Home > Publications > Selected CasesHealth > Selected Investigations Completed AprilJuly 2002 > Part II, Case no. E.2390/00-01
Complaint against Leeds Community and Mental Health Services Teaching NHS Trust (the Trust)
Complaint as put by Mr X
1. The account of the complaint provided by Mr X was that on 27 October 1998 he accompanied his wife, Mrs X, at an outpatient appointment with her consultant psychiatrist (the Consultant). Mr X told the Consultant that Mrs X had felt very unwell the previous night and was drinking large quantities of water. The Consultant arranged for her to be admitted later that day to [a] ward (the ward) at [a] Hospital (the hospital). The hospital is managed by the Trust.
2. Once on the ward Mrs X continued to be very thirsty. The next day Mr X visited and found that she had no water. On asking a nurse about that she told him that Mrs X was not to have any, but the nurse did not know why. Mrs X was pacing up and down the ward in an agitated state.
3. The following morning (29 October) Mr X visited his wife and found her alone in the dining room, slumped across a table and shaking. He called a nurse and they helped Mrs X back to her bed. Believing that she might have had a stroke Mr X asked for a doctor to be called. Two and a half hours later Mr X had to leave the hospital. Before leaving, as no doctor had arrived, he asked once more that a doctor should attend his wife. After arriving home Mr X contacted the ward to repeat his request. The next morning the hospital telephoned to inform him that Mrs X had died during the night.
4. In June 1999, after an Inquest, the Coroner gave the cause of death as septicaemia (due to a urinary tract infection), myxoid degeneration of the mitral valve (degeneration by abnormal proteins on the mitral valve of the heart), and myocardial fibrosis (scarring of the heart muscle). In October 1999 Mr X complained to the Trust about his wife’s care and treatment in the ward. He was dissatisfied with the Trust’s replies to his complaint and an Independent Review Panel was established. The Panel’s report, which was issued on 14 December 2000, contained many criticisms of the care Mrs X received and recorded the Consultant’s doubts as to whether a doctor examined her in response to Mr X’s requests on 29 October 1998. The Panel made a series of recommendations and recorded the Trust’s acceptance that some aspects of the way they had handled the complaint were inexcusable. Mr X considered that the Panel’s report failed to answer important questions concerning his wife’s care and that the Trust had not provided adequate information about the measures they had taken to prevent a recurrence of the failings identified by the Panel.
5. The matter subject to investigation was that the care and treatment provided to Mrs X between 27 and 30 October were inadequate.
Investigation
6. The statement of complaint for the investigation was issued on 9 May 2001. The Trust’s comments were obtained and relevant documents including clinical records were examined. The Ombudsman’s Investigating Officer took evidence from Mr X and Trust staff. Two Consultants in Old Age Psychiatry and a Director of Nursing were appointed to advise on the clinical issues in this case and their report is produced in its entirety in paragraph 39 below. I have not included in this report every detail investigated, but I am satisfied that no matter of significance has been overlooked.
Mr X’s evidence
7. At interview Mr X said that the outpatient appointment with the Consultant on 27 October 1998 had been a routine monthly appointment. He told the Consultant how much water his wife had been drinking and that she was in physical pain from her shoulder. He believed that he might also have said that she had vomited the previous evening. The Consultant decided that his wife needed to be admitted and Mr X understood the admission to be for mental health care rather than there being any physical cause. When Mr X and his daughter visited Mrs X that evening she was pacing up and down and did not have any water by her bed. Her daughter obtained some for her. The next day when Mr X visited there was again no water by his wife’s bed. On enquiring he was told by a nurse that she was not to have any water but the nurse could not explain why and did not offer to find out.
8. On 29 October Mr X went again to the hospital and found his wife in the dining room, slumped in a chair, shaking and obviously very weak and poorly. He was convinced that she might have suffered a stroke and told a nurse about his concerns. Mr X asked the nurse to help him take his wife back to her bed. He said that he asked the nurse at least four times to call a doctor to see his wife. He said that the nurse assured him that she would call one but none came while he was there. He had to return home at around 2.00pm to attend to an urgent task. He was no longer sure whether he had telephoned the ward on his return home to repeat the request for his wife to be seen by a doctor.
9. In his letter of complaint to the Ombudsman Mr X stated that he was dissatisfied with the report of the Independent Review Panel because he still did not have sufficient information about the actual care and treatment which had been provided for his wife and because the panel had failed to come to any conclusions based on the evidence that had been heard. He had not been advised about the implementation of the action plan which the Trust had drawn up as the result of his complaint. Mr X and his daughter said at interview that they hoped that as a result of this investigation all concerned would learn from what had happened and never repeat the same mistakes.
