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Selected Investigations Completed April - September 1997 > Part II, Case no. E.1478/95-96

Part II - Full Texts of Selected Investigations

Case No. E.1478/95-96 - Unreasonable delay in Accident & Emergency (A and E) Department, nursing care and communication

Matters considered: Unreasonable delay in A and E department - nursing care and communication

Complaint against: Kingston Hospital NHS Trust, Surrey

Complaint as put by the complainant

1. The account of the complaint provided by the complainant was that on 27 December 1995 her 87 year old mother was taken by ambulance to the accident and emergency (A and E) department of Kingston Hospital. She arrived at about 2.30 pm, in pain and extremely distressed, and was placed on a trolley without a blanket or pillows. She was then left in a corridor without treatment for over five hours. When the complainant asked for oxygen to help her mother's breathing, a nurse told her she would have to use the oxygen equipment herself as they did not have time to assist her. A doctor examined the complainant's mother at about 7.15 pm and said she would be given medication and admitted to a ward. By 8.00 pm the complainant's mother had still received no medication, and was semi-conscious. She was rushed to a resuscitation room. About 30 minutes later a doctor told the complainant that her mother had been given medication and advised her to go home and telephone the hospital later. When the complainant telephoned from home at about 9.30 pm a ward sister told her that her mother was asleep. About 20 minutes later she received another telephone call from the hospital to say that her mother had died.

2. On 9 January 1996 the complainant complained, through her MP, to the Trust, which manage the hospital, about her mother's care. The chief executive wrote to her on 14 February, but the complainant was dissatisfied with his reply.

3. The complaints investigated were that:

1. there was unreasonable delay before the complainant's mother was assessed and treated by staff in the A and E department;

2. she was left on a trolley for over five hours and there was inadequate bed linen;

3. nurses were too busy to give oxygen and asked the complainant to operate the oxygen equipment herself; and

4. the complainant was not told that her mother's condition had deteriorated.

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Investigation

4. The statement of complaint for the investigation was issued on 9 May 1996. The complainant was told that her complaint could in part concern actions taken in the exercise of clinical judgment which, at the time of the events complained of, were outside the Commissioner's statutory jurisdiction. The Commissioner's staff took evidence from the complainant, her brother and from the Trust's staff.

Medical records

5. According to the complainant's mother's clinical records she arrived in the A and E department by ambulance at 2.36 pm. Records provided by the London Ambulance Service say the ambulance arrived at 2.29 pm. She was assessed by a nurse (triaged) 'on arrival' but part of the record where her priority should have been recorded had not been completed. An electrocardiogram (ECG) - a recording of the electrical activity of the heart - was made at 3.02 pm. An x-ray was taken at 5.19 pm and the report on that was received at 5.43 pm. A locum medical registrar (the registrar) examined her at 6.10 pm and ordered various tests. He decided to admit her and to treat her with antibiotics, 28 per cent oxygen and an intravenous dextrose infusion. One antibiotic was to be given intravenously at 8.00 am, 2.00 pm and 10.00 pm and another orally at 8.00 am, noon, 6.00 pm and 10.00 pm. The registrar asked for the patient's oxygen saturation level to be monitored. She had a second ECG at 7.46 pm. The registrar saw her again at 8.00 pm when her condition had deteriorated. Increased oxygen was given. Her pulse and blood pressure were monitored every five or ten minutes between 7.55 pm and 8.30 pm. She had a third ECG at 8.12 pm. As a result of the ECG, at 8.30 pm the registrar prescribed intravenous digoxin (a drug to regulate the heart beat) to be given over four hours. He requested a cardiac monitor to be used when she moved to a ward and for her blood pressure to be measured every 15 minutes. She was transferred to the ward at about 9.00 pm. The digoxin infusion began at 8.30 pm and ran for 30 minutes (with a dextrose solution) before it was recorded in the ward that the cannula (through which the drug passed into her arm) had become dislodged at 9.00 pm. There is no record that the cannula was replaced. The drug records show that she was given the intravenous antibiotic at 10.00 pm. A fluid balance chart appears to show that she was given digoxin at 10.00 pm (but see paragraph 36). The complainant's mother was certified dead at 10.45 pm.

