Triage
13. The main function of triage is to make a system for prioritising patients when there is high demand.
14. Ms KN says when they arrived in the ED it was full, with patients sitting and lying on the floor. She says Mrs K was taken into a side room where her blood pressure was taken and they were then asked to wait in the waiting area. She says Mrs K was bleeding, in pain, agitated and frightened. She says Mrs K was not triaged properly and should have been referred for an immediate ECG, blood tests and her wound should have been dressed. Ms KN gave us detailed notes of what happened.
15. The Trust apologised for the lack of seating and the overcrowded waiting area. It said that since Mrs K’s experience, those who need minor injury care now wait in another area, making more space in the main waiting area.
16. The Trust said Mrs K was triaged within six minutes. It says it completed a full set of observations and her vital signs were all normal. It said Mrs K was properly triaged but it missed the next step, referring Mrs K for an ECG and blood tests. It also accepted that it should have dressed the wound. The Trust apologised fully for these mistakes and has taken action to stop this happening again.
17. RCEM (standard 3) says triage, ‘should be ideally delivered within 15 minutes of arrival in the department’. According to the Trust’s records, triage was delivered within six minutes of arrival, and this is in line with the guidance. Ms KN says triage was started after waiting 53 minutes. This is not in line with the guidance. We have carefully considered the different accounts of what happened.
18. The events are clearly detailed in Ms KN’s notes and were backed up in our conversations with her. The Trust has accepted that the ED was ‘gridlocked’ that day and that several aspects of care and treatment were delayed. We think it is more than likely that Mrs K arrived at the ED when Ms KN says she did, and they waited for triage.
19. It was not good that the standard was not met, and triage was delayed. However, we have taken into consideration the pressures on the ED that day and nationally across the NHS. We cannot say that the wait for triage for a minor injury fell so far short of the standard to be a failing.
20. Our adviser says the triage nurse used the MTS (standard 2) which is a clinical risk management tool to help clinicians safely manage patient flow, when clinical need is greater than capacity. This is the relevant national standard.
21. According to the history and assessment by the triage nurse, Mrs K was classed as priority three using the MTS standard. Our adviser says this was correct based on Mrs K’s condition.
22. Since the Trust used the right guidance to assess Mrs K, we think the priority given was reasonable.
23. We can see the ED was under stress and overcrowded. We appreciate it is a stressful experience waiting for medical attention for a loved one, particularly when they are older and vulnerable.
24. Even if the tests had been done quicker, it does not mean that Mrs K would have been seen by a doctor any earlier. The Trust has recognised it made mistakes and given a full apology for the stress caused. We think this is enough to put things right and we did not find any further failings.
Pain management
25. Ms KN says Mrs K was not given pain relief until 4.20pm and she suffered unnecessarily. She says paracetamol and codeine were prescribed but did not relieve the pain. She says the Trust did not give Mrs K anything else.
26. The Trust said an ED doctor reviewed the pain at 4pm and gave pain relief at 4.20pm. The Trust apologised this was not early enough and said it has reminded the triage nurse to offer pain relief to every patient upon arrival.
27. The relevant national guidance is RCEM (standard 4). It says patients should have their pain assessed within 20 minutes of arrival and once pain relief is given, it should be reassessed within one hour.
28. Our adviser says this would normally be done by the triage nurse and, if necessary, they would ask a clinician to prescribe pain relief.
29. It is distressing to see someone you care about in pain. We have seen no formal pain assessment was recorded at triage. Mrs K had to wait until 4pm to be assessed and prescribed pain relief. This is not in line with standard 4. This is a failing. There is no record that the pain was reassessed, or that further pain relief was given.
30. Mrs K experienced pain unnecessarily for over two hours until 4.20pm. We cannot see evidence of Mrs K getting any more pain relief until she was given local anaesthetic at around 10pm. This was four hours and 40 minutes later. Experiencing pain would have added to Mrs K’s distress during what was already a stressful and confusing time for her. As a vulnerable adult with a diagnosis of dementia and someone who was already frightened of hospitals, this painful experience would likely have added to this fear. We have made a recommendation to put this right for Mrs K.
Doctor review
31. The Trust says Mrs K was seen by an ED doctor at 4pm and then by the ED consultant at 7.30pm. It apologised and said she should have been seen by a senior doctor earlier. The Trust said the consultant examined Mrs K, reviewed the investigation results including the CT scan and, because of the complexity of the wound, referred Mrs K to the on-call plastic surgeon.
32. In its responses the Trust did not mention, though the records show, that Mrs K was also reviewed by an ED doctor at 6pm who ordered the CT scan, ECG and blood tests.
