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Part II—Full Text of Selected Cases

Case no. E.215/00-01Poor care and treatment, record-keeping, communication and complaint handling

Complaint against: South Manchester University Hospitals NHS Trust (the Trust)

Complaint as put by Dr F

1. The account of the complaint provided by Dr F was that her father, Professor F, was admitted to [his local hospital] on 10 December 1997 as a result of a fall at home. The next day he was transferred to Withington Hospital (the first hospital), which is managed by the Trust, for maxillofacial surgery. The surgery was successful, but Professor F subsequently developed breathing difficulties. On 17 December he was transferred to Wythenshawe Hospital (the second hospital), where he died in the Intensive Care Unit on 26 January 1998. Professor F’s family considered that the standard of care provided post-operatively by the medical and nursing team at the first hospital was inadequate. The family also had difficulty in identifying and contacting the consultant responsible for Professor F’s care.

2. Dr F complained to the Trust on 11 February 1998. On 2 September, dissatisfied with the Trust’s reply, she requested an independent review of her complaint. The Trust’s Convener refused the request in respect of two grounds on 28 June 1999, and in respect of the remaining four grounds on 8 December.

3. The matters investigated were that:

(a) the medical and nursing team at the first hospital failed to provide proper care and treatment, and to make proper records of their management, between 11 – 17 December 1997, in that:

(i) they failed to obtain the timely and appropriate intervention of a chest physician;

(ii) oxygen was not properly administered; and

(iii) the drug regime was lax;

(b) undue difficulty was experienced by members of the family, and the family General Practitioner (GP), for example on 16 and 17 December 1997, in identifying or contacting the Consultant Physician in charge;

(c) communication between nursing and medical staff was inadequate; and

(d) the handling of the complaint by the Trust, and the Convener, was dilatory and inadequate.

Investigation

4. The statement of complaint for the investigation was issued on 2 August 2000. The Trust’s comments were obtained and relevant documents including clinical records were examined. The Ombudsman’s investigating officer took evidence from Dr F and members of her family, the family GP and Trust staff. Two professional assessors, a Consultant Physician and a Senior Nurse, were appointed to advise on the clinical issues in this case, and their reports are attached at Annexes A and B. 

Complaint (a) the medical and nursing team at the first hospital failed to provide proper care and treatment, and to make proper records of their management, between 11 – 17 December 1997:

Background

5. Several members of the family had been suffering from a stomach ‘bug’ and Professor F had experienced diarrhoea and vomiting on 10 December 1997. After this he fainted and fell forward into a glass-fronted bookcase, causing severe facial lacerations. He was taken first to his local hospital and, after being assessed there, it was decided to transfer him to the larger facility at the first hospital where he had surgery to repair his injuries in the early hours of 11 December. At 21.45 on 12 December Professor F was found to be unresponsive and a cardiac arrest call was sent out; however, by the time the team arrived he was breathing spontaneously and by midnight was noted to be much better. A review by the on-call medical team on 14 December concluded that it was unlikely that Professor F had had a heart attack on 12 December. On 17 December a respiratory consultation was requested and later that day Professor F was transferred to the high dependency unit (HDU) at the second hospital. His condition gradually deteriorated and on 25 December he was transferred to the intensive care unit (ICU) where he sadly died on 26 January 1998. 

Documentary evidence

6. In her letter of complaint to the Health Service Ombudsman dated 27 April 2000 Dr F said that the family:

‘… considered there were serious systemic failures that needed addressing and made our request [for an IR] in the hope that others might be spared a similar experience.

‘… consider that the standard of care provided by the medical team at [the first hospital] fell short of what one would reasonably expect. This is based on our own medical knowledge … our personal experience as visitors to the ward and various attempts to contact the medical team by telephone. While it is difficult to identify any one factor as being the cause of my father’s respiratory problems, there can be little doubt that a combination of factors aggravated his condition.’

7. Dr F also provided copies of notes, written or dictated by her father, whilst in the care of the first hospital, detailing his medical condition and the areas he was concerned about. These notes include:

‘For [Dr F] ring here she needs to be informed of my problems and discuss with the RMO [Responsible Medical Officer] [the first hospital] to produce plan of action.

‘Problem 1

Fluid and electrolyte problems action daily blood electrolyte IV Frusemide [a diuretic used to treat fluid retention associated with heart, liver or kidney disease] drip, oral potassium supplement. ... Catheter out tomorrow oral frusemide suggested.

‘Problem 2

Blood gases oxygen saturation without oxygen approx 82%, breathless. With [oxygen] about 93%.

‘Problem 3 lungs

Breathing shallow. Daily chest X-rays antibiotics, temp. check

‘Problem 4 general circulation

B.P. approx 4 times a day 105/65 B.P. E.C.G. daily

‘Problem 5 lack of appetite 

feel nausea on trying to eat can only take some fluids, water & tea by mouth. Plus 2x125cc cartons of “Fortisip”. Protein supplement drink

‘Problem 6 Nose.

Nasal cartilages a good job seems to have been done’

Extracts from fluid balance charts

The fluid balance charts showed entries for intake and output as follows but had not been balanced. The balances would be cumulative and so the reference in the Locum Consultant Physician’s evidence (see paragraph 18) to Professor F having passed over seven litres of urine (on 12 December) would reflect this.

11/12/97 – intake 4580 mls output 5700 mls [daily balance –1120]

12/12/97 – intake 1280 mls output 3065 mls [daily balance –1785]

13/12/97 – intake 980 mls output 2320 mls [daily balance –1340]

14/12/97 – intake 1480 mls output 1680 mls [daily balance –200]

15/12/97 – intake 1600 mls output 2600 mls [daily balance – 1000]

16/12/97 – no chart available

17/12/97 – intake 2630 mls output 1800 mls [daily balance +830]

Nursing records

8. It was noted that there was a gap in the nursing records on 12 December. An entry had been made at 06.00 hours; there then followed a blank of approximately a third of a page until the entry concerning the cardiac arrest call out at 21.45 (see paragraph 24). There are no references in the nursing notes to concerns expressed by the family and only one to Professor F himself expressing concern; there is no indication that this concern was passed on to the medical team.

‘14.12.97 19.00

‘[Professor] F has been concerned that he has been having difficulty breathing deeply enough and also that his saturations are dropping when off oxygen. He has been given reassurance to some effect.’

There is only one reference to Professor F having difficulty swallowing his medication:

‘11.12.97 13.05

‘…encouraged to take Solpadol [a painkiller] although finding it difficult to swallow…’

Trust’s response to statement of complaint

9. In her formal response to the statement of complaint, dated 21 August 2000, the Chief Executive’s comments included:

‘(i) [the medical team] failed to obtain the timely intervention of a chest physician.

‘The team caring for Professor F were alert at an early stage for the possibility of underlying problems: he was seen by an anaesthetist, a surgeon and a physician within a short time of his operation and the possibility of cardiological input was discussed.

‘Professor F was initially treated for pulmonary oedema (a form of waterlogging of the lungs) but, as this started to resolve, the team became more suspicious about other complications. This [led] to treatment for pulmonary infection with antibiotics being given from 15 December, following blood cultures. Professor F appeared on several occasions to be responding to treatment but then developed further symptoms including pyrexia [fever].

‘At a ward round on the 17th December, the maxillo-facial team were relatively pleased with his post-surgical progress but referred him to the chest team as a result of a failure to resolve his breathing difficulties.…

‘There was appropriate clinical dialogue maintained between the surgeons and the physician during Professor F’s stay at [the first hospital] and the entries in the medical records do demonstrate that he was carefully monitored.

‘(ii) Oxygen was not properly administered

‘Oxygen was prescribed post-operatively and was in progress at 0600 hours on 11th December 1997 in the recovery area. There are no direct entries in the nursing records regarding the administration of oxygen being continued up to 2100 hours on 11 December 1997 after transfer to the ward. It is therefore possible that oxygen was not given up to this timewe would accept the family’s observations as to this and have offered our apologies. There are subsequent entries in the nursing notes that record the administration of oxygen therapy. It is also noted … that Professor F did not tolerate the use of the oxygen mask on occasion.

