Selected Investigations Completed April - September 1998

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Part II - Full Texts of Selected Investigations

Matters considered: Failures in medical and nursing care; delay in transfer to intensive care unit (ICU) at another hospital; unsatisfactory complaint handling

Complaint against: Warrington Hospital NHS Trust

Complaint as put by Mrs B

1. The account of the complaint provided by Mrs B was that on 28 November 1996 her husband, Mr B, was admitted to Warrington General Hospital (the first hospital), which is managed by Warrington Hospital NHS Trust (the Trust). When the family visited him the following day they noticed blood on the front of his pyjamas after his return from the x-ray department. They later learned that he had pulled out his drip (a tube providing fluids to correct his dehydration) before he went to x-ray and that there had been a two-hour delay in re-siting (replacing) the drip. Mr B was in a distressed state, and his sons had to restrain him. The family received no help from the nursing staff, and they felt that Mr B's well-being was left in their hands. The following day the family were again left to care for Mr B.

2. At 5.45pm on 30 November a doctor told Mrs B that her husband was in a critical condition, and that arrangements were being made to transfer him to the intensive care unit (ICU) at another Hospital (the second hospital). The doctor said that the following six hours would be crucial. At 7.00pm Mr B's eldest son asked at the nursing station why his father had not been transferred, and was told that the anaesthetist, who needed to treat Mr B before he could be transferred, was delayed in the operating theatre but would be there within the hour. Over the next four hours Mr B's eldest son enquired about the delay several times. An anaesthetist did not attend to Mr B until 11.45pm. Mr B died of Legionnaires' disease (a form of pneumonia) two weeks later at the second hospital. On 9 January 1997 St Helens and Knowsley Community Health Council (the CHC) complained to the chief executive of the Trust, who has since left the Trust (the former chief executive), on Mrs B's behalf. The family attended a meeting at the Trust on 29 January. On 5 March Mrs B wrote to the former chief executive listing points in the Trust's notes of the meeting with which the family disagreed, and requesting an independent review (IR) of her complaint. On 9 April the Trust's convener refused the request for an IR. Mrs B remained dissatisfied.

3. The complaints investigated were that;

the medical and nursing care which Mr B received at the first hospital were unsatisfactory;
there was an unacceptable delay in transferring Mr B to the ICU at the second hospital; and
the Trust's handling of Mrs B's complaint was unsatisfactory.

Investigation

4. The statement of complaint for my investigation was issued on 25 September 1997. The comments of the Trust were obtained and relevant papers, including Mr B's medical and nursing notes, were examined. One of my investigators took evidence from Mrs B and members of her family and from the Trust staff involved. I appointed three independent professional assessors to advise on the clinical aspects of the complaint. Each assessor accompanied my investigator at most of the interviews with Trust staff from his or her particular specialty. The assessors' report is appended to this report.

Complaint (a)
The medical and nursing care were unsatisfactory

Evidence of Mrs B and her family

5. Mrs B's daughter told my investigator that her father was admitted to a single room in ward A1. When the family visited him on 29 November 1996 her father was being taken for an x-ray. The family waited in his room and noticed blood on his bedding and on the floor. When he came back from x-ray he had blood on his arm and pyjamas. The nurses told her that he had pulled out his drip before going to x-ray, and they had decided not to clean him up until he got back. Mrs B told my investigator that she had had to ask the nurses to change her husband's pyjamas. Over the two days that he was in ward A1 her husband was delirious and kept trying to remove his oxygen mask; his sons had to restrain him and found that distressing, but the family had not received any help. The nurses did not offer any information: the family had to ask if there were any test results. Mrs B's eldest son told my investigator that it had been 'a real strain' keeping his father in bed, keeping his oxygen mask on, and keeping him calm. The family had not asked for help because they were too busy caring for Mr B themselves. Staff thought they were managing: 'they thought it best to leave us to it'. The nurses gave care only when his father deteriorated on 30 November. He could accept that the nurses were very busy, but thought that the doctors were 'disgraceful' because their care had been non-existent.

Trust response to statement of complaint

6. In her formal response of 17 October 1997 to my statement of complaint the then acting chief executive of the Trust (the acting chief executive) wrote:

'The staff agree that a good deal of basic nursing care was provided to [Mr B] during his stay by members of his family. It is clear ... that the nursing staff relied heavily on the family for assisting with his care. However, at that time they thought and probably hoped that the family were happy with this arrangement.
'The Trust accepts that the family are justified in making complaints regarding the medical and nursing care [Mr B] received. The care ... was less than optimal and the lack of adequate communication between doctor to doctor, doctor to nurse and nurse to nurse is also acknowledged. This resulted in confusion in the information that was being provided to the family. The medical treatment he received for his condition however was correct.'

Evidence of nursing staff

7. None of the nurses interviewed, who were on duty in ward A1 while Mr B was a patient, could remember him going to x-ray on 29 November 1996. A staff nurse in A1 (the first staff nurse) told my investigator that she changed Mr B's drip at 1.00pm. At 3.00pm she recorded that the drip had come out; and she then went off duty before it was re-sited. She could not remember how many times she checked on Mr B that day, and she could not recall giving any help to the family. The ward manager for A1 said that the first staff nurse asked her to re-site Mr B's drip, which she did around 4.00pm. After the complaint was received she had checked with x-ray; and their records showed that Mr B attended at 2.15pm.

