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Selected Investigations Completed April - September 1997 > Part I, Case no. E.1144/95-96
Matters considered: Unreasonable delay in A and E department - nursing care and communication
Complaint against: Kingston Hospital NHS Trust, Surrey
Summary of case
In December 1995 a woman was taken to the A and E department at Kingston Hospital. She was admitted to a ward and she died shortly afterwards. In January 1996 the woman's daughter complained to the Trust that there was an unreasonable delay before her mother was seen in the A and E department, that her mother was left on a trolley for over five hours with inadequate bed linen, that nurses were too busy to give oxygen to her mother and the daughter was asked to operate the oxygen equipment herself, and that she was not told that her mother's condition had deteriorated. The chief executive wrote to her in February 1996 but she remained dissatisfied.
Findings
I found that the department was unusually busy that day and there was a delay in the woman being assessed by a doctor. I was unable to make a finding on whether there was sufficient bedlinen available while the woman was on the trolley as there was irreconcilable conflicting evidence. The nursing staff told me that they would not have told a relative to administer oxygen and in the absence of any other evidence I could not make a finding on that part of the complaint either. I upheld the complaint about communication in that an opportunity to provide more up to date information to the woman's daughter before her mother's deterioration might have been missed by ward staff. I was very concerned that staff in the ward to which the patient was transferred appeared unaware of, and did not act on, the A and E doctor's instructions that the patient should be put on a cardiac monitor and have her blood pressure measured every 15 minutes.
Remedy
The Trust apologised and agreed to review the arrangements for communication between staff in the A and E department and ward staff, and between staff at shift changes. They also agreed to take any other action necessary to ensure that very sick patients transferred to wards from the A and E department received the necessary treatment and monitoring directed by doctors.
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