‘With regard to the use of humidified oxygen this is not explicitly detailed in the records. We accept, however, that humidified oxygen should be given when possible as good practice. … The use of humidified oxygen should be recorded in the notes and is not. It therefore appears probable that the oxygen therapy was not humidified. We have apologised for this lapse.

‘Subsequent to the complaint … staff on the ward had been reminded of their responsibility to ensure that postoperative therapy is carried out as prescribed by the medical staff.

‘(iii) The drug regime was lax.

‘There are two occasions recorded when Professor F did not receive his oral medication … The records also show that Professor F did decline to take some of his medication: on a third occasion … it was not recorded if Professor F was given Solpadol, a painkiller.

‘As the staff considered that Professor F was generally reasonably lucid and capable of taking his oral medication it appears that they left drugs at the bedside without necessarily giving direct supervision.

‘The Trust accepts that staff should supervise patients while taking their medication … This issue was addressed with ward staff to ensure that they were reminded that patients must be supervised and that medication should not be left on the top of lockers. Where patients decline non-essential medication this should be documented …’

Interview evidence

10. Dr F said at interview that she felt the treatment her father received in the first hospital bordered on the negligent; his fluid balances were not regulated; he did not receive oxygen as prescribed after his operation; and medical and nursing notes fell below standard. Dr F said that she was concerned that her father had requested a referral to a Chest Physician on at least three occasions but this was ignored. When the Trust responded to Dr F’s complaint she felt that the response was defensive and relied upon the inadequate notes for information and was thus, itself, inadequate and sometimes inaccurate.

11. Mrs F told the investigating officer that she was concerned that the staff treated her husband too much like a professor and not enough like a patient. Professor F missed several doses of antibiotics in the first few days because sometimes the nurses brought them to him and would just leave the tablets by the bedside and he did not always take them. When the family pointed this out they were told “Well he’s a doctor, he knows how important it is to take them.” Mrs F said that she wonders if ultimately the staff ‘did him any favours’ by operating so quickly, and although she appreciates the sentiments of doing so, she wonders if he might have been able to cope better if they had waited. She and her son, Mr R F, were concerned that they were giving Professor F drinks with no apparent monitoring of fluid input and output as the staff did not ask them if they had given him any drinks. Mr R F was with his father the night he was in the local hospital and later transferred to the first hospital; in an e-mail addressed to the investigating officer, dated 23 May 2002, it was stated that during that time he observed the administration of at least four ‘bags’ of [IV] fluids. Mr R F said that as the oxygen that his father was being given was not humidified, he was ‘constantly’ drinking to relieve his dry mouth. (Note: one of the reasons given for not calling in a chest consultant sooner was that the medical staff thought the breathing problems were initially caused by fluid overload (see paragraph 14).) Professor F had written some notes (see paragraph 7) about his condition which his son e-mailed to Dr F in Australia. Professor F had asked again for a chest consultation as the staff at the first hospital had ignored his own request for one relayed via the family (see paragraph 10). 

12. The family was also concerned that despite being prescribed humidified oxygen for the immediate post-operative period, Professor F did not receive oxygen at all until about 24 hours later and then it was not humidified. The oxygen mask and the non-humidified oxygen were making Professor F uncomfortable and he often took the mask off, so was not getting the prescribed amount.

13. The Specialist Surgical Registrar (who is now working in another Trust) told the investigating officer in a telephone interview that he did the initial assessment of Professor F in the A&E department at the local hospital, which has no Maxillofacial in-patient operating beds. He conferred with the Maxillofacial Consultant and they decided to transfer Professor F to the larger ‘hub’ facilities at the first hospital so that they could operate as soon as possible. Once the Specialist Surgical Registrar had finished the emergency case he had been dealing with at the local hospital, he went to the first hospital. He and the Maxillofacial Consultant had a discussion with the on-call Anaesthetist who was concerned that the cause of Professor F’s earlier collapse had not been positively identified and wanted to wait to operate. However, the Maxillofacial Consultant and the Specialist Surgical Registrar felt that Professor F’s injuries could not wait, nor could the procedure be done under local anaesthetic. 

14. The Specialist Surgical Registrar said that the surgical team felt that the procedure had been successful and that Professor F was recovering well from his injuries. He said that as Professor F’s breathing difficulties were initially put down to fluid overload, this was a problem that most physicians or surgeons could deal with and he felt he should leave the medical team to do so. He said that while it is now not possible to say whether an earlier referral to a chest specialist would have changed the eventual outcome, it may have been helpful.

15. The Maxillofacial Consultant was in theatre when Professor F was first admitted to the local hospital and he saw him some time after his admission. It was his suggestion that Professor F be transferred to the first hospital. He told the investigating officer that he was pleased with the result of the surgery performed by his Specialist Surgical Registrar and, apart from some scarring, expected Professor F to make a full recovery. However, he was aware that there were problems with Professor F’s general condition. The Maxillofacial Consultant said that the surgical team were guided by their medical team colleagues as to what referrals were appropriate and he told the investigating officer that the medical team had taken over responsibility for Professor F’s care ‘almost immediately’.

16. The Locum Consultant Physician had worked at the first hospital from November 1997 to February 1998 and had responsibility for the intake and in-patients for 8-10 wards. The Locum Consultant Physician told the investigating officer that he thought he had seen Professor F four times but it was at least three, on 12, 15 and 17 December 1997 and possibly 16 December (Note: there are two documented visits on 12 and 15 December). He said that at first the team thought that Professor F had pulmonary oedema but an ECG (a recording of the electrical activity of the heart) did not confirm this, so the Locum Consultant Physician suspected an infection such as bronchial pneumonia. He prescribed antibiotics and oxygen but told the investigating officer that he could not recall if he requested humidified oxygen and that it was not now possible to tell this from the notes.

17. The Locum Consultant Physician said that by 17 December Professor F’s condition was not improving and he requested a chest consultation. When asked if he had considered this before, the Locum Consultant Physician said that he might have thought about it, but not strongly enough to call someone out from the second hospital. The Locum Consultant Physician said that having the chest physicians at another site was not like having a colleague ‘next door’ and that it may seem ‘a bit over the top’ to call them out for every one of the cases he may have some concerns about. The Locum Consultant Physician was not sure about the procedure at the first hospital for requesting a referral, but said that the House Officers would have known. (Note: the request is documented as having been actioned by the Senior House Officer.)

18. When asked about the monitoring of fluid balances, the Locum Consultant Physician said that he thought Professor F was catheterised and that the nurses would have been monitoring this. He said that he knew at one point he noted that Professor F had passed seven litres of fluid. He did not consider this an unusual amount of fluid to pass while being treated with diuretics for fluid overload.

19. The Specialist Registrar (who is now a Consultant in another Trust) to the Respiratory Consultant was based at the second hospital but was sometimes, as in this case, asked to see patients at the first hospital on behalf of the Consultant. She saw Professor F on 17 December and although she has not noted the time, she said she thought it was in the afternoon. The Specialist Registrar said that she felt Professor F was in critical respiratory failure and she diagnosed a possible aspiration pneumonia (where fluid is vomited or coughed into the lungs causing pneumonia to develop) or atypical pneumonia. She recommended urgent transfer to the second hospital for a series of tests and investigationsshe told the investigating officer that she regarded this as emergency treatment for someone dying of respiratory failure. When asked if she considered that an earlier referral should have been requested the Specialist Registrar said that in her opinion a referral should have been made on 12 or 13 December after the cardiac call out.

