Selected Investigations Completed April - September 1999

Parliamentary

Access to official information

Health

Parliamentary

Access to official information

Health

Hot topics

Cymraeg

Freedom of Information

Accessibility

Other Ombudsmen and complaint handlers

Feedback

Satisfied with our service?

Part II - Full Texts of Selected Investigations

Complaint against: The Royal Hospitals NHS Trust (now Barts and The London NHS Trust)

Complaint as put by Mrs Q

1. The account of the complaint provided by Mrs Q was that on 28 May 1997, she took her late brother, Mr N, a man with Down's Syndrome, to the Accident and Emergency (A & E) Department of the Hope Hospital, which is managed by Salford Royal Hospitals NHS Trust (the Trust). Mr N had been unwell for several days. He was discharged the same day with a diagnosis of viral infection. On 30 May, Mrs Q found Mr N unconscious and with a high temperature. Mr N was taken to the A & E Department of the hospital, where he was examined by a specialist A & E registrar (the first registrar) and an A & E consultant (the first consultant). At that time Mr N had a degree of neck stiffness and a marked weakness on his left side. The first registrar ordered blood tests and a CT scan (cross sectional imaging of the brain or body using X-rays), and gave Mr N intravenous antibiotics. The first registrar considered several possible diagnoses, including meningitis, but did not record these in Mr N's notes. The first consultant supported the registrar's assessment, but also did not record this in Mr N's notes.

2. The CT scan was clear, and Mr N was referred to the medical team for a decision as to whether he should be admitted to hospital. An unsuccessful attempt was made to fit a urinary catheter. That evening Mr N was seen by a resident medical officer (the second RMO), who prescribed antibiotics and discharged him. Both Mrs Q and the A & E staff nurse expressed concern to the second RMO about her decision and the staff nurse also spoke to the nurse manager and another A & E registrar (the second registrar) about her concerns. Mr Q took Mr N to the Royal Oldham Hospital the following day, where he was diagnosed as having meningitis. He died a week later.

3. Mrs Q complained about the care provided to Mr N on 30 May and the decision to discharge him. She asked for an independent review; and this was granted. The subsequent panel report was critical of communication, but concluded that Mr N's discharge from hospital on 30 May had not been inappropriate. Mrs Q was dissatisfied with the outcome of the review.

4. The complaints I have investigated were that on 30 May 1997:

(a) the staff involved in Mr N's care failed to keep an adequate record of the treatment they gave him; and
(b) his discharge from hospital was inappropriate in the circumstances.

Investigation

5. The statement of complaint for my investigation was issued on 4 August 1998. The Trust's comments were obtained; relevant papers, including Mr N's medical notes for 28 and 30 May 1997, were examined; and one of my investigating officers took evidence from Mrs Q, Mrs Q's brother and Mrs Q's daughter, and from the medical and nursing staff involved in Mr N's care. Two external professional assessors (my clinical assessors) were appointed to advise me on the clinical aspects of this case: their report is at Appendix A. A note setting out the working relationship between key clinical staff involved in Mr N's care is at Appendix B. I have not put into my report every detail investigated; but I am satisfied that no matter of significance has been overlooked.

6. As I have indicated, Mrs Q's complaints were considered by an independent review panel, which was advised by clinical assessors appointed by the NHS Regional Office. Mrs Q was dissatisfied with the outcome and complained to me. In these circumstances, it is not for me to substitute my or my clinical advisers' opinion for that of the independent review and its assessors. I seek to provide an independent and authorative review of the evidence, which I do in this report.

Independent Review

7. The independent review established to consider Mrs Q's complaints considered the following terms of reference:

' To enquire into the care given to Mr N in the A&E Department at Hope Hospital on 30 May 1997, and the decision to discharge him on that date.'

8. The panel met on 19 January and 2 February 1998 and came to findings of fact about the case, including the following:

- that, though there were no definitive signs, meningitis was suspected when Mr N was seen in A & E on 30 May 1997;
- that the delay in Mr N being seen by the [second] RMO was a result of pressures on the department that afternoon;
- that the notes studied by the [second] RMO did not mention meningitis;
- that a staff nurse made representations to the [second] RMO that Mr N was too ill to be discharged;
- the [second] RMO discharged Mr N as a result of her assessment of his condition and told Mrs Q to bring him back if there was any change.

The panel concluded, in summary, that:

- Mr N's was a very difficult case to diagnose and that it is much easier after the event to detect the signs of meningitis than it was for the [second] RMO in a busy A & E department;
- the delays that occurred before Mr N was seen by an RMO were unfortunate but not uncommon in busy A and E departments;
- that it was proper for the [second] RMO to have decided whether or not to admit Mr N and that she made a reasonable decision on the available evidence. The fact that her diagnosis was wrong did not mean that she had been negligent;
- that, though the family had found the RMO's manner abrupt, the panel did not believe she had been offensive or discriminatory in her dealings with Mr N and his family.

The panel recommended a review of communications and handover arrangements between A & E and medical staff; a review of the practice of early administration of antibiotics in A & E (in view of the opinion of the panel's clinical assessors that antibiotics may have obscured the subsequent clinical picture in this case); and a review of strategies for reducing the period during which 'amber' coded patients have to wait for medical team assessment. In response to the panel's findings the Trust Board ordered and implemented a number of changes in procedure.

Complaints (a) and (b) That, on 30 May 1997, staff involved in Mr N's care failed to keep adequate records of the treatment they gave him; and that his discharge was inappropriate in the circumstances

National Guidance

9. In a letter dated 3 February 1988, the then chief medical officer advised doctors about the early management of meningitis. His letter included the following:

' .... If the diagnosis [of meningitis] is suspected .... it is important to consider giving parenteral benzyl penicillin .... '.

Local Guidance

10. A document published in March 1996 (before the events subject to investigation) by the Salford and Trafford Health Authority's Department of Public Health entitled "Guide-lines for the Control of Meningococcal and Haemophilus Influenza B Disease in Salford and Trafford" includes, in a section on the role of the general practitioner/casualty officer:

' .... For suspected meningitis the drug of choice is benzyl penicillin .... '

The Trust's formal response

11. In her response to me the chief executive's senior manager wrote:

'Account of the Complaint

The Trust concur with the account of the complaint provided by Mrs Q save that:-

* Mr N was not formally examined by the consultant. The consultant briefly saw Mr N and confirmed the findings of his Specialist Registrar.

* Mr N was reported to be semi-conscious on admission not unconscious.

* Mr N's temperature on admission was normal.

* [The second RMO's] statement [to the panel] records no expression of dissatisfaction to her by the family about her decision to discharge Mr N.

'Response to [the first complaint] ....

' .... The IRP recommended that "a review be undertaken between the A & E staff and the medical staff". The Trust accepted this recommendation. The "communication" referred to by the panel related specifically to reviewing the way in which a patient's care is transferred from the A & E staff to general medical staff to ensure continuity of medical care. Whilst this is essentially a verbal handover the Trust accepts that supporting written documentation is also of importance.