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Complaint (a) Unreasonable delay in assessment and treatment in A and E Evidence of the complainant and her brother.

6. The complainant said that her mother was referred to the hospital by a general practitioner (GP). The complainant and her brother also attended. They all arrived at about 2.00 pm. About 15 minutes later a nurse took the complainant's mother's blood pressure and an ECG was done within half an hour. The complainant was told that her mother was tenth on the list to see a doctor so she would have to wait about five hours. Her condition gradually deteriorated. The complainant agreed that it might have been at 6.10 pm that a doctor saw her mother (as recorded) but she thought it had been about three quarters of an hour later. The doctor apologised for the delay. He examined the complainant's mother, looked at her x-ray and said she had 'a touch of pleurisy and very slight pneumonia'. He said they would find a bed for her and admit her for a couple of days. He put a needle in the back of her hand ready for a drip and said he was prescribing medication immediately but she did not receive any, despite the complainant's reminders to staff. Just before 8.00 pm her mother's condition deteriorated further and the complainant insisted that a nurse should see her. A male nurse arrived about three minutes later and did an ECG. He took her mother in to the resuscitation room and said that her heart rate had changed. The complainant thought her mother might have survived if she had been treated sooner and been given the medication prescribed by the doctor when he first saw her. The complainant's brother gave similar evidence in a separate interview with the Commissioner's staff.

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The Patient's Charter

7. Guidance issued by the Department of Health (the DoH) in 1992 defines a charter standard as 'a level of service which the patient can expect to be delivered other than in exceptional cases'. At the time the Patient's Charter standard for waiting time for initial assessment in A and E departments said 'you will be seen immediately and your need for treatment assessed'. In another investigation conducted by the Commissioner the DoH explained that they did not intend the Patient's Charter standard on initial assessment to apply to patients referred by a GP, as such patients had already been assessed.

8. Guidance issued by the DoH in 1992 said that from 1 April 1992 district health authorities should have set clear local charter standards, which should be publicised, for waiting times in A and E departments after the need for treatment has been assessed. The Patient's Charter said that from April 1995 patients who are admitted to hospital through an A and E department could 'expect to be given a bed as soon as possible, and certainly within three to four hours'.

Trust policy

9. All patients (whether or not they have been referred by a GP) are assessed on arrival in the A and E department and their priority level is determined. The Trust's categories are:

1. Patients with life threatening conditions - to be seen by a doctor immediately on arrival.

2. Patients with serious conditions which have a potential to become a threat to life and limb - the next patient to be seen by a doctor.

3. All patients with serious or painful conditions that do not threaten life or limb should be seen within half to three quarters of an hour.

4. Minor injuries - should be seen within two hours.

The Trust's Charter Standards are that all patients should be assessed by the triage nurse within five minutes of arrival. Between October and December 1995, 93 per cent of patients were seen within five minutes. No patient should remain in the A and E department for more than four hours after the decision to admit has been taken. Between October and December 1995, 88 per cent of patients left the A and E department within four hours of the decision to admit.

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Correspondence

10. In a letter to the complainant dated 14 February (but sent on 27 February) the chief executive said that he agreed that in this case the wait had been too long and apologised for that. He explained:

'I am afraid on the day in question we received a large number of emergency patients in the Accident and Emergency Department which made it very difficult for the medical teams to see the patients as quickly as we or you would have liked. This was further exacerbated by the absence of one of the team of doctors on that day and our inability to recruit a locum doctor to cover. We have in the past couple of weeks received approval to increase the number of doctors on the Medical Unit by five to allow for more rapid assessment of patients.'

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Staff evidence

12. The senior nurse then in charge of the organisation and staffing of the A and E department, who was on holiday on 27 December (the senior nurse), said that when a patient was referred by a GP the nurses would tell the medical team when the patient arrived. The doctor would look through the records for the waiting patients and decide who to see next.