20. On the subject of the oxygen therapy the Specialist Registrar said that she did not think that whether the oxygen was humidified or not was important, but as Professor F’s notes record that his SATS (oxygen saturation in the blood) were ‘very poor’ he should definitely have been receiving oxygen. She said that if Professor F was removing the mask because the oxygen was drying his face and mouth, that should have been acted upon. Similarly, if he was missing doses of antibiotics because he did not want to swallow, this should have been addressed, possibly through intravenous administration. The Specialist Registrar said that she felt the main issue was that Professor F had been ‘left languishing’ on a surgical ward for too long before being seen by a chest physician. He was seen by a series of junior clinical staff and the Specialist Registrar thought that this was where things had started to go wrong.

21. The Consultant Respiratory Physician said that she was asked for a chest review on 17 December 1997 and asked her Specialist Registrar to see Professor F on her behalf, which she did that afternoon. The Specialist Registrar called the Consultant Respiratory Physician later that day and told her that Professor F was in serious respiratory failure. The Consultant Respiratory Physician arranged for him to be transferred to the HDU at the second hospital where she assessed him the following day and diagnosed adult respiratory disease syndrome (ARDS) with aspiration pneumonia as her differential diagnosis. The Consultant Respiratory Physician told the investigating officer that she also involved the Consultant Intensivist at this time as there is a high mortality rate of 60-70% for ARDS and she wanted his opinion at an early stage. Professor F remained in the HDU with input from the Consultant Respiratory Physician and the Consultant Intensivist; he was transferred to the ICU on 25 December.

22. The Consultant Intensivist said that he was asked by the Consultant Respiratory Physician to give a second opinion on Professor F’s condition while he was still in the HDU. He told the investigating officer that this was a difficult diagnostic problem, which he was seeing several days after its onset. The respiratory failure could have been secondary to any one of a number of causes. On the subject of the antibiotics, the Consultant Intensivist said that it was important to start these right away if an infection is suspected and that if a patient can’t or won’t take them orally, alternatives should be considered. The Consultant Intensivist said it was not possible now to say if an earlier chest consultation would have made a difference to the outcome.

23. The Sister in charge of the ward explained that this was an old style (Nightingale) ward with 32 beds of which roughly half were for Maxillofacial patients and roughly half for orthopaedic patients, but some also designated as ‘winter crisis’ beds. She said that she did not recall Professor F as she was off duty for most of his stay; however, she would have expected the nurses to stay with a patient while any prescribed drugs were taken and to record any occasions where drugs were declined. The usual system would be for drugs to be dispensed during a ‘trolley round’; one registered nurse can issue drugs other than controlled drugs (for which a second registered nurse is required for checking and countersignature). Oxygen therapy is recorded in the notes, but the Sister told the investigating officer that it is not specified as humidified oxygen; humidified oxygen would have been available but should be specified by the medical staff. 

24. On the subject of fluid balance, the Sister said that when a nurse gave a drink it would be recorded on the fluid chart and that she would expect nurses to ask the patient and/or family if the patient had had any other drinks. Any imbalance between fluid intake and output should be recorded. (Note: none of the fluid charts I have seen have this information recorded; some have no totals of intake/output and one date, 16 December, does not appear to have been charted at all.) The Sister could not explain the blanks in the nursing records on 12 December but speculated that, as there had been a death on the ward on 13 December, that patient may have been taking up staff time the previous day, causing full record-keeping on other patients to be neglected. The Sister said that she would have expected Professor F to recover as all appropriate referrals had been made; she said that she felt great sympathy for his family.

25. The Nursing Staff (two Staff Nurses and one State Enrolled Nurse) interviewed all confirmed that they would record any drinks they gave to a patient and would at the same time ask, and document, if they had had any drinks in between. One of the Staff Nurses told the investigating officer that the ward did not operate a ‘named nurse’ system, but instead had a designated nurse in charge of each end of the ward. They also confirmed that Professor F had been receiving oxygen but that it was not humidified oxygen; at the time there was no set protocol for oxygen therapy but it should have been recorded in the notes that he was receiving it. On the subject of the drug regime, all the staff interviewed said that they would normally stay to observe a patient taking prescribed drugs, but that patients could not be forced to take them. However, they all said that if drugs were declined, they knew that they should record this fact; they were all aware of the revised drug protocol, which was issued in February 2000.

26. The Director of Nursing and Quality at the time had responsibility for nursing (but not nursing staff) in the Trust, and also for the complaints department (now called the Patient Liaison Service). She confirmed that the policy for oxygen therapy was under review and the Trust was developing a nurses’ recording form for oxygen. She said that the standard procedure at the time would be to give normal oxygen unless humidified oxygen had specifically been ordered by the medical staff, and that the nursing staff could not recall a request for humidified oxygen. The Director of Nursing felt that the fluid balance charts were satisfactory; there was however, at the time of the interview, a general review of record-keeping under way in the Trust. This was in response to several issues which had been raised around this time.

27. On the subject of antibiotics, the Director of Nursing acknowledged that there had been failings identified in this area in that two occasions can be identified from the records when antibiotics were missed.

Findings (a)
(i) failure to obtain the timely and appropriate intervention of a chest physician

28. The Trust’s Chief Executive has said in her formal response to the statement of complaint that the team caring for Professor F were alert at an early stage to the possibility of complications and that Professor F was initially treated for pulmonary oedema. While this may have been a reasonable course of action initially, I am concerned that the monitoring of Professor F’s fluid balance was not well documented. The fluid charts that I have seen are incomplete. The nursing staff interviewed have said that they would normally ask patients and visitors if drinks, other than those given by staff, had been taken. However, oral evidence from the family suggests that they were giving fluids on many occasions, which were not recorded on the charts.

29. There is evidence from the family that both they and Professor F himself were concerned that no Chest Physician had been called in to give an opinion. The Specialist Registrar who eventually saw Professor F on behalf of the Consultant Respiratory Physician, has said in her evidence that, in her opinion, a referral should have been made on 12/13 December. The Ombudsman’s professional assessor, in paragraph 13 of his report at Annex A, concurs with this view. The assessor has also said in paragraph 19 of his report that, had the chest physicians been based at the first hospital, they may have been asked to see Professor F sooner, and the evidence of the Locum Consultant Physician indicates that location was a factor in the decision making process. I have been guided by the assessor in this matter. I acknowledge that more than one of the clinicians interviewed has said that, while an earlier consultation might have been advantageous, no-one has been able to say that it would have altered the tragic outcome. However, I accept the assessor’s advice that an earlier specialist opinion should have been sought. I therefore uphold this aspect of the complaint. I recommend that the Trust consider compiling a written protocol for referrals where the specialists concerned are located off-site. 

(ii) oxygen was not properly administered

30. Oxygen was prescribed post-operatively and, while Professor F was in the recovery area, it is documented that oxygen was administered. The next mention in the notes of oxygen therapy is at 21.00 hours on 11 December 1997 and the Ombudsman’s nursing assessor has said at paragraph 3 of her report at Annex B, that it is unclear as to whether the post-operative plan for oxygen therapy for up to 48 hours at 4 litres per minute was followed. While oxygen was undoubtedly administered while Professor F was a patient in the first hospital, the documentation of its administration is such that it is difficult to ascertain exactly when and how much oxygen was administered. I uphold this aspect of the complaint. However, I acknowledge that the Chief Executive, in her formal response to the statement of complaint, has agreed that where oxygen therapy is indicated, humidified oxygen should be given as a matter of good practice and I welcome that statement. I am also pleased to note that the Trust have been considering this aspect of care and were in the process of finalising a revised oxygen therapy policy at the time of this investigation. I recommend that the Trust continue to review and revise their policy on oxygen therapy and its documentation in the patient notes and ensure that all relevant staff are aware of and adhere to the policy.