The Trust’s response to the statement of complaint
10. In his formal response to the statement of complaint the chief executive of the Trust wrote:
‘The Trust accepts that aspects of the care and treatment provided to Mrs X between 27 and 30 October 1998 were inadequate. System failures have been identified with respect to communications (oral and written, notably record keeping), nursing observations, and physical assessment of patients. The Trust considers Mr X’s complaint about the care and treatment of his wife between 27 and 30 October 1998 is justified.
‘With respect to the point that, “The [Independent Review] Panel’s report …contained many criticisms of the care Mrs X received and recorded the Consultant’s doubts as to whether a doctor examined her in response to Mr X’s requests on 29 October 1998” the Trust accepts the Panel’s findings.
‘…
‘An action plan was formulated to address the recommendations of the Independent Review Panel and thus prevent a recurrence of the failings identified.
‘There was a time lapse between the Independent Review Panel report being issued and the action plan being documented. A copy of the action plan was sent to Mr X on 29 March 2001. However it will be noted that most of the actions identified on the plan were already completed or in hand at this time. Moreover action had been taken prior to the Independent Review Panel [held on 17 November 2000]. Reference was made to this in the letter [and enclosure] dated 21 August 2000 from the Director of Nursing and Quality to the X family … The Independent Review Panel did not specify that evidence of action plan implementation should subsequently be sent to Mr X and so it has not been. [This information has since been supplied to Mr X at the Ombudsman’s request.] Mr X’s complaint that the Trust has not provided adequate information about the measures taken to prevent a recurrence of the failings identified by the panel is not justified.
‘The Trust regrets the identified failings in the care and treatment of Mrs X and the distress suffered by Mr X and his family over Mrs X’s death and over their subsequent communications with the Trust. The issues raised by the complaint have been subject to systems analysis, lessons have been learnt and measures put in place to prevent recurrence.’
Documentary evidence
11. From the medical notes:
27.10 98 Mrs X was admitted to the ward from the Consultant’s outpatient clinic. The medical notes state:
‘…becoming increasingly agitated, not sleeping, drinking +++water and tea, talking about dying, kept husband awake all night, ordering him to bring water …well since August. Multiple admissions over the past 2 years. No obvious precipitating factors for this episode.
…
Speaks English with a strong accent…states that she is ‘too poorly’ to talk, needs a drink …pacing up and down the room during the interview
… complains of being very thirsty, … has been drinking pints at home, complaining of sore joints.
… known to wander off ward’
28.10.98 ‘in view of blood +++ in urine … commenced on [antibiotic]. Not drinking so much today, try to maintain her on a lower fluid intake.’
29.10.98 Consultant’s ward round. ‘Lithium level had been low previously, repeat bloods especially lithium level next week. Continually pacing, not sleeping, not drinking as much as previously, not eating.’ The lithium dose was increased.
…
30.10.98 ‘09.15 hrs. Certified dead.’
12. The nursing notes state:
27.10.98 ‘… On level 2 observations … MSU [mid stream urine sample] sent …discussed with [doctor] [antibiotic] prescribed … phone call from [the consultant] … thinks excess fluid intake will be due to mental state, urgent bloods taken at 4.45pm. Very small amount of diet taken but did come and sit in the dining room, otherwise has been mostly pacing up and down, calm on approach. Told me she was very shy, prefers the quiet and doesn’t like a lot of people around her’.
28.10.98 ‘6.45am. Nursed on level 2 observations. Milka has remained awake throughout the night. She has spent from commencement of shift until the time of report pacing along the corridor. Accepted prescribed medication at 22.00, reluctant to communicate, …, refused offers of fluid and food throughout the night.’
‘Mrs X has been pacing up and down the corridor all morning. …’
‘Mrs X has continued to pace the corridors all p.m. Looks very flushed. When I approached her and asked if she felt OK she responded with a hostile stareno verbal communication. … Duty Dr. contacted.’
29.10.98 Night report ‘Mrs X appeared aggressive on approach, unwilling to communicate, hostile in body language, seen by [duty doctor] who prescribed 1mg haloperidol [a tranquilliser] administered at 21.00, [Mrs X] has spent the night sat on her bed from 0100 hrs. Prior to this pacing the corridor, observed to be awake throughout the night.’
am. ‘Mrs X has been much more settled this amappears physically exhausted – Mrs X has had small amount of fluids (sips) and is presently sleeping on her bed. Obs to be done. From the ward roundto increase lithium … to continue haloperidol …’
pm. ‘Mrs X has been asleep all pm.’
30.10.98 Night report ‘In bed at start of shiftsettled but reluctant to take meds [medication] but did eventually. Slept throughout the night.’