13. The sister in charge of the late shift in A and E (the sister) said that 27 December was a very busy day and there were already patients waiting on trolleys in the corridor when she arrived at 1.00 pm. Relatives of some of the patients who were waiting became quite rude and aggressive about the delays - one nurse was in tears as a result. The sister checked the complainant's mother's blood pressure, temperature, pulse and oxygen saturation level and filled in her casualty card as soon as the complainant's mother arrived in the A and E department. She accepted that she should have recorded a priority level on the casualty card and could not remember why she had not done so. From the details on the card she thought the complainant's mother would have been category two or three. The doctor would have been told that the complainant's mother was in the A and E department and she would have given her an idea of when the doctor might see her. She thought she told her she was eighth on the list which meant she would have to wait at least a few hours. Most of her medication had been written on the prescription sheet to start the next day. If the antibiotics had been needed straight away the doctor would have asked for that and they would have been given in the A and E department. As it was, they were prescribed for regular times and would be given in the ward.

14. A staff nurse on duty in the A and E department (the first staff nurse) said that the nurse responsible for the complainant's mother's care when medication was prescribed would have been responsible for giving it to her.

15. A nursing care assistant who was on duty in the A and E department (the first NCA) said that if drugs were prescribed they would have to be administered by one of the qualified nurses. If the drugs were not available in the A and E department they would get them from one of the wards.

16. The registrar said that when he came on duty at 5.00 pm the A and E department was already very busy. There were about ten people waiting to see him and another five expected. He saw the patients in the order of their arrival. If a patient's condition deteriorated the nurses would ask him to see that person out of chronological order. He asked the sister who was the next patient to see. When he saw the complainant's mother she looked pale but he did not think she was about to die. She had pneumonia so she needed oxygen, antibiotics for her chest and intravenous fluids. He decided to admit her. After he had taken blood samples and written up the drugs chart it was the nurses' responsibility to arrange her admission and medication. When he saw the complainant's mother again she was in the resuscitation area. She was cold and clammy and had a fast, irregular heart rhythm. He gave her digoxin to slow her heart rate. She had not been given any of the medication he had prescribed earlier but that would not have made any difference to her condition then, because the drugs would have taken 12 to 24 hours to take effect. It was not unusual for medication to be delayed in a very busy A and E department.

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Findings (a)

17. The Trust have accepted that the woman's wait in the A and E department was too long. From the Trust's records she waited about three and a half hours before seeing a doctor for the first time, and then just under three hours before going to a ward. The woman's assessed priority was not recorded: but that assessment is a matter of clinical judgment which was outside the Commissioner's jurisdiction at that time. The department was unusually busy that day. More junior doctors have since been appointed. Antibiotics were prescribed when the complainant's mother was seen at 6.10 pm but were not due to be given until 10.00 pm. One antibiotic was apparently given then but the second, oral, dose was not given at all. Whether the registrar should have prescribed an initial dose to be given before 10.00 pm is a matter for clinical judgment and again is not a matter for the Commissioner. As the registrar pointed out, the antibiotics would have taken several hours to take effect: accordingly any delay in giving them to the complainant's mother would not have affected the outcome. After an earlier report - E.296/94-95 - the Trust agreed in June 1995 to take steps to make sure that they met their own targets for waiting times for patients to be seen by a doctor. It is disappointing to find that similar problems were still being encountered in December 1995. I uphold the complaint insofar as there was a delay in the complainant's mother's assessment by a doctor.