8. A second staff nurse in A1 (the second staff nurse) who was on duty in the afternoon of 29 November, told my investigator that the family were concerned because Mr B kept trying to remove his oxygen mask, and she told them it was important that he should keep it on. She was concerned about him, but one of his sons seemed happy to help to keep the mask on; the family did not ask for help with Mr B - they only asked whether the oxygen was all right, and the drip running. She checked that and reassured Mr B.

9. The ward manager for A2, to which Mr B was transferred at 4.00pm on 30 November, told my investigator that Mr B was very poorly when he arrived in the ward; and she immediately contacted the medical staff. For the rest of the shift she cared for Mr B herself and spent time collecting specialist equipment required by the doctors. She said that the night sister who took over from her arranged for a nurse to give Mr B one-to-one care. She had not been able to arrange that during the day shift because extra staff were not available. The nurses had relied on the family; they were 'a big help' because Mr B was restless and responded better to his family. The family had not provided nursing care, but had calmed and encouraged Mr B. In retrospect she thought that perhaps the family had felt that they were pushed over the 'fine line between caring for him and being with him'.

10. A staff nurse in A2 (the third staff nurse) told my investigator that she and the ward manager for A2 were both surprised at Mr B's condition when he arrived in the ward; he was sweating, short of breath, and agitated. She rang A1 to ask if they realised how ill he was; and the nurse there said he must have deteriorated since the transfer. She asked the family if they had been told how seriously ill he was, but they 'had no inkling'. She checked Mr B's blood pressure, pulse, temperature, and respiration every 15 minutes. His sons were restraining him because he kept trying to pull out his drip; but the family gave the impression that they were coping.

Evidence of medical staff

11. The consultant physician told my investigator that the medical care in this case had 'fallen down'. He saw Mr B on the morning of 29 November and ordered a chest x-ray and arterial blood gas tests (to measure the level of oxygen in the blood). He then left the ward, but was in the hospital all day. He relied on his juniors to report test results to him, but heard nothing in this instance. The x-ray results were not documented, so he could not be sure whether they had not been seen, or were seen and not acted on. The blood gas results had been written in the blood book (which is kept in the ward and used to record results which have been telephoned through by the pathology laboratory). However, nothing was recorded that day in Mr B's notes. The consultant physician had not been able to establish who had made the entry in the blood book, but thought it might have been a ward clerk. Nurses would have recognised the result as abnormal; but a ward clerk would not have understood the urgency of the results. (Note: The house officer (the HO) told my investigator that a nurse asked him to see Mr B at 9.00pm on 29 November. He reviewed Mr B's notes but the blood gas test results were 'not to hand' at the time. Mr B's chest x-ray film was in the file, but there was no report there on the x-ray).

12. The consultant physician said that he was concerned that senior staff had not been alerted to the test results, which were significant and indicated the need for greater surveillance, repeat tests, and ventilation (assistance with Mr B's breathing). The consultant physician was also concerned about gaps in the nursing and medical notes for that day and the following day: he would have expected more notes for a patient as ill as Mr B. There were lessons to be learned from the complaint: all along it had not been fully appreciated how ill Mr B was, or how significant the blood gas result was. The hospital had been under pressure that winter, and it could be said that there were insufficient medical staff to deal with the volume of work; there was now an extra senior house officer.

Ward blood book

13. The first staff nurse and the ward manager for A1 both confirmed that the ward clerk had entered Mr B's blood gas test results in the blood book. The first staff nurse said that a patient's named nurse would usually be told if the laboratory telephoned with results; that had not happened here. The blood book was checked only when a doctor did the early evening round, but the doctor would be looking for the results of patients admitted to the ward that day. The ward manager for A1 said that the ward clerk had taken the telephone call as a favour because staff were busy. She did not know why laboratory staff had let an assistant take abnormal results; they should have asked to speak to a doctor or nurse. As a result of the complaint all telephone calls to A1 about test results now had to be taken by a qualified member of staff. If an unqualified person answered the telephone he or she had to call a qualified member of staff, who was then responsible for entering the results in the blood book and the patient's case notes and informing the named nurse. The named nurse was now responsible for taking action if results were abnormal.

Assessors' report

14. The report of the assessors (reproduced in full in the Appendix to this report) includes the following comments on Mr B's nursing care:

'... we could not determine what happened when [Mr B's drip] came out. [Mr B] is thought to have returned from x-ray at about 2.45pm and the drip was noticed to be out at 3.00pm. The venflon (small plastic tube placed into a vein for connection to the drip) was reinserted at 4.00pm by the ward manager from A1. A delay of up to two hours in re-siting this drip (putting it back in) is not unreasonable and would not have been detrimental to [Mr B]...
'The initial nursing assessment and subsequent nursing care were satisfactory overall but fell below the standard we would reasonably expect in the following areas: firstly the nursing assessment of [Mr B's] breathing, secondly the formal evaluation of his fluid balance (how much fluid he drank and passed) and thirdly the communication with [Mr B] and his family, which we would expect to be greater given their level of attendance.'

