aspirin 150 mg and a trial dose of Lisinopril were prescribed.  It is noted that Frusemide and Aspirin were not administered until the 25 December 1996, representing an interruption in the treatment plan.  In 1996 it would be expected that these items would be stock items on a General Medical ward.  Lisinopril is given as a single small dose and the patient’s condition is closely monitored, including bed rest and frequent blood pressure recordings, to ensure that the patient’s blood pressure does not fall.  There is some doubt as to whether this drug was administered, owing to the incomplete records.  However, there is no evidence that appropriate monitoring took place. 

(ii)  Nursing staff tend to avoid administering Frusemide in the evening to avoid the patient being disturbed during the night by the need to micturate (pass water).  However, any decision to delay prescribed medication should be fully discussed with the medical staff and there is no evidence that this occurred.

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8.   Findings

8.1  Nursing Assessment

(i) The nursing assessment was completed by a D grade staff nurse on behalf of the named nurse.  Mr P was not accompanied to the Hospital by a relative.  His next of kin was Mrs P, his wife the complainant.

(ii)  The nursing assessment refers to the fact that Mr P had experienced shortness of breath for a couple of days prior to admission.  Mr P had been taking Beechams powders believing the cause of his shortness of breath to be viral.   It was recognised that  Mr P may need assistance with mobility, hygiene and dressing.  His appetite was recorded as being good but it is noted that Mr P had not eaten since the previous Thursday.  He said that he had had gastroenteritis and loose stools and had been taking milk of magnesia, which he reported settled his stomach.

(iii) Mr P’s pulse was 89 bpm [beats per minute] and his blood pressure is recorded as 99/68 mm HG [millimetres of mercury]. The nursing assessment records that Mr P said that his skin was intact and that Mr P did not appear to be anxious.  The assessment sheet does not require the nurse to actively establish the patient’s  understanding of their condition.

(iv)A tissue viability assessment form was completed based on the Waterlow Risk Assessment tool.  Mr P’s age is incorrectly recorded as between 65 and 74 years. The assessment categorised Mr P as a low risk of developing pressure sores.  A manual handling assessment form was completed which states that Mr P was self caring. 

(i)When interviewed, the nurses stated that the standard of documentation was ‘not good’.  The model of care adopted by the ward is based on Ropers model of care, which attempts to identify the problems the patient encounters achieving the activities of daily living.  The nurse is required to identify an objective for the patient, expressed by the Hospital as a desired outcome.  The nurse will then identify the nursing actions that will be taken to achieve the desired outcome.  The nursing assessment forms the basis on which to develop a nursing care plan.

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(ii)  The problems with the activities of daily living that nursing staff believed Mr P to have were:

1.  Hygiene and dressing

2.  Mobility

3.  Respiration

(iii)Mr P’s shortness of breath appears initially to have been related to exertion. This fact is not reflected in the identification of his ‘problems’. Consequently the nursing actions are sparse and vague and do not describe nursing interventions designed to address the patient’s ‘problems’.  Mr P’s ‘primary’ problem was the shortness of breath that he encountered on exertion, and given that Mr P had not experienced shortness of breath since admission when the care planning process was completed, an accurate evaluation of his problem was not completed.  There is no evidence that Mr P was given advice on:  

A how to minimise his episodes of shortness of breath should they occur; and

B  the action to take in the event of an occurrence of shortness of breath.

(iv) The care plan related to mobility states that: 

 “Mobility may be restricted if there is further shortness of breath”. 

(v) The nursing action described refers entirely to the prevention of pressure sores, including the use of prophylactic dressings. This is despite the fact that Mr P was assessed as a ‘low risk’ of developing pressure sores.  The recorded nursing action is inappropriate to address the identified problem of anticipated ‘mobility’ difficulties.

(vi) The care plan refers to the fact that Mr P may require assistance with hygiene and dressing.

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Conclusions

9.  Based on the findings the conclusions in the case of Mr P are as follows:

9.1  Mr P was admitted as an emergency with a recent history of shortness of breath.  The admitting doctor believed the cause to be cardiac in origin.  This fact was not known by the nursing staff on duty at the time of Mr P’s admission. This is despite the fact that Mr P was admitted directly to Ward 8A and the assessment was completed on the ward.

9.2  Blood tests taken on admission revealed that Mr P had raised cardiac enzymes which may be indicative of myocardial infarction. There is no evidence to suggest that nursing staff were aware of this fact.