' .... the Trust recognises that aspects of certain staff's documentation could have been more complete. The Trust accept, in part, .... that while some of the staff involved in Mr N's care failed to keep adequate records of their treatment there is no evidence that all staff involved in Mr N's care failed to do so ....

'The Trust do not accept [the second complaint] [that Mr N's discharge from hospital was inappropriate in the circumstances] as justified ....

'The [second] RMO assessed Mr N at approximately 18.00hrs. [She] was aware of [his earlier] investigation results. GCS [Glasgow Coma Score - a measure of the level of consciousness] is recorded as 14 (normal 15). The decision to discharge Mr N was made by [the second RMO] on the basis of the available history, the examination by others, and herself and in the light of the normal investigation results and his clinical improvement .... '

Evidence of Mrs Q, her brother, Mr P, and her daughter, Miss Q.

12. Mrs Q told my investigator that Mr N had a lively and outgoing personality and was, generally, in very good health. On 30 May, Mr N was taken straight to the resuscitation room of the A & E Department. Mrs Q was upset and went into the relatives' room. Later in the afternoon Miss Q told her that Mr N's CT scan was clear; that the first consultant had said that Mr N was poorly; that he was worried about his left side; but that he had not suffered a stroke. When Mrs Q returned to the resuscitation room at about 4pm, a nurse told her that they were waiting for Mr N to be catheterised before admission.

13. A junior doctor arrived just before 6pm. After making several unsuccessful attempts to catheterise Mr N, she went to fetch a more senior colleague. She returned with the second RMO, who Mrs Q assumed would catheterise Mr N before sending him to a ward. At that time, Mr N was lying flat on a trolley and was completely uncommunicative. The second RMO asked Mrs Q and Mr P whether Mr N was able to communicate, and what his level of pain was. They both stressed to her that Mr N's current condition was quite unlike his normal lively self. The second RMO said that she thought Mr N might have had a small fit. Mrs Q told her that he had not had a fit for many years. The second RMO then said that they could take Mr N home. Mrs Q had been 'dumbfounded'; and she and Mr P protested that they could not possibly take him home in his condition. The second RMO said that they should be grateful that all his tests had been clear, and then left.

14. The family told the staff nurse that the second RMO had said that Mr N could be discharged. The staff nurse looked very surprised, and went to see the second RMO. She returned with the doctor, and gave Mrs Q and Mr P look of "frustrated resignation". The second RMO handed the family some antibiotics to give to Mr N, but gave no advice as to what they should do if his condition deteriorated. Mrs Q said that it took three people to lift Mr N into a wheelchair. She described him as semi-conscious and as slumped to one side. When Mr N left the hospital he was unable to support himself in the wheelchair.

15. Mr P said that when he first saw Mr N he was "completely out of it". When the second RMO arrived, Mr N was lying down flat on the trolley and was still unresponsive. The second RMO told him and his sister that they could take Mr N home. He said that he was "amazed", and kept telling her that they could not take Mr N home in his condition. When they told the staff nurse what had happened she went to speak to the second RMO; but the second RMO came back with some tablets for Mr N, and he was discharged. Mr N was semi-conscious at the time and unable to hold himself upright. Miss Q said that she was present during Mr N's examination by the first registrar, but not when the first consultant saw him. She had been given the impression that Mr N was very poorly and would be admitted.

Documentary Evidence

16. Mr N's medical notes for 28 May include:

'Urinalyasis NAD [nothing abnormal detected]
'.... D/W[Discussed with][the A & E specialist registrar]
'Probable viral infection
'Plan Regular paracetomol
'Encourage fluids
'see GP if no better'

17. In Mr N's medical notes for 30 May the first registrar wrote:

' .... Seen 2/7 ago in A & E. Was fully conscious and responsive .... Now semi conscious and hardly responsive for a few hours. No witnessed fits ....
'GCS 9 ....
'Responsive only to pain ....
'2nd Survey: Apyrexial (no fever)
'PERL(pupils equal and reactive to light)
'Marked neck stiffness
'Head rotated to R side
'Motor power markedly reduced on L side (upper and lower limbs) ....
'Given Benzyl Pen. 1.2g
'Ceftriaxone lg
'CT scan arranged
'15.30: CT scan reported as normal
'Refer to RMO .... '

Mr N's neurological observations include at 17.20:

'Best Verbal Response - Confused ....
' Limb Movement - Legs [on left side] no response' ....

The second registrar's review includes

'GCS 15 .... '

The first registrar's evidence

18. The first registrar told my investigator that in May 1997 all acutely ill patients, other then planned GP admissions, were seen by the A & E team and were then referred to the RMO for admission to an appropriate ward. Before being seen by the RMO, patients would be kept under observation in the A & E department, either in the resuscitation room or in trolley bays depending on the severity of their condition.

19. When Mr N was brought into the A & E department on 30 May, the first registrar was asked to examine him by the nurse in charge of the resuscitation room. Mr N had been triaged (a system of priority classification in any emergency situation) as "orange", meaning that he needed to be seen within 10 minutes. He was told by Mrs Q that she had found Mr N unconscious, and that he had banged his head several days ago. He was also aware of the notes recording Mr N's attendance in A & E on 28 May. Having conducted a "primary survey" to eliminate any life-threatening illnesses, he assessed Mr N's GCS as 9, which is one point above comatose. He then conducted a head-to-toe examination and checked all Mr N's organ systems. He noted that he had marked neck stiffness, that his head was turned to the right, and that he had motor weakness on the left side of his body. He noted also that Mr N's reflexes were increased on the left side of his body. The first registrar said that, given his findings and Mr N's symptoms, he had considered there to be three likely diagnoses: meningitis or an irritation of the meningeal membranes; a subarachnoid haemorrhage; or, given the bang to his head, a bleed to the brain. He did not make a note of these possible diagnoses in Mr N's records, and admitted that this was an oversight on his part. He commented, however, that the record of his findings and his actions would clearly indicate those diagnoses to anyone reading the notes.

20. The first registrar said that where meningitis is suspected the Trust's protocol is to prescribe two antibiotics - benzyl penicillin and ceftriaxone. He prescribed these to Mr N, and also ordered a CT scan to exclude the possibility of a bleed to the brain or a subarachnoid haemorrhage. He expected that the next procedure would be a lumbar puncture, though he did not document this. (Lumbar puncture is a procedure for the sampling of fluid from the area between the membrane which surrounds the brain and the spinal cord - the meninges - and the spinal cord, to exclude or confirm a diagnosis of meningitis.)

21. The first registrar discussed his findings with the first consultant, and explained his diagnoses and proposed plan of action. The first consultant briefly examined Mr N, and told the first registrar that he agreed with his diagnoses and his management of the patient. The first registrar said that he had not recorded the consultant's views in Mr N's notes, as it had been an informal discussion. He saw Mr N regularly during the next couple of hours, but was not aware of any marked improvement in his condition.