With regard to the medical care that Mr B received, the assessors' report includes:

'Chest x-ray and arterial blood gases were performed on the morning of admission. The x-ray confirmed the diagnosis of pneumonia and the arterial blood gases showed that he had a low level of oxygen in the blood. There is, however, no record that these results were seen or acted on by the medical staff. These results taken with [Mr B's] clinical state would show features that should indicate the need for more intensive monitoring, particularly of the level of oxygenation, and consideration should have been given at that stage for transfer to an ICU. ...'The medical care received by [Mr B] was suboptimal particularly in that there appears to have been a failure to recognise the severity of his respiratory illness and in that the initial chest x-ray and blood gas results were not acted on which could have led to closer monitoring and a move towards more aggressive intervention at an earlier stage.
'[Mr B] was, however, on an appropriate antibiotic regime on the morning of the 29th November. It is unlikely that the final outcome was affected by the deficiencies in care that have been identified.'

Findings (a)

15. When Mrs B complained to me about the care her husband received, she and her family identified specific aspects of care that concerned them. In their formal response (paragraph 6) the Trust accepted that Mr B's medical and nursing care were not as good as they should have been, and in particular cited poor communication 'doctor to doctor, doctor to nurse and nurse to nurse'. Mrs B was concerned that her husband was left in blood-stained pyjamas after he pulled out his drip, and that there was a delay in re-siting the drip. Mrs B's daughter said that nurses told her that her father's drip came out before he went to x-ray, which would have explained why there was blood on the floor and on his bedding. The nurses could not comment on that when questioned by my investigator because they could not remember Mr B going to x-ray. However, I have no reason to doubt the family's version of events. The evidence indicates that Mr B's drip was out for about two hours. My assessors have said that that would not have had an adverse effect on his condition. I accept that. However, it is not satisfactory that Mr B was left with blood-stained pyjamas and bedding until the family asked for them to be changed.

16. The family complained that Mr B was agitated and his sons had had to restrain him, but staff did not give them any help. There is no doubt in my mind that the family were left to cope with a difficult and distressing situation; and although nursing staff have said that the family appeared to cope, the family themselves were not consulted about that. These failures, and the Trust's admission that the medical and nursing care were suboptimal would, in themselves, be sufficient for me to uphold the complaint. However, in the course of the investigation it became apparent that there were other serious failings which the family were not aware of and could not have been expected to put to me.

17. On the morning of 29 November the consultant physician ordered a chest x-ray and blood tests. The results of those tests indicated the need for closer observation and earlier intervention. However, the results were not seen by the nurses or doctors caring for Mr B and were therefore not acted upon. I am extremely concerned that abnormal test results were overlooked in this way and that there was no system for routinely checking the blood book for the results of patients, other than that day's admissions. I strongly criticise the Trust for that. I note that as a result of this complaint the Trust have changed their system for notifying and acting upon such test results in ward A1 (paragraph 13). The assessors have advised me that it is unlikely that the deficiencies in care affected the outcome. I hope that the family can take some comfort from that. I accept that earlier intervention might not have saved Mr B; but he and his family would have had the reassurance of being in the ICU earlier, and that everything possible was being done. The delay which I consider under head of complaint (b) below, and the additional stress that that placed on the family, might also have been avoided. I uphold the complaint.

Complaint (b)
Delay in transferring Mr B to the second hospital. Evidence of Mrs B and her family

18. On 9 January 1997 the CHC wrote to the Trust, enclosing an undated letter from Mrs B. In her letter Mrs B said, of her husband's transfer to the second hospital on 30 November 1996: '... at 5.45pm I was told my husband was being transferred to an ICU and that the next six hours would be crucial. But my husband was left lying in his bed until 11.45pm ... Did those six hours in a critical condition mean the difference between life and death? ...' Mrs B's eldest son told my investigator that about an hour after his mother had been told that his father was critical he went to the nursing station to ask how soon his father would be transferred. The nurse told him that the anaesthetist had been detained in theatre and would be there as soon as possible. Over the next few hours he went to the nurses' station several times, and each time was told that the anaesthetist had been delayed. Mrs B said that the family later learned that there were three anaesthetists on duty that night; at the time they had been under the impression that there was only one.

Trust response

19. In her formal response to me (paragraph 6) the acting chief executive wrote:

'The Trust accepts that there were unacceptable delays in finalising the transfer of [Mr B] but considers that these delays were unavoidable given the demands that were being placed on the anaesthetic service at the time of [Mr B's] need ... I would wish to stress however and as previously explained to the family, it is not considered that the delay contributed to his subsequent death two weeks later'.