9.3  The initial findings of the SHO who admitted Mr P were discussed with the consultant. The abnormal blood results on admission were recorded in the Medical record after the entry referring to the discussion with the consultant.

9.4  The SHO recorded the fact that Mr P had an ‘old’ myocardial infarction without indicating when he believed the event had taken place.  The entry appears to have been related to the process of establishing the appropriateness of administering thrombolysis.  It was thought that Mr P had suffered a myocardial infarction some days prior to admission, which would mean that the administration of thrombolysis was inappropriate. The entry did form the basis of considerable misunderstanding in the investigation of the complaint.

9.5  The SHO on admission prescribed an initial dose of Frusemide 50 mg, which was administered on the day of admission.  Mr P was reviewed by the SHO on the 24 December 1996, the day following admission, who prescribed Frusemide 40 mg, Aspirin and a trial of Lisinopril.   Frusemide and Aspirin were not administered until the following day and it is not clear whether Lisinopril was given.

9.6  A nursing assessment was completed on admission. The assessment was based upon the patient’s perception of himself prior to his illness. There was no requirement to establish the patient’s understanding of his illness and of the implications of that illness.

9.7  A nursing care plan had been developed based on the nurse’s lack of knowledge of Mr P’s medical diagnosis.

9.8  The care plan did identify that Mr P may experience difficulties with mobility should he experience shortness of breath. The nursing action described refers to the prevention of pressure sores.

9.9  A system of variance reporting had been introduced as a trial. There was no evidence that staff had been trained.  There was no formal system of audit established to ensure that the UKCC standards for documentation were achieved.

9.10  Entries in the evaluation sheet for the 24 and 25 December 1996 indicate that Mr P was experiencing breathlessness.  The care plan was not reviewed.

9.11  The staff nurses interviewed felt that the documentation was not an acceptable standard and stated that their own standards had improved, as had their knowledge of the purpose of records.

9.12  Ward 8A had established a system for processing blood reports.  It was the responsibility of the on-call medical staff to review blood results. Nursing staff did not bring abnormal results to the attention of medical staff, nor was it regarded as part of the role of the nurse caring for the patient.

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9.13  Mrs P believed that Mr P had been missing for a period of 1½ hours.  She said that she had been informed of that fact by another patient.  There is documented evidence that would support the patient’s and therefore Mrs P’s view of the time that elapsed.  This was not acknowledged by the Trust.

9.14  The reference to the mobilisation regime used on Ward 8A was inappropriate and misleading as to the level of knowledge and understanding of Mr P’s condition.

9.15  The standard of nursing care offered to Mr P during his stay on Ward 8A was inadequate, and the documentation of that care did not meet the UKCC standards on record and record keeping.

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10.  Recommendations

10.1  It is noted that the Trust has developed an integrated care pathway for the management of myocardial infarction. The Trust should be assured that full compliance with documentation is achieved and that variance reporting and recording is subject to vigorous audit.

10.2  The Trust should ensure that the standard of documentation for these patients with a diagnosis other than that of myocardial infarction meets the requirements of the UKCC guidelines for records and record keeping 1999.

10.3  Any trial in documentation should have clear parameters against which to establish success.  A trial should be introduced with a clear timescale followed by a period of evaluation.  The trial should include training for all staff concerned and careful monitoring of the impact of changes on the standard of care given to patients.

10.4  All professionals involved in the care of the patient should act in the patient’s best interests.  The nursing staff were informed of abnormal blood results for Mr P and the reports were received on the ward. It was not felt to be the responsibility of the nursing staff to bring these results to the attention of the on-call medical staff.

10.5  Following the admission of a patient to a ward, the SHO should ensure that the patient is verbally handed over to the nursing staff, including provisional diagnosis, initial treatment plan investigation and observation requirements.

10.6  Nurses acting in the best interests of the patient and their relatives should ensure that they have a full understanding of the condition of the patients in their care.  They should therefore familiarise themselves with the medical diagnosis to provide a framework to support the care planning and assessment process.

10.7  The Trust should ensure that nursing staff are familiar with the procedure for the administration of medications, and risks to patients of prescribed test doses of medication, which may present a risk to the well being of the patient, and that the patient care is planned and documented accordingly.

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Last updated: 18 October 2005