22. As soon as he received the clear CT scan, the first registrar referred Mr N to the on-call RMO (the first RMO). He said that a patient would not be given a priority coding at the time of referral. The RMO would assess the priority with which that patient needed to be seen after discussion with the referring doctor. The first registrar told the first RMO about Mr N's presentation on admission; that he had administered antibiotics and had ordered a CT scan, which was clear; that he suspected meningitis or a subarachnoid haemorrhage; and that the next step would be a lumbar puncture. He was very concerned about Mr N's condition and would therefore have indicated to the first RMO that he needed to be seen 'with some urgency' (see also paragraph 27). He said that when he, as an experienced specialist registrar, referred a patient to the RMO (an SHO and more junior doctor) his expectation was that the patient would be admitted. The first registrar was, therefore, "completely and utterly taken aback" to learn that Mr N had been discharged that evening.

23. When he handed over to the A & E registrar (the second registrar) at around 4pm he would not have mentioned Mr N as he had already been referred to the RMO and was, therefore, no longer the responsibility of the A & E team.

The first consultant's evidence

24. The first consultant said that he happened to see Mr N only because he was walking past the resuscitation room just after Mr N had been brought in and noticed that something was "going on". The first registrar demonstrated his findings to him, and he briefly examined Mr N. He agreed with the first registrar's diagnoses, and considered that there was sufficient suspicion of meningitis for Mr N to be given the standard treatment of benzyl penicillin and ceftriaxone. As the result of Mr N's CT scan had been clear, he had assumed that a lumbar puncture would be the next procedure and that Mr N would be admitted.

25. The first consultant said that his normal practice was to make a note in the patient's records of his findings or of any tentative diagnoses. He acknowledged that he should have done so in Mr N's case. He also said that it was common practice for his staff to make a note of any discussion with a senior colleague, although in practice this would depend on the degree of involvement and the severity of the patient's condition.

26. The first consultant said that, in May 1997, the A & E cards of all patients who were referred to the RMO were placed in different colour coded boxes in the doctor's room to indicate the urgency with which they should be seen. The referring A & E doctor was also expected to make a verbal referral to the RMO, which would include a patient's presenting condition, their general condition, and any tentative diagnosis. The hospital now has a medical assessment unit to which all patients, apart from the seriously ill, are referred to be seen by the RMO, having first been triaged by A & E staff. More seriously ill patients are kept in the resuscitation room under the care of the A & E registrar until the patient is seen by the medical registrar and transferred to the medical team. In November 1998 the Trust introduced a revised A & E record card which includes a section for the referring A & E doctor to indicate whether the patient is to be referred for admission or an opinion.

Evidence of the first RMO

27. The first RMO told my investigator that she remembered Mr N, as "N" is a family name. The first registrar referred Mr N to her at around 4pm: he told her that he thought Mr N had some kind of neurological deficiency, but that his CT scan had been clear. The first registrar also told her that Mr N's condition had improved since he arrived, that he was stable, but that he remained unhappy about him. The first registrar did not mention meningitis or a lumbar puncture. The first registrar told the first RMO that Mr N 'did not need to be seen urgently' (see also paragraph 22) and therefore Mr N's A & E card would have been put in the box in the doctor's room and he would have been seen in order. She did not see Mr N before finishing her shift at 5pm, when she left A & E to go on a ward round with a consultant physician (the second consultant). The second RMO was due to take over from her at 5pm. The first RMO is certain that a handover of patients between her and the second RMO took place but could not recall where this had happened. She said that, in the course of the handover, she would have passed on the information given to her by the first registrar (see also paragraph 30).

Evidence of second consultant

28. The second consultant told my investigator that in May 1997 two medical SHOs would have been on duty from 9am, with one responsible for the wards and the heart care unit and the second working in A & E as the RMO for A & E referrals. The SHOs exchanged responsibilities at 5pm; but at 5pm the second consultant also asked the SHO who had been working on the wards to accompany him on an informal ward round of the heart care unit, provided the RMO's clinical priorities permitted this. He said that he would have expected to have been informed if that SHO was needed urgently in A & E. The second consultant said that it was accepted practice for an experienced SHO to discharge a patient even though he or she had been referred to the medical team by a more senior A & E doctor.

Evidence of the house officer

29. The house officer told my investigator that her role was to 'clerk' patients who had been referred to the medical team by A & E staff, having first read their casualty notes. She would then refer the patient to the RMO or the registrar for a decision about admission or discharge. She could remember very little about Mr N other than what she had recorded in his notes. She could not recall having been asked to catheterise him, and had not recorded her unsuccessful attempts to do so in the notes. Her notes include:

' .... Seen in casualty 2/7 days ago - seen by reg - and discharged home /\ of UTI [diagnosis of urinary tract infection] ....
'CNS [Central Nervous System] - P.E.A.R.L_ ) Done by
Not formally examined_ ) casualty officer
'PNS - Reflexes, R=L=N ...._ ) and RMO
'Imp =? viral illness
' Plan = revision by SHO
'S/B [seen by] SHO
'Mostly like viral illness superimposing UTI
'Plan for discharge on 200mg Trimethroprin for 3/7
'Advise to see GP if further problems'

The house officer said that she would not have conducted a neurological examination, as Mr N would be examined by the RMO. She left a space in her records to finish the 'clerking' of the patient after they had been read by a more senior doctor.

Evidence of the second RMO

30. The second RMO told my investigator that patients referred to the RMO by an A & E doctor were classified in priority terms as red, amber or green, and a card indicating the priority marking would be put in a box. Amber, which was Mr N's classification, meant that a patient should be given priority after cases of a life-threatening nature, including, for example, heart attack patients. It was normal practice for the RMO to review the house officer's 'clerking' of a patient and for the RMO to decide whether or not a patient should be admitted. If the RMO needed further advice the registrar would be contacted. After 5pm the registrar would be 'off the hospital premises' but 'on-call'. The second RMO said that, usually, there was no handover between the incoming and the outgoing RMOs, and that there was no handover between her and the first RMO on 30 May (see also paragraph 27).

31. The second RMO said that on 30 May she had been due to take over from the first A & E RMO at 5pm. However, as she had accompanied the second consultant on a ward round of the heart care unit between 5 and 6pm, she did not go down to A & E until 6pm. Five or six patients were waiting to be seen, including Mr N, who had just been examined by the house officer. While the house officer was finishing her notes the second RMO made herself aware of Mr N's history by reading his A & E cards for both 28 and 30 May. She noted that Mr N had been discharged from the hospital on 28 May with a viral infection, having suffered a bang to the head several days before. She also noted that he had been found semi-conscious; that he might have been in that condition for one or two hours; and that on admission he had returned a GCS score of 9. She noted that the first registrar had recorded that Mr N had marked neck stiffness, that his head rotated to the right, and that he had left-sided weakness. She said that the first registrar's findings suggested that Mr N had suffered from either a stroke or a bleed, but that no differential diagnoses had been recorded in his notes. She had noted that Mr N's CT scan had been clear. She had not drawn any specific conclusion from the first registrar having prescribed the antibiotics benzyl penicillin and ceftriaxone. The house officer read out her findings, and the second RMO noted that she had made a provisional diagnosis of "possible viral illness".