Evidence of Trust staff

20. The medical registrar told my investigator that he saw Mr B around 5.30pm on 30 November. Blood gas tests and a chest x-ray suggested pneumonia and possible respiratory failure. He began a course of intensive treatment and contacted the anaesthetic registrar, who agreed that Mr B needed to be ventilated. The ICU at the first hospital was full, so the medical registrar arranged for Mr B to go to the second hospital; but they would take him only after he had been intubated (a procedure carried out under anaesthesia to insert a breathing tube into the windpipe). The anaesthetic registrar said he would take Mr B to the recovery area by the operating theatre to intubate him there. The medical registrar thought that that was going to happen soon: Mr B was poorly, and the anaesthetic registrar was aware of that. The medical registrar said that he was busy for the rest of the night seeing to Mr B and responding to calls from other wards. He thought that nursing staff had tried to contact the anaesthetic registrar but was not sure; he could not remember speaking to the family himself apart from at around 5.30pm, when he told them that Mr B was poorly. The HO told my investigator that he had spoken to the family at around 5.00pm. His responsibility for Mr B ended then, because the medical registrar and anaesthetic registrar took over.

21. The third staff nurse told my investigator that she was not aware of any delay initially; a bed and transport had been organised, and the doctor said that Mr B was going to recovery to be intubated; the nurses thought that the transfer would take place soon. The ward manager in A2 said that she paged the anaesthetic registrar around 7.50pm and was told that he was with an emergency patient in theatre and Mr B would be taken to recovery to be intubated. She had not taken steps to chase up the transfer because she thought that the doctors had it in hand. Members of the family made enquiries at the nursing station; but she could not remember what was said.

22. The anaesthetic registrar told my investigator that when he saw Mr B he assessed his condition as 'urgent, but not an emergency'. He spoke to the on call consultant anaesthetist (the consultant anaesthetist), who agreed that Mr B should be transferred to another ICU. He asked the theatre sister if he could bring Mr B to the recovery area to be intubated, but she refused because that would block theatre and her nurses were fully occupied. (Note: The theatre sister confirmed the anaesthetic registrar's evidence on this point.) The anaesthetic registrar told my investigator that that night the anaesthetists had responsibility for three patients who needed emergency intervention. Those patients' needs were more urgent than those of Mr B; and the anaesthetic registrar said that his responsibility was to them. He did not know whether staff in A2 had tried to contact him. On one occasion he had spoken to the nursing station and was told that Mr B's condition was unchanged. Around 10.45pm the medical registrar contacted him and told him that Mr B had deteriorated and might develop respiratory arrest. He said that the anaesthetic senior HO went to the ward to intubate Mr B, then brought him to the ICU around 11.45pm, where the anaesthetic registrar stabilised him.

23. The consultant anaesthetist told my investigator that he was called in that day to give assistance when a patient undergoing a routine hernia operation (the first patient) developed complications which required major surgery. While he was in theatre the anaesthetic registrar told him that Mr B needed intubating; and around the same time another patient (the second patient) had a severe bleed. The anaesthetic registrar had seen Mr B and said that he did not need emergency intervention; and the consultant anaesthetist decided that Mr B should be transferred to another ICU. The second patient's condition was so serious that it required all three anaesthetists. As they were finishing, a patient in the ICU (the third patient) developed a collapsed lung. The consultant anaesthetist said that he was aware that Mr B was waiting; but he understood that Mr B was not in urgent need and decided that they should attend to the third patient. They were stretched to the limit that evening and his priority was 'the patient in front of me'.

24. The Trust's medical director (the medical director) was on call that evening. The medical registrar contacted him, and he agreed that Mr B should be transferred, but heard nothing more about it; had he known about the delay he would have tried to find a compromise. He had since emphasised to staff that they must involve him if there is a problem. The consultant physician told my investigator that if he had been involved he would have contacted theatre personally to find out what was happening, and would have considered whether there were any alternatives. They had learned from the complaint that 'we've got to speak to anaesthetists, consultant to consultant'.

25. The director of anaesthetic services told my investigator that when the complaint was received he looked to see if he could identify what had gone wrong. He concluded that the team had been overstretched, but that staff had made the right decisions according to the clinical needs of the patients. 'In all honesty' he had not been able to identify any avoidable factors; it was a difficult situation and staff had done their best. The only alternative would have been to transfer Mr B without intubating him; but that would have been substandard care and not acceptable. Following the complaint, at the request of the former chief executive, he had produced a 'communication pathway' which clarified the procedures to be taken when a patient urgently required an anaesthetist. That document stated clearly that the consultant in charge of the patient should communicate with the consultant anaesthetist on call.

Assessors' report

26. In the conclusion to their report my assessors say:

'Once the decision had been made to intubate and ventilate the delay in carrying this out is ... suboptimal management, but this was probably unavoidable in the context of the other problems facing the anaesthetists that evening. It is regrettable that there was not more direct communication between the medical and anaesthetic staff involved during that time and that senior physicians were not involved when the delay became apparent.
'It is unlikely ... that the delay in transferring [Mr B] contributed to the final outcome.'