8.45am. ‘Found in bed by [Staff Nurse]. Unresponsive to touch … Mrs X pronounced dead at 9.15am …’
Evidence of Trust staff
Nursing evidence
13. In her written statement to the Independent Review Panel held on 17 November 2000 the Associate Nurse who had been looking after Mrs X on the morning of 29 October said that:
‘…after lunch Mr X asked me to help him walk with Mrs X to her room. I remember that she looked tired and I supported one of her arms as we walked. Mr X and I chatted in general conversation, he then asked if his wife had had a stroke. I said that I did not think so as there was no facial or one-sided weakness and her mobility did not seem impaired although she did seem exhausted. On reaching her bed, Mrs X lay down and appeared to fall asleep. I think I recall Mr X asking for her to be seen by a doctor. It was [the consultant’s ward] round that afternoon and I assumed that, as Mrs X had recently been admitted to [the] Ward and had been seen by the duty doctor the previous night, she would have been seen by her Consultant. I think I informed Mr X of this but …due to the passage of time, I am uncertain…’
14. The nurse allocated to care for Mrs X between 1.00pm and 9.00pm on 29 October 1998 (the Allocated Nurse) explained at interview that she had worked for the Trust as a bank nurse since 1990. Usually a patient who was new to the ward and still under the first 72 hour assessment would not be allocated to a bank nurse as the continuity of care by the primary and associate nurses was considered important until the patient’s care plan had been drawn up. At the beginning of her shift the Allocated Nurse found the nurse who had been caring for Mrs X on the previous shift and asked her to introduce her to Mrs X as she had not met her before. Mrs X was lying on top of her bed and asleep. The Allocated Nurse was told that she had been pacing up and down since her admission and that this was the first time she had slept properly. She was asked to do her routine temperature, pulse and respiration (TPR) and blood pressure (BP) observations when she awoke. She did not recall being told of Mr X’s concerns or of his request for a doctor to see his wife.
15. The Allocated Nurse remembered checking on Mrs X during the afternoon. She covered her with a blanket and put a jug of water and a glass on her bedside table. She was not aware of any fluid intake restrictions being in place and if they had been would have expected to see a fluid balance chart. The patient in the bed opposite had visitors during the afternoon and the Allocated Nurse remembered drawing the curtains round Mrs X’s bed to give her privacy and to create the right environment to enable her to sleep. She checked her every 20 minutes. It was not hospital policy for a record of this level of observation to be kept. Mrs X appeared to be sleeping peacefully. The Allocated Nurse knew that she had a urinary tract infection but that this was a common occurrence and nothing untoward. Some wards she had worked on would have been monitoring fluid balance in this circumstance but others would not. She did not disturb Mrs X to do the routine observations.
16. The Allocated Nurse said that if a patient’s primary nurse was on duty she would attend the ward round. Otherwise another permanent member of staff would attend. As a bank nurse the Allocated Nurse did not attend the ward round during the afternoon of 29 October and was not asked by the nurse who did for any up to date information about Mrs X. If she had been asked she could only have said that she was sleeping peacefully as she was not aware of Mr X’s concerns and his request for a doctor to see her. Her own assessment was that there was no indication that a doctor was required.
17. The Allocated Nurse remembered very clearly asking a colleague if she should wake Mrs X to offer her some refreshment at teatime. She was told to leave her as she needed to sleep. She was not aware of Mrs X getting out of bed during the afternoon and it was her impression that she had been asleep during her entire shift and this is what she wrote in the nursing record. She was not allocated to care for Mrs X the following morning and was very shocked and surprised to hear of her death.
18. In a witness statement prepared on 8 June 1999 for the Coroner’s inquest held on 25 June 1999 the nurse caring for Mrs X on the night of 29/30 October 1998, the Night Nurse, stated that:
‘When I returned to duty for [the] nightshift on 29 October…Mrs X was already sat on her bed, she took her tablets from [another nurse], and a drink and then settled down to go to sleep on her bed, wearing her day clothes … this was apparently the first time she had had a proper sleep so we simply kept her covered with a blanket to keep her warm and comfortable. She was a level 2 observation patient and was checked regularly, but other than moving the blanket to keep her warm, as it was moving whenever she turned in her sleep, we had no reason to disturb her …’
19. At interview the Director of Nursing said that the ward to which Mrs X had been admitted (the ward) had 24 beds for elderly people suffering from psychological rather than physical disease. On most occasions in the past Mrs X had been admitted to a similar ward in another hospital (the second hospital) but in October 1998 that ward was closed.