32. The second RMO said that when she examined Mr N the back of his trolley was raised and he was sitting up independently with his eyes open. He was holding his groins and complaining of pain. She introduced herself to Mr N and asked him some questions, to which he was able to respond clearly. He told her his name and date of birth; and he knew that he was in the Hope Hospital and that it was Friday. The second RMO asked his relatives what their main concerns were. They stressed that Mr N was not his usual self, and explained his recent history. The second RMO then conducted a full physical examination, checking for signs of a serious neurological condition. She recorded a GCS score of 15, and concluded from his clear CT scan that he had not suffered from a stroke or a bleed. She noted that Mr N had suffered from neck stiffness earlier on, and that this could indicate several causes, including meningitis. However, she said that when she examined him Mr N was able, when asked, to perform a full range of movement, and he had no rash and no photophobia (aversion to light). She commented that left-sided weakness and head rotated to the right was an unusual combination in meningitis cases, and that it was also unusual for someone to feel unwell for over a week if suffering from meningitis. On the basis of the available clinical evidence the second RMO concluded that Mr N might have suffered a transient ischaemic attack at around 12 noon, which would have explained the improvement in his GCS score. Alternatively, she thought he might have suffered a seizure at 12 noon, which would also have fitted the clinical findings. She knew from the clinical notes that Mr N had experienced fits in the past, although he was not receiving medication for them. Given his symptoms when she examined him, the pain in his groins, the production of less urine, and what was indicated on his neurological chart, the second RMO concluded that Mr N had a urinary tract infection which had lowered his threshold for a fit.

33. The second RMO said that, in considering whether or not to admit Mr N for observation she had taken into account that Mrs Q was a trained auxiliary nurse - a fact that was recorded in his A & E records - and that she seemed a very capable person who would be able to observe and care for her brother. The second RMO stressed, however, that if there had been clinical evidence to indicate that Mr N required admission to hospital she would have arranged it. The second RMO explained to Mr N's relatives that his tests were clear; that she thought he was suffering from a urine infection; and that she could either admit him for observation, in which case he would be in unfamiliar surroundings and might be afraid, or he could go home with them. She asked what they thought; and they seemed content with her suggestion that they should take him home, and expressed no dissatisfaction or surprise. The second RMO told them that if there was any change or deterioration in Mr N's condition they should bring him back to the hospital.

34. When the second RMO began to write up her notes she realised that she had not checked Mr N's reflexes and so went to the doctor's office to fetch a tendon hammer. There she met the staff nurse who asked her what was happening about Mr N. The staff nurse did not express any concern about her decision to discharge Mr N on either her or his relatives' behalf. When the second RMO went back to check Mr N's reflexes, neither the staff nurse nor Mr N's relatives said anything further to her about his discharge.

The staff nurse's evidence

35. The staff nurse said, when interviewed, that she was in the resuscitation room when Mr N arrived at 2pm and, again between 4.15pm and 9pm. She described the later shift as "very busy" and that they did not have a bay free all evening. She looked after Mr N until his discharge. She said that he was "very poorly" on admission and had improved only slightly by 4.15pm. He was conscious, and was sitting up on the trolley supported by the back-rest. He did not converse, but answered questions put to him in monosyllables. She mentioned to the first registrar that Mr N's relatives were concerned that he had not passed urine for some time. The first registrar said that Mr N had been referred to the medical team, and that she should speak to the first RMO about catheterising him. She did not speak to the first RMO about Mr N. She was concerned that there appeared to be no RMO on duty in A & E between 5 and 6pm, and that Mr N was still waiting to be seen by a doctor.

36. The staff nurse was present when the house officer made two unsuccessful attempts to catheterise Mr N. However, she was busy with another patient when he was seen by the second RMO. After the RMO had left Mr N's bay she went in and asked Mrs Q what the RMO had said. Mrs Q said that the RMO had examined Mr N and said that she thought he had a urine infection and that she was discharging him. The staff nurse said she was shocked that Mr N was to be discharged, and told his family that she would speak to the second RMO.

37. The staff nurse said that there was no procedure to follow when a nurse was concerned about a doctor's decision to discharge a patient, but that she had no qualms about raising such concerns. She spoke to the second RMO in the doctor's room, and asked what was to happen about Mr N. The second RMO said that she could find nothing clinically wrong with him; that she thought he had a urine infection; and that she was sending him home. The staff nurse told the second RMO that she was concerned that Mr N was still unable to move his left side, and that his family were unhappy with the decision to discharge him as he was unable to communicate normally. The second RMO repeated that she could find nothing wrong with Mr N; and so the staff nurse returned to the resuscitation room. There she said to both the senior nurse, who was on duty with her, and to the second registrar, that she "couldn't believe that they were sending that man home". She explained that this was said more as a passing comment than a formal raising of a concern.

38. She asked the senior nurse to assist her in helping Mr N off the trolley and into a wheelchair. The trolley was high, and it was good practice for two members of staff to help a patient off it. She was unable to recall whether Mr N had difficulty in sitting up in the wheelchair.

Evidence of the senior nurse

39. Thesenior nurse said when interviewed, that once a patient had been referred to the RMO, their A & E card would be put in one of two colour-coded boxes, either amber or green, in the doctor's room. Patients whose cards were in the amber box would have priority over those in the green. On 30 May, she assumed responsibility for the resuscitation area at 4.15pm, but could not recall having been told about Mr N. She said that it was a particularly busy shift, and that they had to move patients around. She could recollect only vaguely the staff nurse saying to her that a patient was to be discharged who should not be. A short time later the staff nurse asked if she would assist her in helping Mr N from the trolley and into a wheelchair. Neither the staff nurse nor Mr N's relatives raised any further concerns about his discharge; and she assumed that the situation had been resolved. She recalled that Mr N was able to sit up in the wheelchair.

Findings(a)

40. My investigation has highlighted omissions and errors in the record keeping of the majority of the staff (the first registrar, the first consultant, and the house officer) who dealt with Mr N on 30 May. In their report at Annex A my assessors note that in Mr N's record for 28 May the SHO on duty recorded both her provisional and her discharge diagnosis, and that she also made a note of her discussion about Mr N with the first registrar. They note, on the other hand, that in Mr N's record for 30 May the first registrar failed to record either his provisional diagnoses or his diagnosis on referral to the RMO; nor is there any record in the notes of the first consultant's involvement with Mr N. The first registrar said that his failure to record his presumptive diagnoses was "an oversight". The first consultant said that it was his "normal practice" to note his findings or tentative diagnoses in a patient's records, and has acknowledged that he should have done so in Mr N's case. My assessors have advised me that it is accepted practice that any involvement by senior doctors should be recorded by junior medical staff, and that when a patient is referred to another speciality both the referral diagnosis, whether provisional or definitive, together with the time of the referral, should be recorded. This practice was not followed when Mr N was seen on 30 May. If it had been, then the second RMO would have had before her a full clinical picture, which would have aided her when she examined Mr N later that day.