Findings (b)

27. When Mr B arrived in ward A2 nursing staff were concerned about his condition and alerted medical staff. The anaesthetic registrar attended; a decision was made to transfer Mr B to another hospital; and a bed and transport were arranged. All of that took place within an hour or so. From then on there were problems. The anaesthetic department was presented with three patients who required emergency anaesthetic intervention, and whose conditions were such that all the anaesthetic staff on duty were fully engaged in stabilising them. The anaesthetic registrar had seen Mr B and had assessed his condition as urgent, but not an emergency; and in the circumstances the consultant anaesthetist decided that his duty was to the patients in theatre. My assessors have advised that, in the context of the problems facing the anaesthetists that evening, the delay was probably unavoidable, which I accept. That said, it still remains unacceptable for a patient to have to wait as long as Mr B did. The assessors have said that the delay in carrying out Mr B's intubation and ventilation was 'sub-optimal management'. I agree. They also consider it regrettable that there was not more direct communication between medical and anaesthetic staff, and that senior physicians were not made aware of the delay. The medical director and the consultant physician have said that they would have tried to find a compromise if they had known about the delay. I cannot say whether a compromise was possible; but the failure to communicate precluded that possibility. I note that as a result of this complaint the Trust have produced a 'communication pathway' which formalises the importance of consultant-to-consultant communication.

28. Mrs B has asked if an earlier transfer would have made a difference. My assessors have advised that the delay did not contribute to the final outcome. I have no reason to doubt that advice. However, while an earlier transfer might not have made a difference to the outcome, it would at least have meant that Mr B was more comfortable and that he received sooner the level of care that he needed. This might have eased the family's distress. Instead, failures in communication added to it. I uphold the complaint.

Complaint (c)
Handling. Evidence of Mrs B and her family

29. On 20 February 1997 the former chief executive wrote to the CHC, who were representing the family, setting out the notes of the meeting held on 29 January. On 5 March Mrs B wrote to the Trust to express her dissatisfaction with the notes. She complained that some aspects of the complaint had been 'glossed over', and other points were omitted. She also complained that the consultant physician made asides during the meeting. The family were referred to as [a variation of their name] throughout the meeting and the Trust's notes referred to them as [a second variation of their name]. Mrs B told my investigator that she was told that the notes would be sent within a week. When the notes finally arrived, after the CHC's intervention, they did not reflect what was said at the meeting. Mrs B's daughter said that the Trust seemed to have their own agenda at the meeting and kept jumping from point to point instead of addressing matters in sequence, as the family wanted. Her husband had been angry because he overheard the consultant physician say to a colleague 'let's hurry this up'.

Trust's response

30. In her formal response to me (paragraph 6) the acting chief executive wrote:

'As part of the Trust's local resolution process, complainants are routinely invited to have a meeting with hospital staff if they feel it would be beneficial to them. ...

'The Trust did experience internal delays in confirming the contents of the Minutes [of the meeting] prior to them being forwarded to [the family] as [the acting director of quality] was unfortunately on sick leave. This resulted in the letter being held within the Trust to await for her return for perusal and approval of the content.

'However, [the CHC] exerted ... pressure to have forwarded to them the notes of the meeting as had previously been agreed. This hasty decision unfortunately resulted in a failure to detect that the family's name was incorrectly spelt throughout the letter. '... [The Trust] does accept ... that the notes of the meeting forwarded to the family did not fully reflect the discussion that took place.
'The Trust is embarrassed that the Ombudsman will see in this complaint the recurring theme of failures in communications both between staff and staff with relatives. The Trust is mindful of its need to improve in this area. In respect of the Trust's procedures for handling clinical complaints a review has been recently undertaken and an action [plan] is currently being formulated.'

(Note: I have seen the implementation plan which the Trust are now adopting following their review of their complaints handling.)

Evidence of Trust staff

31. The consultant physician told my investigator that he felt that the acting director of quality, who chaired the meeting, did not have full command of the situation, and her tone had been condescending; if he had been a relative he would not have been happy. He was embarrassed, made a comment about it to a colleague, and inadvertently upset the family. He was shocked when he saw their letter of 20 February 1997, and wrote to Mrs B to apologise. On the same day he wrote to the former chief executive to express his dissatisfaction with the way the complaint had been handled. That memorandum included:

'My discomfort at the meeting was as nothing compared with the delay in sending out the letter. I felt, and said, that it should have been out well within one week. ... In many areas it was inaccurate and I agree with [the family] that several important areas were glossed over ...'

32. The directorate manager for medicine/care of the elderly (the directorate manager) said that she was asked for comments on the complaint; she thought that staff would discuss the complaint before they met the family, but that did not happen. The family were not happy because the meeting was held at the hospital and the acting director of quality kept returning to that instead of addressing the matters in hand. The consultant physician was irritated, and he made a comment to her about the acting director of quality, which the family overheard. The meeting was open and honest; but the letter that went out did not reflect that. Following the meeting the acting director of quality was on sick leave, and there was pressure to get the notes out. The directorate manager and the consultant physician made changes to the notes, but she thought that they would be discussed at a meeting before being sent out. The former chief executive was not happy with the notes that were sent to Mrs B and blamed the directorate manager and the consultant physician for that; there was a lot of 'trying to blame one another' in the Trust.