(iii) the drug regime was lax

31. The Trust has acknowledged that there were occasions when the drug regime fell below the standards of the Trust’s own policy at the time. This was confirmed by the documentation and interviews with staff. I agree with the nursing assessor when she says in her report at Annex B, paragraph 12 that ‘Drug therapy is a significant factor within the clinical treatment plan and should be maintained and followed as per the prescription chart’. I am also concerned that there is evidence that the nursing staff did not demonstrate consistent adherence to the Trust’s policy with respect to witnessing the taking of oral medication by the patient. Furthermore, the medical assessor has commented that it is both important that prescribed medication be given and taken, and that any reasons for non-administration should be documented. I agree. I am concerned that no alternative form of administration of the drugs, such as intravenous administration, was considered when Professor F experienced difficulty in taking his oral medication. I uphold this aspect of the complaint. I recommend that the Trust takes steps to ensure consistent implementation of their revised drugs policy, and that this is regularly monitored and audited to confirm that acceptable standards are being maintained. I further recommend that alternative forms of drug administration are considered and documented in the notes where patients have difficulty in taking oral medication.

Complaint (b) undue difficulty was experienced by members of the family, and the GP, for example on 16 and 17 December 1997, in identifying or contacting the consultant physician in charge; and (c) communication between nursing and medical staff was inadequate

Formal response to the statement of complaint

32. In her letter of 21 August 2000, the Chief Executive stated:

‘(b) Undue difficulty was experienced by members of the family, and the GP for example on 16th and 17th December 1997, in identifying or contacting the consultant physician in charge.

‘This aspect of the complaint was investigated and although it is acknowledged that members of the family appear to have had difficulty in obtaining information from the Trust [it] is unclear as to why this was … Whatever the cause, this problem clearly added to the family’s worry and I do regret this.

‘(c) Communication between nursing and medical staff was inadequate.

‘It is not clear which aspects of communication this refers to; therefore it is difficult to comment appropriately.’

Interview evidence

33. Dr F said that there was difficulty in identifying who was responsible for managing her father’s overall care. She only managed to speak to the Specialist Surgical Registrar who, although helpful and competent, was not in overall charge of her father’s care and did not have the whole picture of his condition and treatment.

34. Mrs F said that she and her son had difficulty identifying who was in overall charge of her husband’s care.

35. The family GP said in a telephone interview with the investigating officer that she has a note in her 1997 diary that Mrs F had called her on 16 December and ‘put her in the picture’ about Professor F’s accident and that he was in hospital. She said that Mrs F had told her that the family was concerned that they were not getting information from hospital staff and Mrs F asked the GP if she could try to get some information. The GP told the investigating officer that it was quite a common thing for her to call local hospitals to find out if there was anything she could do to support the families of her patients while their relatives were in hospital. She said that she usually tried to speak to the named nurse but on this occasion has noted that she was unable to speak to anyone. She cannot recall if the person she wished to speak to was unavailable or just busy and did not return her call. She has made a note that she tried again the next day and was again unsuccessful and informed Mrs F about this. When asked if she was surprised at the outcome of Professor F’s hospital stay the GP said that she was. She said that Professor F had been her patient since she took over the previous GP’s list in 1992 but he rarely came to see her and she recalled a fit man whom she would have expected to recover from his injuries.

36. The Specialist Surgical Registrar told the Investigating Officer that he became increasingly concerned at Professor F’s deteriorating condition, and the fact that he had difficulty in identifying who, from the medical team, was responsible for his care. The Specialist Surgical Registrar said that one problem was that during the weekend (Professor F initially went into hospital on a Thursday) the on-call medical team were dealing with Professor F and on the Monday the regular team should have taken over; however, there seemed to be some confusion among the medical teams as to who should take responsibility. The Specialist Surgical Registrar said ‘we were always having to chase people up to come and see him’. He also said that there seemed to be some difficulty in getting a senior member of the medical team to review Professor F.

37. The Locum Consultant Physician said that he did not recall seeing anyone with Professor F on any of the occasions that he saw him and did not remember speaking to any of Professor F’s relatives. The Locum Consultant Physician told the investigating officer that he was not aware that the family were trying to contact him but that, as he was staying at the hospital at the time, he would have been available via his ‘bleep’ or his secretary would have passed on any messages.

38. On the subject of the overall responsibility for Professor F’s care, two of the nurses interviewed said that this lay with the Maxillofacial Consultant and one that it was with the Locum Consultant Physician.

Findings (b) and (c)

39. Various family members and the GP have told the investigating officer that they experienced difficulty in identifying and speaking to the Consultant in charge of Professor F’s care. The Trust have said that they found this aspect of the complaint difficult to respond to because they have no records of the family or the GP asking to speak with the doctor or doctors. The family have also said that they, and in particular Mr R F in the first few days, spent long periods of time in the first hospital with Professor F. Yet the Locum Consultant Physician has said in his evidence that he visited Professor F four times (Note: only two of these visits are documented) and did not see or speak to any of the family members. The two versions are difficult to reconcile but I have found that the family and the GP make compelling witnesses.

40. I also note that while the Maxillofacial Consultant has said in his evidence that the medical team took over responsibility for Professor F’s care ‘almost immediately’ (paragraph 15), there was confusion among the nursing staff as to who was in charge. The Specialist Surgical Registrar, who worked with the Maxillofacial Consultant, has said that he found difficulty in establishing who, from the medical team, was responsible for Professor F’s care and that he was concerned that no senior member of the team seemed to be attending Professor F. It is clear that communication between the surgical and medical teams and between medical and nursing staff was unsatisfactory. I uphold both aspects of the complaint. The clinical assessor has suggested that the Trust reviews its policies on cross-discipline care of patients and communication with patients and relatives; I agree. I recommend that the Trust ensures that appropriate protocols for the responsibilities undertaken by medical and surgical teams, where a patient is undergoing care and treatment from both teams, are in place, and made available to all staff. I further recommend that the Trust ensures that guidelines for suitable discussions with patients, and where appropriate, relatives, and that these discussions are properly documented, are put into place, made available to the relevant staff and regularly reviewed. The problems that the family and the GP had in identifying who was in overall charge of the care of Professor F are highlighted by the following comments from the Ombudsman’s professional assessors. The nursing assessor at paragraph 17 of her report has stated that medical records should be contemporaneous and record ‘not only clinical events and information, but any discussions held with the relatives pertaining to Professor F’s care. The documentary evidence does not support this.’ The medical assessor also felt that the records did not show any evidence of discussions with the family about Professor F’s care and treatment. It is good practice for those involved in patient care to communicate with both the patient and their loved ones. I see no evidence that this happened in Professor F’s case and I am disappointed that this was so. The Director of Nursing and Quality said at interview that there was a review of the Trust’s record-keeping policy on-going at the time. I recommend that this and future reviews take account of the shortcomings identified in this case and that the Trust monitor record-keeping standards to ensure that improvements are introduced and maintained. 

Complaint (d) the handling of the complaint by the Trust, and the Convener, was dilatory and inadequate.

National guidance

41. National guidance on the NHS complaints procedures, ‘Complaints, Listening … Acting … Improving’ (the guidance) was issued by the NHS Executive in March 1996. Paragraph 5.21 includes:

‘… Full investigation and resolution of all types of complaints should be sought within twenty working days …’

Local guidance

42. Local guidance produced by the Trust in the form of a loose leaf booklet entitled “Complaints Policy” mirrored the timescales in the national guidance, including:

‘Full response by Trust … [within] 20 working days of receipt …

‘…

‘Decision by Convener … [within] 20 working days of receipt of request [for an IR]’ 

Formal response to the statement of complaint

43. In her formal response the Trust’s Chief Executive accepted this aspect of the complaint and commented:

‘It is acknowledged that there were considerable delays in both the Local Resolution and the Independent Review process that were unacceptable. We have apologised and taken action to prevent a reoccurrence.’

Correspondence

44. Dr F first complained to the Trust on 11 February 1998 and, dissatisfied with the response, requested an IR on 2 September 1998. In June 1999 the convener refused an IR on two of the six issues raised. A meeting was held at the Trust with the Chief Executive, senior Trust staff and members of the family on 21 September 1999. A letter refusing to convene an IR panel was faxed to Dr F on 8 December, following which she wrote to the Chief Executive to express her disappointment with this refusal and also with the way her complaint had been handled.