20. The Director of Nursing said that Mrs X’s clinical presentation was consistent with that on previous admissions to the second hospital. She was very thirsty, agitated and not sleeping. The usual pattern was for Mrs X to pace up and down for the first couple of days and nights following admission, and then to sleep for many hours. On this occasion she also had a urinary tract infection. This had been diagnosed and appropriately treated and there was no sign of any other physical illnesses such as a stroke. The Director of Nursing believed that this was why it was not felt necessary to call a doctor to see her before the ward round on the 29 October. He considered that Mrs X was not seen by the Consultant at the ward round because her presentation was not giving cause for concern and she was getting much needed sleep. She was on normal once a day observations of TPR and BP. She was on level 2 observations and so she should have been observed every 15 minutes. Forms were not completed but the daily rota for performing these observations was written on a white board and erased each day. On previous admissions Mrs X had wandered from her ward and staff and her husband were concerned about a recurrence of this behaviour. Therefore, the purpose of the observations was to check that she was still on the ward and not to monitor her physical health. However, the Director of Nursing believed that during the day it would have been noticed if she had been particularly hot or if her breathing pattern had changed. According to the nurses she was given her antibiotic at 10.00pm on 29 October and then settled down for the night. The Director of Nursing said that the closeness of the observation would reduce at bedtime.
21. The Director of Nursing explained that the ward had a primary/associate/key nurse system in operation. He said that there was a wealth of evidence to demonstrate that verbal handover to all nurses on the shift about all the patients was not effective as specific concerns and issues tended to be missed. All methods of handover had been found to be problematic but the most effective was found to be a combination of brief verbal contact between the relevant primary or associate nurses together with good documentation. He said that he was not aware of any difficulties in the nursing handover system with regard to Mrs X. The Director of Nursing explained that the primary nurse had the responsibility for the care plan and there should have been a primary nurse/primary nurse cover system with associate nurse back up. The primary nurse had a co-ordinating role to ensure that someone was overseeing the patient’s interests when she was not on duty, that the relatives were seen and that things happened according to the care plan and other requirements. The nurse in charge and the associate nurse should also have been familiar with the patient’s needs. The Director of Nursing said that the system should be operated flexibly as available resources had to be allocated to the patient in the most efficient way. He thought that the nurses were aware of Mrs X’s situation but acknowledged that the lack of basic TPR observations meant that her physical condition was not being measured. In his opinion the nursing staff had a good awareness of physical illness in mentally ill patients. On the evidence, he thought that Mrs X’s physical care had perhaps not been sufficiently taken into account. This he felt to be a team rather than a nursing shortcoming. He said that now a patient’s physical care was more explicitly addressed.
22. The Director of Nursing said that, during the early shift on 29 October 1998, the ward manager was acting as shift co-ordinator with an associate (Grade D) nurse and two nursing auxiliaries. There were 26 patients on the ward. He said that this was a normal staffing ratio and mix. The ward manager would have been involved in practical tasks with the patients and would thus have been in the patient area and available for consultation by the nurse or to speak with Mr X.
23. It was the role of the primary nurse to represent the patient at ward rounds. The nurse in charge of the shift would be present whilst all the patients were discussed and each discussion would be documented. In the notes concerning Mrs X taken at the ward round on 29 October no mention was made of her physical condition. The Director of Nursing did not think this unreasonable in the circumstances and believed that it indicated that there was nothing untoward about her condition. He noted that a doctor had not been summoned to see her at any time that afternoon or evening which he felt indicated that she was not giving any cause for concern.
24. According to the records of previous admissions Mrs X often drank copious amounts of water when her mental condition was deteriorating. It was recognised that as she was taking lithium she would have a dry mouth and would need fluids but left to her own devices she would drink as much as 2 litres at once. On admission her electrolyte levels were unbalanced and therefore it was appropriate to restrict her fluid intake to 1.5-2 litres a day. The Director of Nursing said that this should have been explained to her family and a fluid balance chart should have been used. He also recognised that she was in need of fluids due to her urinary infection. The Director of Nursing said TPR and BP were not regularly observed on patients on that ward but he would have expected such records to be kept for Mrs X due to her urinary infection, her lithium level and the electrolyte changes.
25. The Director of Nursing acknowledged shortcomings in the documentation of the 72 hour assessment and the care plan drawn up for Mrs X and said that modification of the forms and more staff training had led to improvement in the process. He said that searches had been made for the medication charts, which were missing, but to no avail. However pharmacy records showed that the antibiotic had been supplied to the ward for Mrs X and the supply on the ward indicated that several days tablets had been taken. Staff also remembered giving her the antibiotic.