33. The acting director of quality, who has now left the Trust, told my investigator that the complaints and litigation officer (the complaints officer) took shorthand at the meeting and then typed up rough notes. The acting director of quality said that she and the complaints officer worked on the notes to produce a draft reply, which was sent to staff for comments. She then went on holiday for a week and planned to check the amendments on her return. However, on return from holiday she was on sick leave for three days. During that time the notes were sent out. When she saw Mrs B's letter about the notes she compared the notes that went out with her version. The emphasis of the letter had been changed, and some of the apologies were not as prominent as they had been. Staff had changed the notes on the basis of their recollection of the meeting; but she had the benefit of the complaints officer's notes.

34. The complaints officer told my investigator that she typed rough notes the day after the meeting. The notes were re-drafted by the acting director of quality, and copies were sent out for comments. The revisions should then have been checked by the acting director of quality, but she was off sick. The complaints officer had a few days' leave; and while she and the acting director of quality were absent the letter was sent out unchecked. The complaints officer accepted that the family's name was spelt incorrectly throughout, and apologised for that.

Findings (c)

35. In her response to the statement of complaint the acting chief executive noted the Trust's embarrassment at the 'recurring theme of failures in communication' in this complaint. The poor communication between clinical staff which was apparent earlier in this report seems to have extended to the handling of the complaint. Staff did not seem to have had a clear idea of what was expected of them before the meeting with the family. During the meeting tension between staff was conveyed to the family who, unfortunately, thought it was directed at them. There was confusion over the content of the notes that went out; and when Mrs B wrote to express her dissatisfaction there seems to have been disagreement over whose fault it was. The family's distress was compounded by Trust staff addressing them by the wrong name throughout the meeting, and using another incorrect name in the notes. All in all, the Trust's handling of the meeting and the notes were highly unsatisfactory. I note that the Trust have reviewed their complaints handling, and are now implementing an action plan which should avoid such unsatisfactory complaints handling in the future. I uphold the complaint.

Conclusion

36. I have set out my findings at paragraphs 15, 16, 17, 27, 28, and 35. The Trust have asked me to convey through my report - as I do - their apologies to Mrs B and her family for the shortcomings I have identified.

Appendix A to E.189/97-98

HEALTH SERVICE OMBUDSMANS ACT 1993 (as amended)

Report by the Independent Professional Assessors to the Health Service Ombudsman for England of the clinical judgments of staff involved in the complaint made by Mrs B

Professional Assessors:

First Assessor, MB BS FFARCS
Consultant Anaesthetist

Second Assessor, DM FRCP
Consultant Physician

Third Assessor, RGN MSc Nursing Studies MBA
Directorate General Manager
Medicine/Medicine Specialities

'The report is based on the documentation provided. The relevant assessors were present at the formal interviews by the Investigating Officer of the Medical, Anaesthetic and Nursing Staff.

The issues addressed are paragraphs 3a and 3b of the statement of complaint [reproduced in paragraph 3 of the Ombudsman's report];

The medical and nursing care which Mr B received at the hospital was unsatisfactory, and

There was an unacceptable delay in transferring Mr B to the ICU at the second hospital.

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Background

Legionnaires' Disease: The final diagnosis in this case was Legionnaires' Disease. Legionnaires' Disease is a common cause of community acquired pneumonia. Although original descriptions of the disease related to outbreaks with a common source of infection, it has become increasingly recognised as a cause of sporadic cases of pneumonia and it ranks in the top three or four causes of pneumonia requiring hospitalisation. The incubation period is from 2-10 days. There is a wide range of illnesses associated with the disease, ranging from a mild cough and low grade fever to a severe illness with respiratory and multi-organ failure. The temperature is often very high, exceeding 40 degrees. In the early stages the symptoms are of generalised aches and pains and headache, symptoms related to the gastrointestinal tract, particularly watery diarrhoea occurring in up to 40% of cases, pneumonic features come later. Legionnaires' Disease has a mortality rate of 19% which rises to 67% in patients who required intubation and ventilatory support. The diagnosis of Legionnaires' Disease is difficult and often depends on antibody response which may not be available for 10 days following the start of the illness. For this reason recommendations for the management of pneumonia include an antibiotic active against the Legionnella from the outset. The recommended treatment for severe infections includes two active antibiotics firstly a Macrolide (Erythromycin or Clarithromycin) and secondly a Quinolone (Ciprofloxacin or Offlaxcin). The features in Mr B's illness from the outset are all compatible with the final diagnosis of Legionnaires' Disease.

Warrington General Hospital is a medium-sized District General Hospital with 647 acute beds. It has three staffed ICU beds and a busy separate maternity unit. The Hospital has an integrated unit of Medicine and Medicine for the Elderly and patients are cared for on wards in both ward blocks at the Hospital. There is an admissions ward for GP referred admissions and cases may also present through the Accident and Emergency Department.

Following their initial management, patients are transferred off the admissions ward (A1) to beds on the other medical wards. The on-call team in the hospital out of hours comprises one Pre-registration House Officer, one SHO and one Senior SHO/Registrar. This number will always be very stretched to cover the in-patients in the hospital and new referrals, but the constraints of the number of staff available and new deal on junior doctors hours does not allow staffing above this number. At the time Mr B was admitted the hospital was very busy with the daily number of admissions approaching twice the usual level.