Interview evidence

45. Dr F stated at interview that she felt the Trust had been defensive, duplicitous and did not provide information needed by the family and which the Trust had promised to them. The information about the complaints procedure generally and the IR process in particular had been poor and confusing. In particular, Dr F said that the meeting that took place at the Trust in September 1999 was thought by the family to be for the purpose of explaining why an IR had not yet taken place. It was only later that the family realised that the Trust and the Convener had regarded this meeting as a conciliation meeting and had therefore discontinued the IR process. Dr F said that she felt the reasons for the refusal of the IR were not properly explained. She also said that she felt that the independent clinical advice to the Convener was based on the inadequate records kept in the first hospital and this therefore did not produce a balanced judgment of the care that her father had received.

46. The Chief Executive said at interview that she had arrived at the Trust after Dr F had started the complaints process and at first did not have a great deal to do with complaints handling while she dealt with other problems. When she realised that there was a problem within the then Complaints Department Dr F’s complaint was already at the IR stage. The Chief Executive said that some of the delays were caused by events outside the control of the Trust, for example in obtaining the services of a Lay Chair and there was a delay in receiving the report of the independent clinical adviser (ICA). There were also logistical problems in communicating with Dr F who lives in Australia.

47. The Chief Executive also acknowledged that there was confusion over what stage the meeting held in September 1999 constituted within the process. The Chief Executive said that the Convener obviously felt this was part of the local resolution process, but that she was just keen to do what she could to assist the process and had not really considered where it fitted. The Chief Executive accepted that the complaint had not been well handled, but told the investigating officer that what was the complaints department had been reorganised, staffing had been reviewed and increased and that their procedures had also been reviewed and revised. I have seen sample documentation which supports this. The department is now known as the Patient Liaison Service (PLS).

48. The Director of Nursing and Quality said at interview that at the time Dr F made her complaint there were staffing problems within what is now called the PLS and these contributed to the delays. There were also, as the Chief Executive explained in her evidence, events outside the control of the Trust. She said that she had hoped the meeting with the family would achieve some resolution of the complaints as they had discussed all of the issues, although the issue of communication in particular was one upon which the meeting could not agree.

49. The Convener said at interview that the logistics of communicating with Dr F exacerbated the other underlying problems that she and the PLS had in dealing with this complaint. There were also many complex clinical issues involved and this was not helped with the delay caused by waiting for the ICA. The Convener said that she felt the PLS staff had done a very good job in trying to chase this report up but in her experience, this is the longest she had ever had to wait for such a report.

50. The Convener went on to say that she was quite clear in her mind that the suggestion of a meeting in September 1999 was part of the local resolution process. She acknowledged, however, that this was not made clear to the complainant. At the time of this complaint it was the usual practice of the Convener to keep her own notes of cases and her conversations with the Lay Chair etc. and then to destroy them on completion of the case. That practice has now been revised and notes are sent to the Trust for storage. The Convener said that several of the areas complained about, e.g. the drugs regime, oxygen therapy and record-keeping, had all been reviewed and the policies revised.

51. The Senior Officer PLS had been on long term sick leave for some of the time that the complaint was being progressed. This was also a time of transition within the department with new systems being piloted and while they were dealing with some staff shortages. Although some of the delays were caused by events outside the control of the Trust, the Senior Officer acknowledged that some delays occurred in the department. However, the Senior Officer went on to explain that new staff are now in place in the department; two new Conveners have been appointed; they have revised the way they deal with complaints at various stages; and a monitoring system is now in place. The Senior Officer meets on a monthly basis with the Chief Executive and the Director of Nursing to keep them informed about the progress of complaints within the department.

Findings (d)

52. In both her formal response to the statement of complaint and her oral evidence, the Chief Executive has been candid about the delays which occurred in dealing with this complaint. I welcome the Chief Executive’s honesty. Some of the delays were outside the control of the Trust and Trust staff did their best to counter these. Where delays have been identified as being the responsibility of the Trust, they have taken action to address these. I also welcome the fact that the Convener accepts that she did not make it clear to Dr F that when she suggested a meeting with the Chief Executive and members of the family, that this was reverting the complaint to local resolution. Furthermore, I am pleased to note that the Trust have reviewed their practice in regard to storing notes made while cases are going through the convening stage of the complaints process. I uphold this aspect of the complaint. I recommend that the Trust continues to monitor closely the progress of complaints and to review their complaints handling procedures on a regular basis.

Conclusions

53. I have set out my findings in paragraphs 28–31, 39–40 and 52. The Trust has asked me to conveyas I do through my reportits apologies to Dr F and her family for the shortcomings I have identified and has agreed to implement the recommendations in paragraphs 29–31, 40 and 52.

Annex A to E.215/00-01

Report by the Professional Assessor to the Health Service Ombudsman for England of the clinical judgments of medical staff involved in the complaint made against South Manchester University Hospitals NHS Trust by Dr F

Professional Assessor:  Dr U, MB. FRCP. Consultant Physician

Matters Considered

The complaint of Dr F as set out in paragraph 3 of the main body of the report.

Basis of the report

Copies of the following documents have been made available by the Ombudsman’s office: 

a. Dr F’s letter of complaint;

b. South Manchester University Hospitals NHS Trust’s responses to the complaint;

c. medical and nursing records made at both the Withington Hospital and Wythenshawe Hospital, regarding Professor F, from 11 December 1997 to 26 January 1998;

d. reports of the interviews with the Consultant Surgeon, Consultant Respiratory Physician, Consultant in ICU, junior medical staff, nursing staff, the Locum Consultant Physician and family members; and

e. a copy of a note from Professor F that he wrote to his daughter.

Medical History

Pre-operation

1. On the 11 December 1997 Professor F was seen at the Withington Hospital having been referred from Stepping Hill Hospital and admitted under the care of the Consultant in Maxillofacial Surgery. He had facial lacerations following an episode of loss of consciousness and a fall on to a glass door. During the day he had experienced diarrhoea and vomiting, as had other family members. On admission he was afebrile (not feverish) with a blood pressure of 120/80 and pulse of 60 beats per minute. He was not in respiratory distress and his Glasgow Coma scale (an assessment of his level of consciousness) was 15 out of 15. He was noted to have extensive facial lacerations with exposure of nasal bones and cartilage but with no active bleeding. No nerve damage was identified. The plan was for an examination under anaesthesia and immediate repair on the same day. Fluids had been started intravenously on 10 December 1997 at the local hospital. At 0100 on 11 December he was seen and assessed by the Anaesthetic Specialist Registrar (ASpR) prior to general anaesthesia. The ASpR noted that there had been a history of a blackout and diarrhoea and vomiting in the previous 24 hours. Professor F had had a similar episode in the ward, whilst attempting to climb out of bed. At that time he was seen by the attending Physician, who noted a decreased blood pressure of 70/40 and a slow pulse rate of 35 beats per minute. However Professor F quickly recovered, such that when the ASpR examined him, his blood pressure was normal at 120/80 with a pulse of 80 beats per minute in sinus rhythm (i.e. regular). His respiratory rate was 15 per minute with good air entry and no added sounds, but Professor F had difficulty with breathing due to the large nasal dressing. The ASpR thought that the cause of the collapse was probably secondary to dehydration and low blood pressure due to the diarrhoea and vomiting. However, he noted the abnormal ECG (which had been taken at the local hospital) and therefore could not rule out an abnormal cardiac rhythm problem. The ASpR noted Professor F was aware of the concerns regarding a possible heart problem. The ASpR was told by the surgical team that emergency surgery was required.

Operation

2. During the operation on 11 December 1997, Professor F was haemodynamically unstable (blood pressure varied from 120/80 to 104/92), with decreased oxygen saturation. Although the cause of this was uncertain, it was thought likely to be of cardiac origin. Following the operation, it was suggested that he should be given oxygen for 48 hrs and that there was a need for repeating the ECG and obtaining a cardiac enzyme reading, to confirm or refute the presence of heart muscle damage (myocardial ischaemia or infarction). Augmentin, an antibiotic, was commenced post-operatively with one dose intravenously followed by tablets to be taken orally.