26. The Director of Nursing managed the Trust’s clinical audit support team. The standard of record keeping and the use of fluid balance charts had been audited recently and an audit of the process of transfer of patients from under-65 to over- 65 services was being considered.
27. The Director of Nursing said that he expected the nurses to call a doctor immediately when the condition of a patient caused concern and if the ward doctor was not on site other medical staff were available.
28. The Director of Nursing recognised that shortcomings in the care that Mrs X received had been identified and improvements in practice made as a result. However he did not believe that these improvements, concerning mainly recording procedures, would have affected the way in which Mrs X’s physical symptoms were treated. He did not believe that there were any signs that she was developing septicaemia. Mrs X was not complaining of feeling ill nor was she distressed. She was asleep. The duty doctor had been called the night before when the nurses did consider that she needed medical attention. The Director of Nursing agreed that there was no evidence that Mr X’s concerns were passed on to those taking part in the ward round. He confirmed that if Mrs X’s associate nurse that afternoon had been a bank nurse she would not have been expected to attend the ward round. The Director of Nursing would have expected the nurse who did attend the meeting to have asked the associate nurse for an up-to-date appraisal of Mrs X’s condition since admission.
Medical evidence
29. The Senior House Officer (the SHO) was working as the SHO to a psychiatrist unconnected with Mrs X’s care. However when he was on call he would see the Consultant’s patients. The nursing notes stated that the SHO had been called to the ward at about 9.00pm on 28 October as Mrs X was agitated, pacing about and aggressive in her manner. He is reported as having prescribed haloperidol. At interview the SHO had no recollection of this and said that if had seen her he would have recorded his visit and the results of his examination in the medical notes. There was no entry in the medical notes. The medication chart was missing and so the signature on the prescription could not now be checked. The SHO said that the nurse could have phoned the duty SHO who might have prescribed over the phone and then completed the drug chart when visiting the ward the next day.
30. The SHO said that he was called to the ward at 8.45am on 30 October to certify Mrs X’s death. This he did at 9.15am. He had no memory of ever having seen her before. He made a clinical finding of rigor mortis and assumed that she had died in her sleep.
31. The Consultant Psychiatrist (the Consultant) had first met Mrs X whilst she was an in-patient in June 1998. Her consultant was being changed because she was approaching her 65th birthday. The Consultant said that there was an informal handover from the previous consultant. She had never seen a written care programme for Mrs X. Since taking over her care the Consultant had seen her twice in outpatients. During this time, whilst being treated at another hospital for a physical illness, Mrs X’s lithium dose had been reduced. The Consultant had wanted to increase it as she considered that it was below a therapeutic level but Mr X would not agree to this.
32. When the Consultant saw Mrs X in the outpatient clinic on 27 October she was very unwell. She was extremely agitated to the point of not being able to sit and wait for her appointment and not allowing herself to be examined. She complained of abdominal pain and was saying that she thought she was going to die. The Consultant asked Mr X if this was how his wife presented when she was psychiatrically ill and Mr X said it was. Discussion with his wife was very difficult as her use of English deteriorated when she was ill. The Consultant was very concerned about her and thought that she needed admission to hospital. She decided that her level of agitation was such that a medical ward would not be appropriate for her and admitted her to the ward. Mrs X was usually admitted to a ward at the second hospital but this ward was closed at the time. The Consultant contacted her SHO and asked her to do blood tests. However when the Consultant phoned later for the results she was told that Mr X had refused to allow her SHO to take blood from his wife as he did not consider her to be a ‘proper doctor’. The Consultant then requested urgent blood tests. The results of the tests did not indicate to the Consultant that there was anything seriously wrong with Mrs X. At the time of admission the Consultant was in possession of the full medical notes which she had had since Mrs X had been transferred to her care. She had been through them and done a summary.
33. The Consultant said that it was her normal practice to see all her patients at the weekly ward round. She would therefore have seen Mrs X unless there was a good reason not to. She assumed that on this occasion she had been told that Mrs X was asleep and, in view of her recent history of lack of sleep, she had decided not to disturb her. The Consultant said that, now, she always recorded in the notes whether a patient had been seen or not and, if not, the reason. She said that she would have expected the nurse to whom Mr X voiced his concerns to have asked the SHO to see either him or his wife and for those concerns to have been relayed to her in the ward round. Her SHO had been on the ward all day and had therefore been available. The Consultant noted the discrepancy in the nursing notes at the time of the ward round on 29 October stating that Mrs X was ‘asleep all pm’ and the account of the ward round in the medical notes stating that she was ‘continually pacing, not sleeping’.