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Complaint (b)
Left on a trolley with inadequate bed linen

Evidence of the complainant and her brother

18. The complainant said that when her mother arrived in the A and E department she was wearing only a bed jacket and nightdress. She was put on a trolley in the corridor. The complainant asked the nurses for a blanket but they said they were too busy to look for one and if there were none around then there were none available. She put her coat over her mother and eventually found a blanket which she had to shake outside before she could use it. Her mother did not have a pillow and there was no sheet on the plastic coated trolley. The complainant asked the sister if she could make her mother more comfortable but the sister said there was nothing more she could do. At this stage her mother was cold and uncomfortable and was becoming upset. At about 5.00 pm a 'helper' moved the complainant's mother into a cubicle. She was distressed and uncomfortable and she kept slipping down the trolley. She was still on the trolley when she was taken to the resuscitation room at about 8.00 pm. The complainant's brother gave similar evidence.

Correspondence

19. In his letter to the complainant the chief executive said:

'We are taking further steps to relieve the pressures on the Accident and Emergency Department, not only by increasing the numbers of junior doctors but also by introducing an additional twenty beds and eventually an observation/assessment ward in the department. We hope, by these measures to improve standards of care in the department with more rapid access to beds.'

'It is unfortunate and regrettable that .... there may have been insufficient bed linen to cope with the number of patients in the department.'

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Staff evidence

21. The sister said that trolleys rather than beds were used in the A and E department because the nurses could get closer to the patients to conduct tests. There were always plenty of blankets in the A and E department and staff could get more if necessary. All trolleys had a plastic coating but had a sheet on top. The complainant's mother's trolley had a sheet on top of a 'spenco' mattress [Note: such mattresses are used for patients at risk of pressure sores. Those used by the Trust were about six inches thick and looked like a large green quilt.] The sister said that the sheet might have slipped. There were never sufficient pillows in the A and E department because they were often taken to the wards and not returned.

22. A nursing care assistant in the A and E department (the second NCA) said that when an ambulance was expected a trolley was made up with a sheet, a strip of blue paper on top of that, a blanket and sometimes a gown. A patient would not be put on a trolley without a blanket and the ambulance crew would not leave a patient without a blanket.

23. The first staff nurse said that she had never known a patient to be left without a blanket in the A and E department and there were spenco mattresses available.

24. Another staff nurse on duty in the A and E department (the second staff nurse) said that trolleys were used because they were compact and easy to move. [Note: The Commissioner's staff noticed that anything larger than a trolley would be difficult to manoeuvre in the A and E department, especially when there were other trolleys in the corridors.] There were spenco mattresses available but on busy days there might not be enough for all the patients who needed them. On very busy days the A and E department tended to run low on blankets but it was always possible to get more and she would not expect anyone to go without a blanket.

25. The first NCA said that when he first saw the complainant's mother at about 7.30 pm she was on a trolley which had a spenco mattress and he rearranged her linen and bedding to make her more comfortable.

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Findings (b)

26. There is no dispute that the complainant's mother spent several hours on a trolley in the A and E department. Although the Trust acknowledged that there might have been insufficient bedlinen, the evidence Trust staff gave on that point conflicted to a significant extent with the complainant's evidence. The complainant said that the trolley had only a plastic coating and that she was left to find a blanket herself, despite asking a nurse for one. Staff said that trolleys had sheets (though pillows were in short supply), no one would be left without a blanket and some staff recollected that there was a pressure relief mattress on the woman's trolley. The pressure relief mattresses used by the A and E department are very obvious and it seems unlikely that the complainant could have failed to notice one. I am unable to reconcile the conflicts of evidence on those points and therefore I cannot make a finding on this aspect of the complaint.

Complaint (c)
The complainant was told to administer oxygen Evidence of the complainant and her brother

27. The complainant said that at about 5.15 pm, after they had moved into a cubicle, her mother's condition began to deteriorate and she said she could not breathe. The complainant went to reception and asked for oxygen but a nurse (whom she was unable to identify further and whom the Commissioner's staff could not trace) said that the oxygen fitment was on the wall and she should get it herself. The complainant said there was a mask attached to the fitment and dials to turn but she did not know what to do. At about 5.30 pm to 5.45 pm she asked a female 'helper' what to do and the 'helper' explained the system to her. The mask did not seem to fit properly and the complainant's mother kept pulling the mask off because she was uncomfortable so eventually the complainant turned the oxygen off. The complainant's brother gave similar evidence about the nurse but could not remember if anyone had explained how to use the system.