Post operation

3. On 11 December 1997 (untimed) the Senior House Officer (SHO) on call was asked to review the ECGs on Professor F. The SHO thought that the ECG taken that day was in sinus rhythm (regular heartbeat) with no acute changes (suggesting altered blood supply), although there was a possibility of borderline left ventricular hypertrophy (enlargement of the ventricle often associated with previous chronic increase in blood pressure). The only previous ECG that the SHO could find was one from the local hospital and was not comparable, so that it was not possible to say if the ECG changes had been present previously. Routine measurement of Creatine Kinase (CK), a muscle enzyme, was thought not to be very reliable as Professor F had fallen. Therefore the cardiac muscle specific enzyme (CKMB) measurement, a better estimate of acute myocardial damage, was suggested. Measurement of the more specific CKMB would be more likely to indicate damage to the heart rather than damage to skeletal muscle. 

Comment:
When Professor F was admitted to the Withington Hospital under the care of the Maxillofacial Surgeon opinions of the anaesthetic department and medical on-call team were sought. From the day of admission, the medical records indicated that he was seen many times by them during his stay. He was also reviewed by the Locum Consultant Physician the day after admission and again three days later. If the Locum Consultant saw him more often than this, it is not documented in the notes. As his main problem was the facial laceration, it was reasonable that he remained under the designated care of the surgical maxillofacial team. However, during this time his care was shared with the medical team. He was also seen by several different members of the medical staff, thus it seems that the ward and surgical team did not know exactly who was looking after his medical care. This was not reasonable; for patients with medical problems on surgical wards, there should be a procedure to determine who precisely is in charge. This is usually decided by who regularly does ward rounds and the junior staff who are looking after the patient. Having said that, Professor F appeared to get an acceptable level of care from the physicians, although the communication between the teams was not good or well documented.

4. Post-operatively, the medical team concluded that there was no evidence at this stage that Professor F had had a myocardial infarction or cardiac event (from the ECGs or cardiac enzyme measurements). However as the pulse had been transiently noted to be reduced at 35 beats per minute, heart block should have been considered and a 24 hour tape (measuring the heart rate over 24 hours) should have been carried out. The diarrhoea was noted to have improved. Although Professor F was still nauseated, no change in treatment was instigated. It might have been reasonable to consider giving him antiemetics. At 16.00 on 11 December, Professor F was seen by the Specialist Surgical Registrar and at that time the skin segment on his upper lip was looking black and discoloured, and the Specialist Surgical Registrar noted that there had been doubt about its viability at the time of surgery. The skin segment was to be left in place with nasal packs for 72 hours and continuation of antibiotics. 

Comment:
This was probably reasonable, but if there had been any doubt about the viability of the skin, this should have been discussed with the Maxillofacial Consultant.

5. On 11 December, at 21.00, Professor F was seen by the Resident Surgical Officer (RSO). He thought that Professor F was in respiratory distress. He was found also to have abdominal tenderness and distension, and complained of a bloated feeling. Rectal examination was unremarkable. He had had 1 litre of fluids orally and 3 litres intravenously in addition to two units of Haemocel the previous day at Stepping Hill Hospital, and had passed only 330ml. of urine. Professor F had a urinary catheter inserted at 21.30 and 1500 ml. of urine was drained in one and a half hours. At 23.00 he was seen again by the SHO, although the entry was not signed. Professor F had become more unwell and the SHO noted that the RSO had seen him earlier. 

Comment:
Clearly Professor F was in respiratory distress because the abdominal distension was restricting his lung movement. He had been given a lot of fluid and was unable to pass this until the catheter was inserted. Catheritisation was a reasonable procedure, but it would have been helpful had he been seen by the medical team at this time. More attention should have been paid to his fluid balance, in terms of ensuring that he was not being given too much fluid, and that he was able to pass fluid from his bladder.

6. At an unspecified time, (chronologically in the notes between 23.00 and 01.45 the next morning) Professor F was seen by a doctor from the anaesthetic department. He was noted to have deteriorated over the course of the day with increasing shortness of breath and hypoxia (deficiency of oxygen in the tissues). At this time he had a respiratory rate of 40 per minute with an oxygen saturation between 85 and 88 % on 100 % oxygen. His heart rate was 109 beats per minute with blood pressure of 130/70 and there were bilateral crackles in his chest. The diagnosis made was that Professor F was in pulmonary oedema due either to fluid overload or cardiogenic causes. A chest X-ray showed pulmonary oedema and Professor F’s arterial blood gas readings were consistent with this diagnosis. He was made comfortable by sitting up in bed and was given Frusemide and 100% oxygen. An entry for 12 December at 13.45, although this was possibly 01.45, was not signed, but suggested a chest X-ray should be reported the next day, with an echocardiogram and review by the RMO. Oral fluid intake was also reduced. Results from the blood test taken at 09.00 on the previous day showed a sodium of 141, potassium 4.4, urea 10.9, serum creatinine of 147 and CK of 113.

Comment: 
Clearly Professor F’s increasing respiratory distress was consequent on too much fluid having been given and he accumulated fluid in his lungs, probably because he did have ischaemic heart disease. His urea and electrolytes showed mild renal dysfunction. The muscle enzyme (CK) was consistent with the previous fall.

7. An appropriate antibiotic, Augmentin, was started on the 11 December to be given orally three times a day preceded by a loading intravenous dose. On two occasions at 22.00 on the 13th and 17.00 on the 14th these are not signed as having been given by the nursing staff and there is no indication as to why this was so. 

Comment:
The reason for non-administration of any medication should be documented. It is important that prescribed medication, unless contraindicated, is given to and taken by the patient. It is unlikely that this failure to give Augmentin on the 3rd and 4th days had a significant effect on Professor F’s course as the pyrexia had subsided and when he again became pyrexial on the 15th an alternative antibiotic, intravenous Ceftriaxone, was prescribed. This is a recognised treatment regimen.

8. On 12th December, another unsigned entry showed that Professor F was reassessed at 02.15. He was found to be improving with a decrease in his respiratory distress. It was noted that the patient had a saturation of 86% on oxygen. He was catheterised and the output was noted to be 3 litres since 22.00, but only 300ml prior to that, giving an output of 3,300 with an input of 3,500. He was apyrexial with a normal blood pressure of 120/70. Professor F was advised to sit up in bed in order to decrease the effort of breathing.

9. At 03.00 he was seen by the SHO in surgery who noted that Professor F had passed 3 litres of urine, but was still tachypnoeic (rapid breathing rate) although he felt slightly better. Oxygen saturations had improved at 90 – 91% on oxygen. He had crepitations to the mid zones on examination of his chest and had jugular-venous pressure raised at +5. A further 80 milligrams of Frusemide was given intravenously and his urine output monitored. He was to be reviewed in the morning as he would probably need further intravenous diuretics and a repeat chest X-ray and ECG to assess left ventricular function were suggested.

Comment:
The fact that Professor F was feeling better was indirect confirmation that with fluid having been removed, the previous clinical signs were due to fluid overload and heart failure. However, on balance, in the absence of any abnormality indicating a heart problem, it was more likely to be due to fluid overload.

10. The Specialist Surgical Registrar saw him at 08.30 when he noted a good response to Frusemide: over 5 litres of urine had been passed. 

11. Later that morning Professor F was seen by the Locum Consultant Physician on the ward round. It was noticed that over 7 litres of urine had been passed and Professor F was feeling better. Results were awaited before deciding on further treatment. 

12. An echocardiogram performed on 12 December showed left ventricular hypertrophy with left ventricular contraction and a left pleural effusion. Later that day he was reviewed by the SHO who noticed that a chest X-ray still showed pulmonary oedema, and he was still tachypnoeic with a pulse of 120 per minute. A further 40 milligrams of intravenous Frusemide was administered and a note made for the on-call physician to review later.