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Ward A1 is a 30 bedded assessment ward. Our experience is that such a ward in a similar sized hospital would expect between 20 and 30 admissions per day. The nursing staffing on ward A1 over the period of Mr B's stay is in our opinion average for the type of ward and the skill mix (ratio of qualified to unqualified nurses) is appropriate.

Ward A2 is a General Medical ward and the level of nursing staff on duty on the afternoon/evening of 30th November is in our opinion adequate for a 25/28 bedded ward. The provision of an additional night nurse to 'special' (care for Mr B only) until his transfer, represented good management of the situation at that time.

The anaesthetic staffing structure at weekends consists of a resident Senior House Officer (the anaesthetic SHO), a resident Middle Grade (the anaesthetic registrar), and an on-call Consultant (the consultant anaesthetist). There is a dedicated Middle Grade Obstetric Anaesthetist on-call for the separate maternity unit. This staffing level is above average for this size of District Hospital.

The anaesthetic SHO who was on duty on 30 November 1996 was very inexperienced, having recently joined the department from overseas. The anaesthetic registrar was an experienced well-trained locum Clinical Assistant. He has a post graduate Fellowship qualification in Anaesthesia (FFARCSI). He had previously been employed as a full-time Registrar at Warrington as part of his Liverpool training rotation and was well known to the hospital staff. The consultant anaesthetist had been in post for ten years.

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The ICU was staffed for three beds. On the afternoon of the 30th November 1996, two of the beds were occupied and the third was reserved for a patient in theatre undergoing emergency abdominal surgery. The nursing flexibility in the ICU was severely restricted by one patient requiring isolation facility, due to infection, and the other patient requiring haemofiltration (kidney dialysis).

Medical Care

Mr B's symptoms developed on the morning of the 23rd November 1996, but it was not until late on the evening of the 28th November 1996 that he was admitted to hospital, at which stage he was severely ill with established infection. His dominant symptoms at presentation were gastrointestinal which obscured the underlying diagnosis of pneumonia. Chest x-ray and arterial blood gases were performed on the morning of admission. The x-ray confirmed the diagnosis of pneumonia and the arterial blood gases showed that he had a low level of oxygen in the blood. There is, however, no record that these results were seen or acted on by the medical staff. These results taken with Mr B's clinical state would show features that should indicate the need for more intensive monitoring, particularly of the level of oxygenation, and consideration should have been given at that stage for transfer to an ICU.

On the afternoon of the 30th November 1996 Mr B was transferred from Ward A1 to A2 and it was only then that nursing staff appreciated how ill he was and summoned the medical staff for urgent review. The medical registrar's assessment at that time quite rightly identifies worsening pneumonia and increasingly low level of oxygen in Mr B's blood as the cause of the continued deterioration and assessed that intensive care management and intubation and ventilation would be necessary. He arranged for Mr B to be seen urgently by the anaesthetic team. Although the anaesthetic registrar agreed to that assessment, because of the involvement of the anaesthetists with other ill patients, the actual intubation and transfer did not occur for some hours. There was no direct communication between the medical and anaesthetic staff during that time to discuss the reasons for the delay or to negotiate ways in which this could have been reduced.

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Anaesthetic involvement on Saturday 30th November 1996

During the afternoon, the consultant anaesthetist was called into theatre when a simple hernia procedure being performed on an elderly patient (the first patient) under local anaesthesia unexpectedly developed into a major abdominal bowel resection requiring general anaesthesia. This was beyond the capability of the anaesthetic SHO, and both the anaesthetic registrar and the consultant anaesthetist were called to give assistance. The first patient was subsequently transferred to the ICU for post-operative management.

Whilst the above case was being performed, the anaesthetic registrar was asked by the medical registrar to review Mr B. The anaesthetic registrar agreed that Mr B was in respiratory failure due to pneumonia and that he would be best treated by sedation and artificial ventilation following endotracheal intubation (a breathing tube being inserted under anaesthesia into the windpipe). He would require ICU facilities following intubation. The anaesthetic registrar was aware that there was no available ICU bed at the hospital and felt that Mr B did not require immediate intubation and could wait until an available ICU bed in another hospital had been arranged by the medical team.

The anaesthetic registrar was then called urgently to a surgical patient (the second patient) with haematemesis (vomiting blood), requiring urgent resuscitation and abdominal surgery. All three anaesthetists then became fully occupied in managing the new admission to the ICU (the first patient) and in resuscitating and anaesthetising the second patient. Furthermore, the ICU patient requiring isolation facility (the third patient) developed a pneumothorax (collapsed lung), an emergency situation requiring immediate anaesthetic attention. The first patient was subsequently transferred out of the ICU to allow the second patient to be admitted post-operatively.