41. My assessors also note that, on 30 May, the house officer incorrectly recorded in her 'clerking' of Mr N that he was discharged home on 28 May with a diagnosis of urinary tract infection. His record for 28 May states, on the other hand, that tests had shown no sign of infection, and that a discharge diagnosis of a possible viral infection had been made. The house officer also failed to record her unsuccessful attempts to catheterise Mr N. My assessors' view, with which I agree, is that all procedures, should be recorded, whether successful or not.

42.I uphold the complaint and I criticise the staff I have mentioned. I am pleased to note that the Trust has taken action to ensure that staff are reminded of the need for all medical records to be accurate and complete and, also that standards of record keeping are subject to audit. I recommend that the Trust should ensure that this reminder is acted upon.

Findings (b)

43. Although my investigation of this aspect of the complaint has centred on whether the decision to discharge Mr N was appropriate, my enquiries have necessarily explored the circumstances surrounding his referral by the A & E staff to the medical team. My investigation has revealed areas of serious concern.

44. There appears to have been confusion amongst both A & E and medical staff about the procedure for referral of a patient from an A & E doctor to an RMO, and how a patient's priority should be assessed by the medical team. My investigator was told by the senior nurse, the second RMO, and the first consultant that once a patient had been referred to an RMO, their A & E card would be placed in colour-coded boxes in the doctor's room; cards of patients who were required to be seen more quickly would be placed in the amber box. As my assessors have pointed out, while such a system suggests that patients would be seen by an RMO in order of priority and as time allowed, the actual referral was an oral one. The referring A & E doctor would be expected to give the RMO, at the time of the handover, a provisional diagnosis and convey the urgency with which a patient should be seen. The significance of the information conveyed at the referral is confirmed by the evidence of the first registrar.

45. Paragraphs 22 and 27 show a clear conflict of evidence between the first registrar and the first RMO. The former has said that, in the light of his concern about Mr N's condition, he would have indicated to the first RMO that he should be seen 'with some urgency'. The first RMO, on the other hand, said in evidence that the first registrar told her that Mr N 'did not need to be seen urgently'. This emphasises, of course, the importance of proper record keeping and clarity in the handover of patients from one clinician to another. On the balance of probability I accept the evidence of the first registrar in view of the fact that he came to a differential diagnosis of meningitis when he saw Mr N on 30 May and prescribed antibiotics accordingly. Mr N, despite being classified as amber, and with a presumptive diagnosis of meningitis, was not seen by the first RMO before she left A & E at 5pm to attend a ward round with the consultant physician.

46. Although the second RMO was due to take over from the first RMO at 5pm, she attended the same ward round as the first RMO (paragraph 45) between 5pm and 6pm, with the result that there was no RMO in A & E during that period. The medical registrar, though on call, left the hospital at 5pm. Consequently, Mr N, and any other patient still waiting to be seen by the RMO at 5pm, waited a further hour before being seen by the second RMO. I agree with my assessors that the delay in Mr N being seen by the second RMO cannot be justified. Given the contradictory evidence I have been given by the first and second RMOs (paragraphs 27 and 30), I have found it difficult to determine whether there was an oral handover by the first RMO to the second RMO or if, indeed, this is common practice at the Trust. Nevertheless, my investigation points to the need for the Trust to ensure that there is an effective handover of patients by outgoing staff to those coming on duty and I am pleased to note that the Trust has already made changes to put a formal handover procedure in place.

47. It emerged from my investigation that, when patients were referred by an A & E doctor to an RMO, they were no longer considered the responsibility of the A & E team, even though, as in Mr N's case, they might have to wait some hours before being examined by an RMO. I am pleased to note (paragraph 26) that the hospital has now established a medical assessment unit to which all but the more seriously ill patients are referred from A & E to be seen by the RMO. I note also that all acutely ill patients now remain in the A&E department under the care of an A&E registrar until they are transferred to the care of the medical registrar.

48. I turn now to the question whether the decision to discharge Mr N was appropriate in the circumstances. I have been given conflicting evidence by his relatives and by hospital staff as to Mr N's level of consciousness and his responsiveness from mid-afternoon until his discharge at 6pm. Mrs Q, who was, understandably, extremely distressed at her brother's condition and the events of the day, recalls that he was lying flat on a trolley and was completely uncommunicative. Her account of Mr N's condition is supported by that of her brother. The staff nurse says, on the other hand, that when she came back into the resuscitation room at 4.15pm, Mr N was sitting up, supported by the backrest of his trolley and was answering questions in monosyllables. Her account supports that of the second RMO, who said that at 6pm Mr N was sitting up on the trolley and was able to answer simple questions she put to him. Despite the conflict in evidence about Mr N's general condition, I have no doubt that he was not the lively individual that his family knew. I am also persuaded by the family's evidence and by that of the staff nurse, that they made their concerns about the decision to discharge him known to the second RMO, and that the staff nurse also expressed to her both the family's and her own concern at that decision.

49. The second RMO maintains that she decided to discharge Mr N on the basis of the clinical evidence available to her. My assessors have noted, however, that while she recorded a GCS score of 15 for Mr N, she appeared not to have taken into account his neurological observation chart, which at 17.20 showed Mr N to be confused and to have persistent left sided weakness. The assessors have also noted that although the second RMO has said that she drew no specific conclusion from the first registrar's administration of the two antibiotics, benzyl penicillin and ceftriaxone, her references to rash, photophobia, and neck movement in the notes of her examination, indicate that she was looking for signs of meningitis. The local and the national guidance referred to in paragraphs 9 and 10 of my report are clear that, where meningitis is suspected, the accepted protocol is to prescribe benzyl penicillin as the initial response. I am advised by my assessors that a doctor of the second RMO's experience should have been aware of this. I agree and I criticise the second RMO for her actions.

50. I have already noted (paragraph 40) that, contrary to accepted good practice, both the first registrar and the first consultant failed to record any diagnoses, including meningitis, when they saw Mr N on 30 May. However, my assessors advise me that when Mr N was examined by the second RMO later that day there was sufficient information in his medical and nursing records to indicate that admission was required in order to confirm or disprove a presumptive diagnosis of meningitis. I agree. However, it is clear that the failings in record keeping of those staff who saw Mr N earlier in the day resulted in the second RMO not having a full picture of Mr N's clinical condition. If she had she might not have made the error of judgment in deciding to discharge him. I uphold the complaint.

Conclusion

51. I have set out my detailed findings in this case in paragraphs 40-50 above. They represent a disturbing account of system failure, poor recording and clinical judgment below that which a patient has a right reasonably to expect. The patient in this case was disabled and was badly let down by the medical staff and by procedures in force at the time - particularly those related to the handover of patients from A & E to other in-house specialties.