13.  At 21.45 on 12 December Professor F was found to be unresponsive by the nursing staff, not making much respiratory effort. A ‘cardiac arrest call’ was put out, but by the time the team arrived Professor F was breathing spontaneously and he had 100% oxygen mask on. He was found to be tachypnoeic with a respiratory rate of 30 per minute, a heart rate of 150 per minute with widespread inspiratory crepitations (clinical signs of pulmonary oedema) in both lung fields. Blood pressure was 110/60 with an oxygen saturation of 85%. His ECG did not show any acute ischaemic changes. The plan was to give him intravenous Frusemide, 100% oxygen and a GTN infusion. He was reviewed at 24.00 and was found to be much better with an oxygen saturation of 93%. He was fully conscious and talking. As his blood pressure dropped to 87/40 on the GTN infusion, this was stopped.

Comment:
Although Professor F’s clinical management at this time was appropriate, dealing mainly with heart failure and breathlessness, it would have been reasonable to have requested a referral to a chest physician at this time. The Specialist Registrar who eventually examined Professor F, said in her oral evidence at paragraph 19 that in her opinion a referral should have been requested after this episode; I concur with this view. Use of GTN was appropriate and was also appropriately discontinued when Professor F developed hypotension.

14. On 13 December at 08.45, Professor F was reviewed by one of the medical Registrars. He was feeling better but had had a restless night. Oxygen saturation was approximately 90%, his heart rate was 90 beats per minute, he was still hypotensive with a blood pressure of 90/60. There were still bilateral basal crepitations to the mid zones indicating severe left ventricular failure and pulmonary oedema. The JVP (jugular venous pressure – which would be raised in a patient suffering heart failure) was normal at +3 centimetres and there was no peripheral oedema (suggesting no right heart failure). It was expected that as the echocardiogram had shown good left ventricular function, the pulmonary oedema should respond to diuretic treatment alone, and therefore intravenous Frusemide was continued. He was reviewed again later that day by the SHO (untimed) when intravenous Frusemide was again continued.

Comment:
Professor F was clearly in left ventricular failure, and it was reasonable to give intravenous diuretics to reduce the load on the left ventricle.

15. He was seen on 14 December when he was comfortable and apyrexial, but with a raised white cell count at 16.3 and it was noted that blood cultures were advised.

Comment:
This was a reasonable suggestion, as bacteria (infection) can easily grow in the waterlogged lungs present in pulmonary oedema.

16. Professor F was assessed on 15 December by a member of the surgical team who suggested a review by the physicians with a view to changing the Frusemide from IV to oral. He was seen later that day by an unidentified doctor who found that his oxygen saturation had decreased without the oxygen and that his blood pressure was 95/55.

17. At 17.30 hours on 15 December Professor F was seen by the Locum Consultant Physician. He was febrile with a raised white blood cell count and more shadowing on his chest X-ray, indicating a chest infection. The Locum Consultant Physician diagnosed bronchial pneumonia. Blood cultures were taken and treatment started with intravenous antibiotic, Ceftriaxone. Professor F was seen on two further occasions: at 19.50 when he was found to be doing well and again later, at an unspecified time. His antibiotics were continued. He was seen by the Specialist Surgical Registrar and found to be comfortable. Alternate sutures were removed, the remainder to be removed the following day. A review by the RMO was requested.

18. When he was reviewed on 17 December, he was still pyrexial; his oxygen saturation without administration of oxygen was only 60% (this was very poor). At that time he was transferred from the surgeons to the direct care of the physicians and a respiratory physician was asked to see him. The referral, made by a house officer, stated that Professor F was in respiratory distress which the team thought was likely to have been due to fluid overload, but there was concern that he had a persisting pyrexia, a raised white cell count and lung shadowing on the chest X-ray, despite having had treatment for two days with intravenous antibiotics and diuretics. His oxygen saturation was adequate with administered oxygen, but dropped to 60% breathing air.

Comment:
It was appropriate to transfer the patient to the medical team as his main problems were no longer surgical. It was also appropriate to seek the advice of the respiratory physicians.

19.  The Chest Physicians, based at the second hospital, were asked to see Professor F on the 7th day of his hospital admission. If they had been based at the Withington Hospital it is likely that they would have been asked for an opinion earlier. There is no indication in the clinical records that an earlier referral was considered.

Comment:
Professor F was prescribed oxygen. This was administered and the oxygen saturation was regularly checked. Oxygen administration is specifically mentioned in the nursing notes but not at every entry. It was also noted that Professor F would on occasions take off the oxygen mask himself. There is no indication as to whether or not the oxygen was humidified. Earlier transfer of the patient to medical care would have been appropriate and might have resulted in an earlier respiratory opinion. However, the medical team did provide advice and saw the patient regularly on the surgical ward. Therefore, in my view, earlier transfer would not have changed the clinical situation. Secondary infection is not uncommon in waterlogged lungs and was managed appropriately by the team.

20. He was seen later that day by the Specialist Registrar in respiratory medicine at the second hospital working for the Consultant Respiratory Physician. The Specialist Registrar concluded the diagnoses were (1) possible aspiration pneumonia, (2) possible atypical pneumonia, (3) critical respiratory failure, and that (4) cardiogenic pulmonary oedema was unlikely. After her visit, Professor F was transferred to the high dependency unit (HDU) at the second hospital later that day.

21. On arrival at the second hospital Professor F was seen by another Specialist Registrar in Chest Medicine who found that he was conscious and fully orientated. He was short of breath with an oxygen saturation of 97%, with a reduced blood pressure of 92/62. The repeat chest X-ray showed bilateral patchy shadowing, although less than four days previously. The treatment regimen was to continue with humidified oxygen and intravenous antibiotics. An arterial line insertion was attempted but this was unsuccessful and the procedure was abandoned.

Comment:
Oxygen administration was improving the oxygenation (the oxygen content) of the blood, but the patient still remained hypotensive, and with radiological signs of severe failure and pneumonia. The attempt to put in an arterial line was appropriate at this stage but was abandoned when difficulties arose, as Professor F was by then very sick.

22. On 18 December, Professor F was seen by the Consultant Respiratory Physician who noted that as the left ventricular function was good, the signs must be attributed to an aspiration pneumonia. Other possibilities to be considered were acute respiratory distress syndrome following gastrointestinal disturbance (i.e. the diarrhoea and vomiting) or possibly a gram-negative septicaemia (specific organism from the bowel which had spread to the blood). Professor F was seen later that day and noted to be improving albeit slowly. He was seen daily with continued slow improvement but he required oxygen and his temperature remained at 37.5 0C and there were still signs of infection in his chest.

23. On 23 December, the Consultant Intensivist saw Professor F regarding the possibility of an adult respiratory distress syndrome and whether or not to give steroid treatment. He thought that it was a difficult diagnostic problem in that the chest X-ray suggested fluid initially (secondary to cardiac overload) but with the normal echocardiogram report, it was more likely to be non-cardiogenic (not from the heart) acute lung injury, the cause for which may well have been the acute gastrointestinal infection. A three-day course of Methyl Prednisolone 150 milligrams IV per day was prescribed. The situation did not improve and following discussion with Professor F he was electively ventilated at 1500 hours on 25 December.

24. Despite ventilation, Professor F continued with a stormy fluctuating course requiring a tracheostomy on 11 January and developing pancytopenia (reduction in all the cells and platelets in the blood) on 22 January. He died in the intensive care unit on 26 January 1998.

Comment:
This procedure was to relieve fluid overload and it was reasonable. After a period of ventilation tracheostomy becomes necessary, as here. It was unfortunate he developed a pancytopenia of unknown cause.

Further Comments

25. Although the Specialist Surgical Registrar probably spoke to the relatives (daughter) on one occasion, there is no documentation in the clinical or nursing records that the medical staff spoke with the relatives to tell them about Professor F’s condition and prognosis. Even though Professor F was under the direct care of the maxillofacial surgical team the physicians were taking part in his medical management and should have been available to speak to relatives. 

