Home > Publications > Selected Cases > Selected Investigations Completed AprilSeptember 2003 > Case No. E.1974/00-01
Complaint against Mid Cheshire Hospitals NHS Trust
Summary of Case
Mrs B who had been suffering with a slow progressive form of leukaemia for around 12 to 14 years was admitted to the Leighton Hospital in May 2000 with pneumonia and septicaemia. Mrs A’s treatment included Heparin (a drug which reduces the ability of blood to clot), which was initially prescribed intravenously (IV) but was changed by the first consultant to subcutaneous (under the skin). Mrs B remained in hospital for eleven days until the senior house officer (SHO) decided that Mrs B should be discharged home. Mrs B still showed signs of a fever on her discharge and was sent home without any anti-inflammatory medication for the swelling around her knees. Mrs B returned home and was looked after by her son, Mr B. Five days after her discharge he noticed a deterioration in his mother’s condition and Mrs B was re-admitted to the hospital. Mrs B was diagnosed as having septicaemia and IV antibiotic treatment was commenced. On the day after her re-admission Mrs B suffered a seizure and an hour later had a cardiac arrest and died. During the early hours Mrs B’s daughter, Mrs A rang the hospital several times. She said that on each occasion she was told that her mother was comfortable and at 7.30 am she again phoned and was told that her mother did not have long to live. Mrs B was very upset that she had been told that her mother was comfortable and because of this she did not attend the hospital immediately. Mrs A complained to the Trust in June and a local resolution meeting was held on 27 October. Mrs A remained dissatisfied and requested an Independent Review (IR). The convener sought advice from the Trust’s director of nursing and clinical director and in December the convener refused Mrs A’s IR request.
Findings
The Ombudsman’s assessors advised that it is unclear why Heparin was administered intravenously as it is normal practice to give Heparin subcutaneously. However, the assessors explained that this type of administration would not have had any effect on the course of Mrs B’s illness. This aspect of the complaint was upheld. The Ombudsman found that Mrs B’s discharge was premature and that the discharge plan was inadequate. That aspect of the complaint was also upheld. In respect of Mrs B’s second admission the assessors reviewed Mrs B’s medical records and whilst the records make reference to IV antibiotics being administered, they could not find a record of IV antibiotics being administered until half an hour before Mrs B’s death. Consequently there was a delay with the administration of the antibiotics and this aspect of the complaint was upheld. The assessors have stated that the word ‘comfortable’ is often used to describe a patient in Mrs B’s condition and it would have been impossible for Trust staff to anticipate her subsequent cardiac arrest. Also, Mr B was present with his mother and it would have been reasonable for nurses to assume that he could have contacted his sister and updated her on Mrs B’s condition. This aspect of the complaint was not upheld. Although the format of the convener’s clinical and nursing advice was of some concern. It was concluded that the nursing director and a consultant physician at the Trust were both independent and appropriate persons under the Directions to NHS Trusts to have offered advice on this complaint. This final aspect of the complaint was not upheld.
Remedy
The Ombudsman recommended that the Trust’s current Heparin protocol be properly followed and that the Trust ensures that nursing staff are reminded of their duty to question what appears to them to be inappropriate prescriptions. The Ombudsman has recommended that Trust staff are reminded of the Trust’s discharge policy and the importance of care planning as a tool of communication and that the Trust’s discharge liaison officer be made aware of this complaint. The Ombudsman has recommended that all medical and nursing staff are reminded of their responsibility for accurate and timely administration and recording of medicines, that repeated or significant telephone conversations with a relative or carer are recorded and that the Trust encourages its conveners to obtain clinical and nursing advice in a written format. The Trust agreed to the recommendations and apologised to Mrs A for the shortcomings identified.
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