34. The Consultant accepted that there was no evidence that TPR and BP observations had been done but she said that it was not standard practice on psychiatric wards. Baseline observations were always done on admission but not routinely during the 72 hour assessment. In this case there was no record of them having been done at all. She would have expected the nurses to have done them if they had written in the notes that they intended to do so. She had not asked for them herself as she did not consider it necessary for charts to be completed for patients with urinary tract infections. The Consultant said that as soon as she was told of Mrs X’s death she went to get the notes and the medication chart. The latter was not in its place and had never been found. The Consultant said that she always looked at the medication charts during ward rounds to check on patient compliance. Accordingly Mrs X must have been taking all her prescribed medication on 29 October.
35. The Consultant said that on admission Mrs X had been drinking excessively. She acknowledged that Mr X had been concerned that her fluids were being restricted and that there seemed to be some confusion amongst the nurses about this. She had asked for the fluids to be monitored as there had been a problem with Mrs X’s sodium levels in the past. The Consultant had not asked for a chart to be kept or for the fluids to be restricted. The Consultant accepted that the raised calcium level revealed in the blood taken on the 27 October could have been causing Mrs X’s thirst but this result would not have been known for some days. In the meantime the Consultant understood that Mrs X had stopped drinking so excessively.
36. The Consultant said that all staff on the ward were aware of the issues surrounding the care of patients with a psychiatric illness who were also physically ill. Deaths were not an unusual occurrence on the ward. The Consultant was very surprised to hear of Mrs X’s death and her first thought was that she had taken an overdose. She had treated many patients for a urinary tract infection but none of them had died before. She did not discover the cause of death until after the inquest but had learned from the pathology department that it was not as the result of an overdose. She had always been sure clinically that Mrs X had not been lithium toxic (having an excess of lithium). She would not have been alarmed at the length of time Mrs X had been asleep as she would have thought this natural after such a period of hyperactivity.
37. The Consultant said that she had reflected at length on what more could have been done for Mrs X but a urinary tract infection had been correctly diagnosed and the Consultant had never known such a patient to die. As a result she now monitored patients with urinary tract infections. Her colleagues however regarded her as over-cautious. She said that the team on the ward had always worked well together and communication was usually good.
The report of the Ombudsman’s professional assessors
(i) In considering this case we have read Mrs X’s medical and nursing notes and documentation supplied by the Trust and Mrs X’s family in relation to the complaint. We were present at the interviews held with Trust staff and have also read a transcript of the inquest conducted by HMCoroner.
Clinical Issues
The Initial Assessment
(ii) Medical
The initial assessment of Mrs X by medical staff was of a satisfactory standard. It not only included psychiatric and physical assessment but also investigations which were performed and acted upon.
(iii) Nursing
Although Mrs X was on an admission assessment ward for elderly people with a functional (psychological) disorder, a 72 hour nursing assessment was not completed. The areas of the assessment which were attempted were poorly recorded and indicated a superficial assessment process. No base-line nursing observations were undertaken and the recording did not comply with guidance on UKCC[1] (now the NMC[2]) Standards of Record Keeping. There were inconsistencies in the nursing records which were not clarified, for example one entry read ‘Mrs X was pleased to be sharing a dormitory with other ladies, said she didn’t want to be on her own,’ and another the same day ‘told me she is very shy, prefers the quiet and doesn’t like a lot of people around her.’ There is no evidence that a care plan was drawn up after the admission process.
The Ward Round
(iv) The Consultant Psychiatrist cannot remember why she did not see the patient and on this we can only speculate. Not seeing the patient was not inappropriate, providing that the Consultant was satisfied with the clinical account of her state, since she had only recently seen her and admitted her. However, if she had seen her she might have detected some developing serious physical ill health if this had been evident at that time. She might then have been able to initiate some useful intervention but with the information now available this cannot be known. Neither Mrs X’s Primary nor her Associate Nurse were present at the ward round and her Allocated Nurse on duty at the time had not been asked about her current condition.
Communication and record-keeping
(v) Insufficient notice was taken of the comments of the family and the request by Mr X for his wife to be seen by a doctor. Mr X has stated that he expressed significant concern that his wife had suffered a further stroke to a particular trained nurse. The records suggest that his concerns were not communicated either to the Senior House Officer who was on the ward through that morning or to the ward round in the afternoon. The note of the ward round records Mrs X as being restless and agitated whereas the nursing notes of that afternoon record that she had been sleeping for some time. It is evident that no concern about Mrs X’s physical health was conveyed to the ward round. The failure to record formally Mr X’s concerns regarding the possibility of a stroke is unacceptable within an admission assessment process, particularly when the nursing staff did not know the patient or the carer. Good communication is crucial to the development and implementation of nursing care. (vi) Record keeping is a fundamental part of nursing practice. It is a tool of professional practice and one that helps the care process. The quality of practitioner record keeping is a reflection of the standard of professional practice. Good record keeping is also a mark of the skilled and safe practitioner. In the case of Mrs X the nursing notes demonstrate that the record keeping fell below the standard expected by the UKCC.