Correspondence

28. In his letter to the complainant the chief executive said:

'I am afraid I am unable to find out who might have said that you should use the oxygen on the wall by yourself. I am quite clear, as is the sister in charge of the Accident and Emergency Department that we would not expect a relative either to know how to use this or to be required to do so.'

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Staff evidence

29. The sister said that oxygen masks were not kept permanently in the cubicles in the A and E department. They were individually wrapped and colour coded to show which percentage of oxygen they were to be used for and a new one was used for each patient. However, if staff were busy an oxygen mask used by the previous patient might have been left. A nurse would not have told relatives to use oxygen themselves because the wrong oxygen level could be very dangerous to certain patients. (The nurses interviewed confirmed that.) She thought that the helper described by the complainant might have been an auxiliary nurse from an agency. She had not seen that nurse before or since.

30. The first NCA said that he had never known relatives to be told to give oxygen to a patient. The complainant's mother's cubicle had room for two patients and it had one fitting on the wall which took two oxygen masks. When he first saw the complainant's mother that evening she was wearing an oxygen mask but it had been incorrectly fitted to the outlet. A nurse would not have connected oxygen in that way so he asked the complainant if she had done it and she said she had.

31. The second NCA said that if a relative asked for oxygen for a breathless patient, and she could not see a doctor or qualified nurse, she would turn on the oxygen and then tell a doctor or qualified nurse what she had done. She knew how to administer oxygen and did not need supervision if it had already been prescribed.

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Findings (c)

32. The Commissioner's investigator was unable to trace the particular 'helper' described by the complainant or the particular nurse to whom the complainant said she had spoken. Neither the NCAs nor the nurses interviewed said they would have told a relative to administer oxygen. The conflicts and gaps in evidence are such that I again can make no finding on the complaint.

Complaint (d)
Not told her mother's condition had deteriorated. Evidence of the complainant and her brother

33. The complainant said that when the doctor initially saw her mother he said that there was nothing to worry about and that her condition could be cured with antibiotics and a couple of days in hospital. When the complainant's mother was taken to the resuscitation room the male nurse said it was because her heart rate had changed. About 20 to 30 minutes later the doctor said that her heart rate had been racing but they had calmed it down with digoxin. When the complainant asked if her mother had deteriorated he said she had slight pneumonia, which was nothing to worry about and that she was going to be fine. The doctor talked to the complainant and her brother about whether their mother should be resuscitated if she had a heart attack; however the doctor said he did not think that she would have one. He advised the complainant to go home and to ring the ward later that evening. The complainant and her brother left the hospital and at about 9.15 pm she telephoned the ward sister who said that her mother was sleeping peacefully but also that she was 'a sick woman'. It was the first time anyone had said that. The sister said that she could visit the next day at any time. About 20 to 25 minutes later the same nurse telephoned the complainant to tell her her mother had died. She was surprised because she had not known her mother was so ill. If she had known she would have stayed with her. The complainant's brother said that when the doctor came out of the resuscitation room and spoke to them he said their mother was very ill.

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Correspondence

34. In his letter to the complainant the chief executive said:

'When the doctor first assessed your mother, it looked as if the pneumonia would be treatable. Your mother's condition then deteriorated as a result of unexpected cardiac problems, and unfortunately efforts to reverse the situation were to no avail.'

Staff evidence

35. The registrar said that when he saw the complainant's mother at 6.10 pm he decided she should be admitted. She looked pale but he did not consider that she was about to die. When he saw her at 8.00 pm her condition had deteriorated. Her blood pressure had dropped and her heart rhythm had become fast and irregular. Since she had an existing heart condition she would tolerate this badly. He did not remember much about his conversation with the complainant's mother's family but his entry in the medical records said he had explained that she was very ill with pneumonia. They discussed resuscitation and in view of her general ill health and frailty her family agreed that it would not be appropriate to resuscitate her or treat her in the intensive care unit if her condition deteriorated further. He did not remember telling the complainant she should go home but he thought he was likely to have done so.