52. I have no doubt from the evidence I have taken and from the detailed advice given to me by my assessors, that the initial judgments reached and actions taken by A & E staff on 30 May were right. The first registrar reached provisional diagnoses of meningitis, subarachnoid haemorrhage, or a bleed to the brain. He then prescribed drugs in accordance with national and local guidance in view of the first of these possible diagnoses and decided upon a CT scan to assess the second and third. However, having done so, he failed to record either his provisional diagnoses or his diagnoses when he referred Mr N to the first RMO. Similarly, he failed to document his expectation that a lumbar puncture would be performed and there is no record of the involvement of the A & E consultant. These failings took on even greater significance when seen alongside the confusion in the referral system (paragraph 44); the failure of the first and second RMOs to conduct an effective handover and conflicting accounts of what was said at that time (paragraphs 22 and 27); further inaccuracies in the records of the house officer; and the error of judgment made by the second RMO. I am unable to say whether, if matters had not taken the course they did, Mr N might have survived. I can say that the failings I have identified, in particular the failure to record or otherwise communicate clinically important information, have serious implications for patient safety and should be addressed as a matter of urgency.

53. The Trust has asked me to convey to Mrs Q - as I do - its apologies for the shortcomings I have identified and has agreed to implement my recommendation in paragraph 42, and those of my assessors, with which I agree, in paragraphs 55 and 56 of their report at Appendix A, though not that in paragraph 54. I am pleased that the Trust has already acted on the recommendations in paragraphs 51-53 and 57 and 58 of my assessors' report.

Annex A

Professional Assessors' report

Matters Considered:

i) The staff involved in Mr N's care failed to keep adequate records of their treatment of him;

ii) Mr N's discharge from hospital was inappropriate in the circumstances.

Basis of report:

1. Particulars of documentation made available to us by the Office of the Health Service Ombudsman:

a) Statement of complaint.

b) Copies of correspondence relevant to the complaint.

c) Notes of the interviews which were conducted by the Ombudsman's investigator with Mrs Q, Mr P and Miss Q.

d) Notes of the interviews which were conducted by the Ombudsman's investigator with the following medical staff in the presence of one of the assessors.

1. A & E specialist registrar (the first registrar)
2. A & E consultant (the first consultant)
3. A & E senior registrar (the second registrar)
4. Senior house officer (SHO)/resident medical officer (RMO) (the second RMO)
5. Consultant physician (the second consultant)

Back to top

e) Notes of the interviews which were conducted solely by the Ombudsman's investigator with the following medical and nursing staff.

1. SHO/RMO (the first RMO)
2. House officer
3. Staff nurse
4. Senior nurse

f) Mr N's medical records for 28 and 30 May 1997.

2. Documentation requested by Assessors

a) CT scan request for Mr N dated 30 May 1997
b) Protocols for CT request - none available
c) Protocol for admission of patients from A&E - none available
d) Protocol for referral of patients from A&E to Medical Team - none available
e) A & E and medical rotas
f) A & E Discharge Policy - none available
g) A & E Patient Register for 30 May 1997 covering patients' attendances from 09.56 to 18.57
h) Triage Protocol

Back to top

Other Documentary Evidence

3. We have both perused and discussed the records of the interviews. We have also perused both the documentation provided by the Ombudsman's office and the documentation requested by the assessors, and Mr N's medical records.

Discussion

4. In discussing our findings, specifically relating to the statement of complaint, it was felt appropriate to deal with these in three sections:

A. Events and Documentation of Procedures in A & E Department on 28 and 30 May 1997
B. Referral and Handover to Medical Team on 30 May
C. Decision to Discharge

Back to top

A. Events and Documentation of Procedures in A & E Department.

5. Mr N was appropriately triaged as "orange" (patient to be seen within 10 minutes) on his arrival in the A & E Department at 13.54 on 30 May 1997. The ambulance report form noted him to be lethargic and unresponsive and with a Glasgow Coma Score ( a measure of the level of consciousness, normal being 15) of 10. Initial nursing and medical assessment was timely and appropriate, as were the initial investigations. His Glasgow Coma Score, recorded as 9, showed a deterioration from the time at which the ambulance assessment was made. Neck stiffness, weakness and unresponsiveness were apparent and were noted in the written record and also on the neurological observation chart. Intravenous anti-biotics were administered and a CT brain scan was ordered which was an appropriate investigation to arrange. The request for the CT scan mentioned relevant clinical data and raised the possibility of a subarachnoid haemorrhage. A verbal report at 15.30 stated the investigation to be normal and this was confirmed in a typed report from a consultant radiologist. Between 15.30 and 16.00 Mr N was referred to the RMO on duty in the A & E department.

6. Mrs Q states that her daughter was present throughout both the first registrar's and the first consultant's examinations of Mr N. The Mrs Q's daughter stated that she was present during the registrar's examination of her uncle though not that of the consultant. As Mrs Q was at that time in the relatives room, we would consider this as being a misunderstanding on her part. The first consultant states that the first registrar demonstrated his clinical findings to him and this is confirmed by the first registrar. There is no record in Mr N's records of the first consultant's attendance in the resuscitation room.

7. In Mr N's record for 28 May 1997, there is a note of a discussion by, we presume, an A & E SHO with the first registrar, with regard to his diagnosis at that time. It would, therefore, appear to be the practice of the examining doctor to record such discussions with a senior member of staff.

8. In Mr N's record for 28 May, a provisional diagnosis has been made and recorded, as has a discharge diagnosis. No provisional diagnosis has been entered in Mr N's A & E record of 30 May, nor is there a note of a referral diagnosis following his A & E investigations.

Back to top

CONCLUSION - A

9. We consider there to be inconsistencies in A & E record keeping. Based on the A & E SHO's entries on Mr N's A & E records for 28 May, we assume that the normal practice is to enter both provisional and definitive diagnoses on patients records.

B. Referral and Handover to Medical Team 30 May

10. The first registrar states that on referral to the first RMO he told her of the nature of Mr N's presentation, the administration of anti-biotics, the ordering of the CT scan and his suspicion with regard to meningitis or a subarachnoid haemorrhage and that the next procedure would be a Lumbar Puncture (not a procedure performed by A & E staff).

11. The first RMO considered the referral to have occurred at 16.00. She states that the first registrar told her that Mr N had been unwell and that he thought that Mr N had some kind of neurological deficiency, but that the CT scan was clear. A discussion with regard to urgency took place, as the first registrar considered Mr N's condition to have improved. There was no mention of meningitis or a lumbar puncture.

12. There is, therefore, a discrepancy between the first registrar's and the first RMO's recollections of the information given at the referral. Mr N was not seen by the first RMO, who left the A & E Department at 17.00., and it was not until approximately 18.00 that Mr N was seen by the house officer and then by the second RMO. The first RMO says she left A & E at 17.00 to go on that consultant's ward round with the second RMO.