(vii) We found confusion which we could not resolve about which doctor, if any, had seen Mrs X on the night of 28 October or whether there was merely discussion in general terms between the on call doctor and the nurse in charge. At any rate, there is no record either of such discussion in the medical notes or of any medical examination, if this took place. The medication chart has been lost and it is impossible therefore to determine from that further evidence of what might have taken place or of who prescribed the medication at that time. These matters seem to sum up the significant confusion about recording important observations, important clinical activity and about documenting observations made, and the preservation of such documents.
(viii) Further evidence of the poor standard of communication and record keeping was the attempt at fluid restriction for Mrs X. It was very unclear as to how this was being achieved and no attempt appeared to have been made to ascertain the effectiveness of this fluid restriction. There remains the possibility that the excessive thirst demonstrated by Mrs X was caused by her raised serum calcium level, which is documented in her file, rather than by her psychiatric condition.
(ix) An important factor in the poor communication between the family and care staff is the fact that the team of the Consultant Psychiatrist was the third psychiatric team to care for Mrs X in a relatively short period of time. Mr X and his family do not appear to have felt that they were in a position directly to contact the medical staff but could only go via the nursing team.
Clinical observations
(x) There is a general lack of evidence of a number of clinical observations being undertaken by the nursing staff. On the balance of evidence presented it appears that no temperature, pulse, respiration and blood pressure (TPR and BP) measurements were taken by the nursing staff at any time including the key 24-36 hour period prior to Mrs X’s death. It seems evident that the nursing team were intending to implement such measurements but in practice no single nurse seems to have done so. No documents are available which record any such measurements. This appears to have occurred as a result of a failure of team working with repeated evidence of poor communication between members of the nursing team and the medical staff.
(xi) Clinical observations are an essential part of any admission assessment process. The Director of Nursing confirmed that base-line temperature, pulse, respiratory or blood pressures were not routinely carried out on this ward. He suggested that the evidence of the value of doing these routinely was not very substantive. We challenge this assumption and regard it as symptomatic of the failure to provide a holistic approach to care on this ward. The rationale for carrying out basic observations during the assessment period is that they provide a baseline from which to assess or plan care. On the evening of 27 October 1998 Mrs X was prescribed Trimethoprim for a suspected urinary tract infection but observations of TPR and fluid balance were not instigated. If these recordings had been taken the signs/symptoms of septicaemia, pyrexia (a high temperature) and fall in blood pressure, shaking and looking generally unwell may have triggered a medical response. It is absolutely essential that nurses understand and operate a system of recording vital signs, particularly in admission wards, to effectively identify problems and to communicate these to the medical staff that they may more accurately identify an appropriate course of treatment or response. The failure to record the observations of TPR and BP was a significant one.
Observation policy
(xii) Mrs X was placed on level 2 observations as she had a history of absconding on previous admissions to hospital. Level 2 observation indicated a check every 15 minutes. There was no evidence in the medical or nursing notes of any process of recording the observations and this is indicative of poor ward supervision. There should have been a rota of staff conducting the observations and there should have been a process or policy whereby individuals were made responsible for recording their actions. Decisions made by medical or nursing staff to either maintain the level of supervision or to make amendments during the period of Mrs X’s admission were not recorded.
Primary Nursing
(xiii) The system of primary nursing in operation on the ward was not consistent with good practice. For the primary care system to work effectively there must be positive commitment demonstrated by evidence of its complete integration into the communication and recording system in operation, the staff rota and the care plans. Although there was an attempt to identify a primary team with a primary nurse the off duty was still arranged in a traditional way. There is no evidence that Mrs X’s primary or associate nurses made themselves and their roles known to Mr X.
Culture of the ward
(xiv) Assessment wards should be able to isolate physical from psychological needs and those focused on elderly people with mental illness must also take into account the process of ageing. At the outpatient clinic the consultant had considered Mrs X sufficiently physically ill to be admitted to a medical ward. It was Mrs X’s degree of agitation which mitigated against this and led to her admission to the ward. In our opinion the on-going assessment and observation of her physical condition then fell below a reasonable standard. The care programme approach was not identified as being part of Mrs X’s care process and indicates the possibility that such an approach was not intrinsic to the culture of this ward. The Ward Manager had only recently been appointed and had the task of formulating both role and care standards and of developing documentation whilst also running the ward on a daily basis. The way that the ward was being run therefore suggests a lack of clinical leadership at a higher level.