26. Although the Locum Consultant Physician was mentioned on two occasions in the medical notes, the nursing staff appeared not to be aware that he was the Medical Consultant involved. It is probable that if the family had asked to speak to the Medical Consultant then he would not have been known to the ward staff; however, the junior medical staff were known and should have been available. There is no evidence of inadequate communication between the nursing and junior medical staff treating Professor F. It is unacceptable that in such a patient where his medical condition was deteriorating despite good efforts to manage the clinical problem, the staff did not inform and involve the relations. There was also inadequate communication between the medical staff at both senior and junior levels.

Comments about Anaesthetics/Surgery in the Elderly:

1. Professor F, although usually in good health, was an elderly man and therefore the risks of an apparently minor accident such as the lacerations suffered by Professor F were greater than in a younger patient. These risks seem not to have been made clear to Professor F and his relatives.

Comment: It is essential to emphasise the risks of surgery and anaesthesia to the individual patient. This may have prepared the relatives for some of the subsequent post-operative problems.

2. Emergency surgery for an elderly patient especially after a fall, where the cause of the fall is not known, presents a greater operative risk than in a younger patient.

Comment: The surgery for the lacerations was correctly regarded as an emergency requiring treatment and was carried out within 24 hours.

3. Post-operative hypoxaemia is common in the elderly due to cardio-respiratory problems. Reduced vascular stability such as that shown intra-operatively is not uncommon.

Comment: Oxygen was appropriately prescribed for 48 hrs post-operatively (whether or not humidified). (Note: although appropriately prescribed, as has been said in the main body of the report, it was not consistently administered.)

4. The suggestion that some of Professor F’s problems might be due to aspiration was made on 18 December.

Comment: This was not an unreasonable suggestion as silent aspiration without coughing can occur due to small amounts of fluid and food being regurgitated and aspirated (breathed) into the lungs due to reduction in laryngeal sensitivity in the older patient.

Conclusion

27. In general the medical care was of a standard which would be reasonably expected. However, his fluid balance was not carefully monitored initially. Although oxygen was administered there is no documentation as to whether or not this was humidified, as would be normal practice. There was laxity in the administration of his antibiotic treatment in that there is no specific record as to why there was delay in commencing antibiotics which may have contributed to the infection becoming more pronounced. The communication between surgical and medical staff at senior and junior level was inadequate and with no documentation of involvement or of any information passed to the relatives. Effective communication with the relatives would be normal good practice in relation to treatment and prognosis in such a sick patient. In addition, the delay in involving the respiratory physician and transfer to the HDU was not appropriate, although it is unlikely to have prevented the final unfortunate outcome. There is also a need to identify which medical team is managing the care of a patient when the patient is still under the direct care of a surgical team. 

Recommendations:

1. It is advisable for oxygen to be humidified, and it is suggested that the Trust review its procedures to ensure that this is the case and that all staff are trained in this process.

2. It is suggested that the Trust review their guidance for joint care of patients, particularly a patient with a medical problem who is admitted to a surgical ward.

3. It is suggested that the Trust review their guidelines for ensuring that staff speak appropriately to the patient where possible, and to the appropriate relatives, bearing in mind the issue of confidentiality.

Annex B to E.215/00-01

Report by the Professional Assessor to the Health Service Ombudsman for England of the clinical judgments of nursing staff involved in the complaint made against South Manchester University Hospitals NHS Trust by Dr F

Professional Assessor: Ms V, MEd. RN RM ADM HTD PGCEA Cert. MHPS.

1. The report is prepared after extensive reading of the clinical records, documents received from the Ombudsman’s Office and interviews held with nursing staff on 8 November 2000.

2. My report is concerned with the matters subject to investigation

a) The medical and nursing team at the first hospital failed to give proper care and treatment, and to make proper records of their management between 11-17 December 1997, in that:

i) …

ii) oxygen was not properly administered; and

iii) the drug regime was lax.

b) Undue difficulty was experienced by members of the family, and the GP, for example on 16 and 17 December 1997, in identifying or contacting the Consultant Physician in charge;

c) Communication between nursing and medical staff was inadequate;

a)(ii) Oxygen was not properly administered

3.   The post-operative plan was for Professor F to receive oxygen therapy for up to forty-eight hours at 4 litres per minute. From examination of the observation chart and nursing documentation it is unclear as to whether this treatment regime was followed.

4. Oxygen therapy was certainly administered from the night of 12 December 1997. The oxygen therapy continued on and off after the specified 48 hours and was a significant component of his clinical management.

5. The oxygen was administered via a face mask and this is documented in the nursing care plan. Oxygen saturation levels were recorded on a regular basis and were satisfactory during the immediate post-operative period. Professor F was on occasions unable to tolerate the mask and as a consequence, his oxygen saturation levels decreased but soon recovered on re-commencement of therapy

Comment:
6. The use of humidified oxygen was not prescribed in the treatment plan or clinical records. Good practice dictates that oxygen therapy should be humidified before delivery to the patient in order to prevent drying of the mucous membranes of the mouth, throat and respiratory tract.

7. From the interviews held with the nursing staff it was confirmed that there was not a Trust policy at that time with respect to oxygen therapy. The usual practice was for the Anaesthetist to document it in the post-operative record and prescribe via the drug chart.

8. There was a lack of guidance and as a result humidified oxygen was not administered to Professor F

Recommendation

9. The Trust should consider (if it has not done so already), the development and implementation of oxygen therapy guidelines across all specialities in order to inform and ensure good practice.

a)(iii) The drug regime was lax

10. The documentation completed by the nursing staff confirms that the policy and good practice with respect to drug administration was not followed.

11. On three occasions it is not recorded by nursing staff on the drug chart that drugs were administered i.e. Augmentin on 13 and 14 December 1997 and Solpadol on 13 December. In addition, Professor F refused some oral medication for four successive days. He apparently had difficulty taking this oral medication, however this was not communicated to medical staff with a view to altering the treatment regime.

Comment:
12. Drug therapy is a significant factor within the clinical treatment plan and should be maintained and followed as per the prescription chart. Nursing staff did not demonstrate a consistent understanding of Trust policy and their responsibility with respect to witnessing the taking of medication by the patient, recording of refusal and action to be taken. 

Recommendation

13. This lack of understanding needs to be addressed through further training and a review of the Trust’s policy concerning the safe administration of medicines.

b) Undue difficulty was experienced by members of the family, and the GP for example on 16 and 17 December 1997, in identifying or contacting the Consultant Physician in charge

14. Professor F, due to the nature of his condition, was being cared for by two medical teams until 17 December and a third from that time following his referral to the specialist respiratory team.

15. It is unclear as to what extent this was a problem – this is not to say that difficulty was not experienced by Professor F’s relatives. The potential for confusion as to who to contact could have been a possibility due to the number of teams involved certainly around 17 December.

16. It is standard practice for nursing staff to make arrangements for family/relatives to speak to medical staff if such a request is made, or need dictates. Nursing staff also need to be clear about who to contact in such instance.

Comment:
17.  The medical and nursing documentation make little reference to communication with the relatives. By their very nature the records are and should be contemporaneous and record not only clinical events and information, but any discussions held with the relatives pertaining to Professor F’s care. The documentary evidence does not support this. 

Recommendation

18. I suggest that through a review of its record-keeping policy the Trust reinforces the need to document interviews/discussions/requests by relatives/carers.

c) Communication between nursing and medical staff was inadequate

19. This can present as a potential difficulty especially when more than one medical team is involved. Nevertheless communication can be ensured through good documentation and record-keeping. Whilst the nursing documentation does not readily suggest communication with the medical staff, cross referencing of the medical nursing notes indicates that some degree of communication took place. When the nurses were concerned about Professor F’s condition, they contacted the medical staff.

Comment:
20. There are, however, examples of breakdown in communication e.g. the missed medication; the breaks in administration of oxygen therapy and the failure to draw medical attention to the imbalance between fluid input and output.

Short report of this investigation

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Last updated: 7 September 2005