13. The senior nurse comments that once the patient had been referred to an RMO, the A & E card was put in one of two colour-coded boxes, either amber, or green, in the doctors room and that the cards were generally put in those boxes by the nurses. From this it would appear that the RMO assigned to the A & E department would deal with those patients as time allowed. However, as the actual referral was a verbal one between A&E medical staff and the RMO, the urgency, we would consider, was conveyed at the time of the referral, rather than waiting for the RMO to peruse the cards in the box. If, as the senior nurse states, patients have to wait three to four hours to be seen by the RMO, then the triage categorisation would appear to have been completely ignored and, therefore, redundant (refer triage score para 5).

14. From the patient attendance record, it is apparent that patients who are expected by the admitting medical and surgical teams because of referral by a GP, are seen by the A & E department in its function as a Medical and Surgical Assessment area. They are given the usual A & E triage categories to determine their priority. A similar practice was in operation on referral of patients by the A & E staff to the RMO. This is confirmed by the second RMO and the first consultant. However, the first registrar states that A & E RMO referrals were not so classified, priority being determined by discussion of the case with the RMO allocated to the A & E department.

15. The first registrar states that on handing over to the second registrar, he did not mention Mr N to him as he had by then been referred to the medical team and was, in his view, no longer A & E's responsibility.

16. The second registrar stated that he would have been informed of any on-going or serious problems with patients in the A & E department, though could not recall mention of Mr N.

17. Thus, Mr N waited some two and a half hours to be assessed by the Medical Team. Throughout this period neurological observations were being performed diligently by the A & E nursing staff.

18. The staff nurse notes that she was on duty in the resuscitation room at the time of Mr N's arrival. The staff nurse describes the resuscitation room as being a 4 bedded room with separate curtained-off bays. Mr N remained there before and after his CT scan. Mention is made of the resuscitation room being busy. Although it is not possible from the patient attendance register to determine whether, or not, any of those patients' triage categories were changed during the time they spent in the A & E department, there are only three patients in the register after Mr N, who required initial assessment in the resuscitation room. One was triaged in the same category as he, arriving at 14.42 when Mr N was in CT, one other arriving at 14.32 and triaged yellow, the other at 15.15 and triaged yellow. There is no record of the length of time these patients spent in the A & E department, or the length of time following referral to the RMO that they waited to be seen, nor the length of time it took them to reach the wards.

19. From the time of Mr N's arrival to the time of his discharge, there were fifteen patients who were considered to need the "Majors Side", which we understand to mean requiring a stretcher trolley. Five of those did not have a triage category, and including those in the resuscitation room, two were triaged orange, including Mr N, five were triaged yellow and three were triaged green. Three of the Majors coded green were pre-arranged attendances.

20. The senior nurse took charge of the resuscitation room at 16.15. There was a hand-over but she could not recall being told about Mr N.

CONCLUSIONS - B

21. A verbal referral between the referring A & E doctor and the RMO would be expected to convey the urgency of a patient's condition and would be expected to include a provisional diagnosis. The first registrar, having given anti-biotics, would, we consider, have come to a working diagnosis of meningitis, as the CT scan had excluded other intra-cranial pathology. This was not apparently conveyed with sufficient emphasis to the first RMO, or she misinterpreted the significance of that conversation.

22. Handover of both medical and nursing staff occurred about the time of this referral and we would consider that the presence of a patient in the A & E department who had required emergency CT scanning, should have been conveyed to both the on-coming senior medical and nursing staff.

23. We also consider that the requirement for such an urgent procedure should have been conveyed to a senior member of the admitting team, especially when it appears that both the medical registrar and the second consultant were in the hospital.

24. It appears that the practice at the Trust was that once a patient had been referred from the A & E department, no further responsibility for that patient was taken by A & E medical staff, though such medical patients could remain within the department for several hours before being seen by the RMO. The assessors consider this practice inappropriate.

25. The use of colour-coded triage boxes in the doctors' office following RMO referral appears in practice to have had no functional significance.

26. The delay in Mr N being seen by the RMO cannot be justified in the assessors' view.

C. Decision to Discharge

27. The second RMO states that between 17.00 and 18.00 she accompanied the second consultant on a ward round. The first RMO states that she was also on the same ward round and that between 17.00 and 18.00 she informed the second RMO of patients who were waiting in the A & E department and who were required to be seen by the RMO. There was, therefore, no RMO present in A & E for an hour. We understand that the medical registrar had left the hospital by 17.00.

28. The second RMO states that the house officer who had already seen Mr N, was completing her notes and she, the RMO, read the A & E records of his attendances on 28 and 30 May. She was aware he had been discharged on 28 May with a viral infection; that he had injured his head several days previously; and that on 28 May he had a Glasgow Coma Score of 15 and had been triaged green. She was aware of Mr N's Glasgow Coma Score of 9 on 30 May and of the first registrar's clinical findings. She was aware from the records that he was unresponsive on presentation. She comments within her statement that the first registrar's findings were suggestive of a stroke or a bleed, but that there was no differential diagnosis recorded in the notes. She confirmed that a CT scan was ordered to look for a bleed, but the result of that investigation at 15.30 was normal. She makes mention of noting the administration of antibiotics, which occurred 4 hours prior to her seeing Mr N, though she did not draw any specific conclusion from this.

29. The house officer read out her findings to the second RMO but she, the RMO, had no discussion with the house officer regarding Mr N's condition. She noted that the house officer had made a provisional diagnosis of "possible viral illness".

30. The house officer's notes record that Mr N had been seen by the second RMO and diagnosed as having a viral illness with superimposed urinary tract infection. The second RMO's notes then follow.

31. From the second RMO's statement we gained the impression that the house officer's notes were completed prior to her reading out her findings to the RMO. We would anticipate that such a presentation would include a history, as well as clinical findings and note that the house officer mentions that she did not perform a central nervous system examination. She then mentions that pupils were equal and reactive to light and accommodation and that reflexes were normal, in parenthesis, indicating that a formal neurological examination had been performed by the casualty officer and the RMO. We find it perplexing that the house officer would leave gaps in her notes to be filled in after senior doctor review and would not have performed a neurological examination, in light of the history, the A&E medical record and nursing observations.

32. In the house officer's notes, there is a record in the history of the presenting complaint that Mr N was found unresponsive by his half sister at midday. She notes the family were aware of no urinary incontinence, no frothing at the mouth and no rigidity of his limbs at that time. She recalls that he was normally very active and talkative, had banged his head approximately one week ago and been unwell for a similar period. He had been complaining of a headache. He had been seen in the A & E department two days previously, seen by the first registrar and discharged home with a diagnosis of urinary tract infection. This was incorrect as examination of his urine at that time showed no evidence of infection and a discharge diagnosis of possible viral infection was made. He was noted not to be improving, hence the re-attendance at the A & E department and was complaining of pain in the lower abdomen, and in the groins and renal areas, and had not passed urine. Mr N was not known to be epileptic but did suffer from some seizures "years back". He was not on any medication for these. It was noted that Mr N had an atrial septal defect and had had surgical ligation of varicose veins. On her examination, the house officer considered Mr N to be conscious, responding to some commands, though rather slowly, and that there had been some apparent improvement since he first came into A & E. She performed a rectal examination and then attempted to catheterise Mr N, as confirmed by Mrs Q and by the staff nurse, though there is no indication of this attempted procedure in the house officer's notes. She notes the administration of anti-biotics, the normality of the CT scan and records the normal haematological and biochemical profiles.