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The anaesthetic registrar and the consultant anaesthetist have no recollection of being contacted about Mr B until around 10.45pm. At no time had there been any direct Consultant Physician to Consultant Anaesthetist communication. At 10.45pm, the medical registrar spoke to the anaesthetic registrar and informed him that Mr B had deteriorated. The consultant anaesthetist then immediately sent the anaesthetic SHO to intubate Mr B. This he did efficiently, but he lacked the experience and expertise to stabilise and transfer Mr B to the nearest ICU bed that had been arranged at the second hospital. The anaesthetic SHO therefore took Mr A intubated to the first hospital's ICU, where the anaesthetic registrar and the consultant anaesthetist were treating the second patient. The anaesthetic registrar stabilised Mr B (without the assistance of any ICU nurses as they were all fully occupied with their own patients). The subsequent transfer of Mr B intubated, ventilated and sedated to the second hospital's ICU by ambulance, accompanied by the anaesthetic registrar was uneventful and Mr B was stable on handover to staff at the second hospital.

Although the diagnosis of Legionnaires' Disease was not established until after the transfer to the second hospital Mr B was started on an antibiotic regime of Clarithromycin and Ciprofloxacin which is appropriate and effective against Legionnella in addition to covering the possible causes of both the pneumonia and the gastrointestinal symptoms.

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Nursing care

The nursing care we would expect to be given for Mr B would include a full nursing assessment of his needs and problems on admission. His main problem was identified as diarrhoea, vomiting and confusion. The problem of dehydration was documented and appropriate care ordered: pushing fluids (encouraging him to drink), starting an intravenous infusion and collecting specimens including the stool specimen to discover the cause and establish a baseline. This care was given by nursing staff although we are unable to discern the frequency of pushing fluids because of incomplete documentation.

With regard to the drip, the identity of the person who accompanied Mr B to x-ray is unknown and therefore we could not determine what happened when it came out. Mr B is thought to have returned from x-ray at about 2.45pm and the drip was noticed to be out at 3.00pm. The venflon (small plastic tube placed into a vein for connection to the drip) was reinserted at 4.00pm by the ward manager from A1. A delay of up to two hours in re-siting this drip (putting it back in) is not unreasonable and would not have been detrimental to Mr B. The collection of the stool specimen was not documented by nursing staff.

Mr B's second nursing problem of pyrexia (high temperature) was highlighted and appropriate care ordered and given in terms of monitoring his temperature every four hours, collecting specimens and making him more comfortable by removing blankets, providing a fan, offering washes and changing the bed linen when necessary and giving prescribed antibiotics.

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A third nursing problem, that of Mr B's confusion, was identified and some reassurance and explanation was given. Mr B was also given low percentage oxygen. The result of the blood test, taken on 29th November to measure the level of oxygen in his blood, was abnormal but was not raised with medical staff as a matter of urgency. Additional nursing problems were identified on 30th November and the nursing care ordered and given was appropriate.

Respiratory assessment does not appear as part of the pre-printed documentation and breathlessness was not identified as a problem in the initial nursing assessment. In our opinion, observation of Mr B's breathing and four hourly recording of his respiratory rate would be appropriate nursing care in order to evaluate the effect of his oxygen therapy and we conclude that this was not perceived as a problem by nursing staff until the night of 29th and was not evaluated by nursing staff on the morning of 30th prior to transfer to A2 ward.

It was identified that Mr B was poorly on 29th and his condition deteriorated further on 30th, it was also acknowledged that Mr B's family were in attendance and understandably anxious. We would expect a short time to be taken on each shift to discuss his condition and this would be the opportunity for staff to discuss his care and check out whether the family were happy to continue to reassure, pacify Mr B and encourage him to keep his oxygen mask on. Whilst some time was given in communication it appears that family involvement was assumed rather than negotiated and that the nursing staff were grateful for their involvement because of the demands of other patients who may have been more critical at the time.

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Conclusion

The medical care received by Mr B was suboptimal particularly in that there appears to have been a failure to recognise the severity of his respiratory illness and in that the initial chest x-ray and blood gas results were not acted on which could have led to closer monitoring and a move towards more aggressive intervention at an earlier stage. Once the decision had been made to intubate and ventilate the delay in carrying this out is again suboptimal management, but this was probably unavoidable in the context of the other problems facing the anaesthetists that evening. It is regrettable that there was not more direct communication between the medical and anaesthetic staff involved during that time and that Senior Physicians were not involved when the delay became apparent. Since this case, a clear communication pathway protocol for patients requiring urgent intensive care has been issued by the Anaesthetic Department. This protocol emphasises the need for senior medical staff to communicate.

The initial nursing assessment and subsequent nursing care were satisfactory overall but fell below the standard we would reasonably expect in the following areas: firstly the nursing assessment of Mr B's breathing, secondly the formal evaluation of his fluid balance (how much fluid he drank and passed) and thirdly the communication with Mr B and his family, which we would expect to be greater given their level of attendance. The standard of nursing communication was unacceptable in the area of results reporting. We would expect abnormal blood test results to be communicated urgently to the medical staff for immediate action. In this respect the nursing care was unsatisfactory.

Mr B was, however, on an appropriate antibiotic regime on the morning of the 29th November. It is unlikely that the final outcome was affected by the deficiencies in care that have been identified, or that the delay in transferring Mr B contributed to the final outcome.'

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Last updated: 12 January 2006