36. The staff nurse in charge of the ward during the night shift on 27 December (the third staff nurse) said that the late shift had been very busy and so that the staff could go home she agreed to complete the formalities of the complainant's mother's admission after coming on duty at 9.10 pm. There was an admission form to complete which was normally written by the person who admitted a patient to the ward. (The Commissioner's staff were unable to interview the nurse who admitted the complainant's mother to the ward because she had left the country.) Her duty would have begun with a handover discussion about the patients with the previous shift. She started a round of the ward to administer drugs at about 9.40 pm and had not reached the complainant's mother when the night sister, who was visiting the ward at the time, called her to the woman's bed. She had just died. The third staff nurse had not been involved in her care. She completed the nursing records later that night by looking at the woman's clinical notes. She had made a mistake in noting on the fluid balance chart (paragraph 5) that digoxin was given at 10.00 pm. She had intended to refer to the infusion begun at 8.30 pm. Although her initials were against the entry on the drug chart to show she had given the intravenous antibiotic at 10.00 pm, she could not remember making the entry. She said she would not have signed the chart if she had not given the drug but could not explain how that could be the case when she had also said that she had not contributed to the woman's care and had not yet reached her on the drug round. She had not seen the entries which said that the complainant's mother should have been on a cardiac monitor and had her blood pressure measured every 15 minutes. The complainant's mother had not been on a cardiac monitor; none was kept in the ward but it would have been easy to get one from another ward. She could not recall whether she had had either of the two telephone conversations with the complainant. The night sister, said that she could not remember the events of that night.

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Findings (d)

37. The registrar's evidence was that when he first saw the complainant's mother her condition did not appear to be critical but when he saw her a second time her condition had deteriorated. He tried to explain the situation to the family at the time and, it is not disputed, discussed with them their views about resuscitation. It was a difficult path to tread between presenting too gloomy and too optimistic an impression of the woman's prospects of recovery. I see no grounds for criticising the registrar in that regard: although he tried not to paint a hopeless picture, he had raised with the family the possibility of the woman's further deterioration by discussing resuscitation with them. When the woman was moved to the ward she arrived just before a shift handover. The late shift had been very busy and the staff nurse in charge of the night shift agreed to complete the documentation. Although not the subject of this complaint I am very concerned by the apparent failure of the ward staff to be aware of and act on the treatment and monitoring requested for the complainant's mother. It seems possible that her arrival in the ward just before the shifts changed contributed to that failure. If so, that may help to explain but not to excuse shortcomings. When there is no record that the intravenous cannula dislodged at 9.00 pm was replaced, it is hard to see how the 10.00 pm dose of intravenous antibiotic could have been given as shown on the drug chart. It has not been possible to ascertain which nurse spoke to the complainant.

38. I cannot comment on whether the apparent shortcomings in the woman's care following her admission to the ward may have had any bearing on her condition and her death before the treatment and monitoring regime required was fully operative. This is because at the time in question the Commissioner could not investigate issues involving clinical judgment, and this was accordingly not part of the complaint investigated. I recommend that the Trust review the arrangements for communication between staff in the A and E department, ward staff and between shift changes to avoid the possibility of similar problems in communicating about patients' intended treatment. I also recommend that they take any other action necessary to make sure that very sick patients transferred to wards from A and E receive necessary treatment and monitoring as directed by doctors. I uphold the complaint to the extent that an opportunity to provide more up to date information to the complainant before her mother's deterioration might have been missed by ward staff.

Conclusion

39. I have set out my findings in paragraphs 17, 26, 32, 37 and 38. The Trust have agreed to implement my recommendations in paragraph 38 and have asked me to convey through this report - as I do - their apologies to the complainant for the shortcomings I have identified.

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Last updated: 7 February 2006