Conclusions
(xv) The Consultant Psychiatrist appears to have conducted ward rounds in line with acceptable practice. The performance of nursing observations, their recording and the retention of the documentation appears not to have been in line with acceptable practice. We are particularly concerned about the loss of the medication charts.
(xvi) The indications are that concerns about the state of the patient and, particularly, concerns expressed by a family member about the state of the patient, were not conveyed to the medical team and, in particular, to the ward round. This is not in line with acceptable team practice. There are doubts about the quality of the communication with the concerned family member by the nursing team in relation to what response would occur following the expression of these concerns. Acceptable practice would be that proper feedback occurs and that both this and the concerns articulated are properly documented in nursing records, as well as communicated to the rest of the team, and in particular, to the medical team.
(xvii) If there was an opportunity to intervene in the serious illness which led to Mrs X’s death it seems that this opportunity could only have arisen from TPR and BP measurements having been taken and then acted upon appropriately if abnormalities had been revealed. It is possible for an elderly person to be overwhelmed by septicaemia and succumb quickly without much clinical evidence of the serious state of ill health prior to rapid demise. However, this is unusual in a ‘young’ elderly person and it seems unlikely that no abnormalities would have been detectable through TPR and BP measurements had these been undertaken. If such abnormalities had been detected the nursing staff would have been expected to communicate these findings to the appropriate clinical team.
(xviii) We conclude, therefore, that the in-patient care of the late Mrs X was not managed in a satisfactory or adequate manner with regard to the following matters:-
· The failure to perform basic observations of TPR and BP by nursing staff was not acceptable.
· Communication between nursing staff and other members of the team was not of an acceptable standard.
· The management of the communication between Mr X and the care team was not of an acceptable standard.
(xix) It is not possible to say whether any single action by any single individual would have made a difference to the outcome in this case. However, it is evident that if there was any opportunity to make a difference to the outcome such an opportunity could not have been taken when TPR and BP records were not made. These are the failings of a team of people rather than one individual.
Recommendations
(xx) It is important that training should ensure that nursing staff are appropriately aware of the physical health problems which are likely to arise in older people with both functional and organic mental health problems.
It is important that all such patients admitted to assessment wards should have base line TPR and BP measures made and recorded as a matter of routine.
It is essential that monitoring of these parameters be undertaken consistently, and that such monitoring is recorded appropriately, when significant physical ill health problems arise.
It is important that nursing staff are clear that serious concerns raised by family members should be reported to the medical team and particularly to the ward round.
It is important that nursing staff, when told of serious concerns by family members, report back to such family members that they will be addressing these.
Patients and their families should take part in a genuine dialogue with care staff when change is proposed with regard to the provision of care by a different and unfamiliar team. This should take place with the agreement of the patient and family. It should also involve written documentation in terms of hand-over of details of the care plan.
Findings
39. Mr X and his family were understandably shocked and distressed by Mrs X’s sudden and unexpected death and felt that the care and treatment provided for her had failed to meet her needs. The Trust have accepted that aspects of the care and treatment provided to Mrs X between 27 and 30 October 1998 were inadequate. Failures in the systems of communication, particularly record keeping, in nursing observations and the assessment of patients’ physical needs were identified and an action plan was formulated to inform future practice. I note with approval that the Trust have taken steps to implement the recommendations of the independent review panel held on 17 November 2000 and that evidence of these has now been supplied to Mr X.
40. In their report the Ombudsman’s professional assessors highlighted a number of shortcomings in the care and treatment provided for Mrs X. They especially emphasised the failure to perform basic observations of TPR and BP, and failures in communication between staff members, and with Mr X. As the assessors point out, the absence of the recording of TPR and BP measurements precluded the opportunity to monitor and intervene in the development of her serious illness: if abnormalities had been revealed appropriate action could have been taken. It is also evident, for example, that record keeping and the secure retention of essential documentation did not meet acceptable standards. I recommend that the Trust review the recommendations made by the assessors in paragraph 38 (xx) of this report and implement those which have not already been put into effect. In particular, the requirement that the measurement of baseline TPR and BP should be incorporated into the Trust’s care planning policy in cases such as this during the initial assessment period and when significant physical ill health problems arise. I uphold this complaint.
Conclusions
41. I have set out my findings in paragraphs 3940. The Trust has asked me to convey – as I do through my report – its apologies to Mr X for the shortcomings I have identified and has agreed to implement the recommendation in paragraph 40.
[1] The United Kingdom Central Council for Nursing, Midwifery and Health VisitingNurses’ professional body
[2] The Nursing and Midwifery Council
Short report of this investigation
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