33. We note that blood cultures were also taken by the A & E staff, but the result was not in the clinical records.

34. The neurological observation chart, which at 17.20 showed Mr N to be confused and to have persistent left-sided weakness was available to the house officer, though there is no comment on it in her notes.

35. In reviewing Mr N's notes, the second RMO would have been aware that on his attendance on 28 May 1997, he had been fully alert and orientated, able to give a coherent and concise history, had had no urinary frequency, had a temperature 37.7 degrees Centigrade instead of normal temperature and that a urinary tract infection had been ruled out by examination of a specimen of urine.

36. The house officer's history asked specifically for indications of Mr N's having had a fit and recorded that there were none. The second RMO's record indicates that she noted all the information recorded by the house officer. There is no mention in her notes of any reference to fits or to transient cerebreal ischaemia. When interviewed she stated that from the available clinical evidence she considered that Mr N might have suffered from a transient ischaemic attack or a seizure at about 12pm, the threshold for which had been lowered by a urinary tract infection.

37. She noted that the first registrar's finding were suggestive of the possibility of a stroke or a bleed, and noted the normal CT, which excluded these conditions. (It also excluded his having had an intra-cranial event secondary to the bang on the head).

38. She also noted that he had no bladder distention to suggest urinary retention. In the light of Mr N's recorded symptoms of abdominal and loin pain, pain on urinating and lethargy, she concluded that he had a urinary tract infection. However, she came to this diagnosis in the absence of urine for testing on 30 May.

39. She noted that he had a Glasgow Coma Score of 15, yet not that the neurological observation chart indicated continuing weakness, though it showed improvement from the time of its commencement at 14.00.

40. Although the first registrar's notes indicate no specific diagnosis, they do record, as do the house officer's notes, the administration of two specific anti-biotics which the second RMO states caused her to draw no specific conclusion with regard to the requirement for such administration.

41. Her examination notes, however, indicate that she was specifically looking for signs of meningitis with her references to neck movement, photophobia, alertness and rash. These two matters are, therefore, contradictory, the administration of such medication being the accepted and recommended treatment for meningitis to be given as soon as possible, once that diagnosis is suspected. It is recommended that family practitioners should initiate such treatment prior to transferring patients with suspected meningitis to a hospital. It is then anticipated that the necessary investigations will be done to prove or disprove that diagnosis. We consider that a practitioner of the second RMO's experience as a SHO in medicine, should be aware of this nationally accepted, Department of Health, protocol.

42. The staff nurse notes that she was 'shocked' to learn that Mr N was to be discharged and spoke to the second RMO about this. Both her emotive reaction to this decision and her subsequent action in speaking to that RMO are confirmed by Mrs Q and by Mr P.

43. The staff nurse said that having spoken to the second RMO away from the resuscitation room, she then returned to it and spoke to the senior nurse and to the second registrar who were dealing with a child with a broken arm in that room.

44. The staff nurse states that there was no protocol in place for her to action if she had concerns about the condition of a patient being discharged. She did, however, take appropriate action in speaking to the senior nurse and to the second registrar. The senior nurse states that she could not determine the level of the staff nurse's concern and the second registrar had no recollection of the staff nurse speaking to him nor of any concern.

45. The second RMO's conclusions that the family were happy to take Mr N home is disputed by both Mrs Q and by Mr P. The family's expectation that Mr N was to be admitted is apparent in the statements of Mrs Q, Mr P and Miss Q who telephoned the ward on which she worked to inform them of his likely admission.

Back to top

CONCLUSION C

46. We consider that the staff nurse's actions were appropriate, though there is no protocol operating in the A&E department if a nurse is concerned about a patient's discharge.

47. Though there is minor inconsistency in the house officer's transposition of the notes of 28 May regarding the discharge diagnosis on that day, it was evident on perusal of those records what that discharge diagnosis was and the neurological status of Mr N on that date. We consider that in his written records, investigative reports and nursing observation records and in the action of A&E medical staff on 30 May, there was sufficient information to necessitate his admission for further investigation to confirm, or disprove, a presumptive diagnosis of meningitis.

48. The assessors therefore consider that Mr N's discharge from hospital to have been inappropriate.

49. OPINION

We are of the opinion that:

1. The staff involved in Mr N's care failed to keep adequate records of their treatment of him, and

2. Mr N's discharge from hospital was inappropriate in the circumstances.

Recommendations

50. The specific requirement for accuracy and completeness of medical records, both within A&E and elsewhere within the hospital, should be reinforced and audited. The accepted practice is that, in all instances, senior medical involvement and any conclusions should be recorded by junior staff. All procedures whether successful or not must be recorded.

51. Provisional "working" diagnoses should be entered on all patient records. The time of referral to other specialities, preferably to a named and recorded doctor, with the referral diagnosis, provisional, or definitive should be recorded.

52. Responsibility for patient care must be clarified and a protocol agreed upon by A&E and the physicians, and other in-hospital specialities, to ensure no patient is left "in limbo" as in this case.

53. The referral procedure requires to be specified and priority determined at the time of that referral. The present usage of the Triage system, specifically an A&E tool, is inappropriate for staff outside the A & E department.

54. Medical and nursing handovers in A & E must include all patients in the resuscitation room and "Majors Side". Those patients in A&E, save for the "pre-arranged GP referrals", must remain under the care of A&E until seen by the doctor to whom the referral has been made. A&E must accept responsibility for all patients in the Department until that care is officially taken over by another doctor, who should be present at the time.

55. All patients discharged must be considered "safe" and a protocol instituted for nursing staff and other A & E staff having concern about the discharge of a patient. Senior A & E staff must action all such concerns and record their action and decisions in the medical record.

56. Staffing arrangements and organisation of junior physicians need to be specified and reinforced, so that ward rounds do not result in the RMO being absent from A & E when referred patients are waiting to be seen. The role of the medical registrar should be reviewed as it was inappropriate that he was away from the hospital at 17.00, when there were patients waiting two to three hours to be seen by the RMO.

57. "Fast track" policies should be developed to ensure that patients causing concern in A & E are assessed quickly and taken over by the admitting medical team, and direct admission by A & E staff to medical admission wards facilitated.

58. CT request policy requires formalisation and all patients being scanned reviewed by senior medical staff.

Annex B

STAFF INVOLVED IN MR N'S CARE ON 30 MAY 1997

A & E Staff

A & E consultant (the first consultant)

A & E registrar (the first registrar)

Medical staff

Medical consultant (the second consultant)

The first RMO (the senior house officer on duty in A & E between 9am and 5pm)

The second RMO (the senior house officer on duty in A & E between 5pm and 9am)

The house officer

Nursing staff

The senior nurse

The staff nurse

Previous < Contents > Next

Short text of this investigation

Last updated: 9 January 2006