33. MTS (standard 2) recommends that priority three patients should be seen by a clinician within an hour. Both Ms KN and the Trust say Mrs K was seen by a junior doctor at around 4pm. Unfortunately, there is no documented record of this, but since both parties confirm this, we see no reason to disagree.
34. Since Mrs K was not seen by an ED doctor for two hours ten minutes, this was not in line with standard 2. However, this delay needs to be seen in the context of what ED’s could practically do at the time.
35. The NHS constitution states patients should be admitted, transferred or discharged within four hours. Our adviser says major EDs throughout the NHS have often failed to hit this target at busy times, for a variety of reasons. Our adviser says commonly there is a lack of hospital beds available, which makes a backlog in the ED, known as exit block. This, together with staff shortages and other resources, has caused massive overcrowding with delays in care and assessment. In situations where patients arrive with problems that are not immediately life-threatening, it has become acceptable for the four-hour target not to be met. The King’s Fund (standard 1) gives more background information and an explanation of waiting times in EDs.
36. In these circumstances, we do not think the delay to see a doctor fell so short of the standard to be a failing.
37. Our adviser says there is no national requirement for an ED consultant to review a patient, other than in specific circumstances detailed in RCEM (standard 5), as follows:
• a traumatic chest pain in patients aged 30 years and over • fever in children under one year of age • patients making an unscheduled return to the ED with the same condition within 72 hours of discharge • abdominal pain in patients aged 70 years and over.
38. Since Mrs K was not in one of those patient groups, there was no need for her to be seen by a consultant. She was, however, seen by a consultant at 7.30pm.
Fluids, food and drink
39. Ms KN says Mrs K was dehydrated because intravenous (IV) fluids were not given on time and no food or drink was given to her.
40. The Trust apologised refreshments were not offered due to the busy nature of the ED. It apologised fluids were not given earlier.
41. At 5.17pm the nurse took Mrs K’s observations and given that they were normal, there was no need for urgent IV fluids.
42. At 8.33pm, because of the blood test result, the consultant prescribed and gave IV fluid. Our adviser says this was correct given that Mrs K’s urea level (an indicator of kidney function) was slightly raised. This is a sign of mild dehydration commonly found in older patients. In this situation a dose of IV fluids may be given. However, it may also be recommended that a patient increases their oral intake of fluids instead. Our adviser says there is no national guidance that covers this situation and the action taken is the clinician’s decision.
43. From the evidence, there was no need for IV fluids before 8.33pm. The consultant took the safe option and prescribed IV fluids. This was reasonable.
44. We recognise that it would have been better if food and drink had been offered. We do not underestimate how confusing it is for a vulnerable person with dementia and we are sorry to hear Mrs K’s experience. We have found that there was no significant clinical risk of lack of fluids, and it is unlikely that lack of food during this time would have been harmful. There is no clinical failing and the Trust’s apology for the inconvenience and stress is reasonable.
Vulnerability
45. The Trust apologised for the time taken in the ED and said it was not ideal for an older and vulnerable patient.
46. There is no record of Mrs K being agitated, distressed, or needing additional support that would need immediate action by ED staff.
47. Our adviser explained that with the many other demands on ED staff, it is not a priority to give patients their routine medication during short stays in the ED.
48. It is accepted that vulnerable patients should receive additional support. However, in an overcrowded, busy ED this may not have been possible as staff need to give priority to patients with life-threatening problems.
49. We understand that Mrs K was upset and confused by the wait and the circumstances in the ED. Since there is no clinical record of agitation or distress, we cannot say these were ignored. It appears the Trust dealt with Mrs K according to the relevant guidelines for prioritising patients whose needs could not be addressed immediately.
50. In the context of a fairly short visit to ED we do not see any signs of failings around her routine medications. There is no evidence that not giving Mrs K her routine medication for her mental health had any significant harmful effect.
ID bracelet
51. Ms KN says Mrs K was not given an ID bracelet and this was a risk to her health, as there could have been confusion over her identity.
52. The Trust says that since the events complained about, it has changed its procedure and now everyone entering the ED is given an ID bracelet.
53. We understand Ms KN’s concern and the risk that confusion over a patient’s identity can cause.
54. Ms KN has not said that Mrs K not having an ID bracelet caused an actual issue, and we have not seen any issues. The Trust has taken action to reduce the risk of identity confusion. Therefore, we have no individual patient or systemic concerns with this issue.
Attitude
55. Ms KN says the attitude of nurses and doctors in the ED was poor. She says on arrival the first nurse was rude and aggressive. She says she and her sister were shut down by another nurse when they tried to get someone to see to Mrs K to give her pain relief. She says the doctor they saw at 4pm was rude and aggressive.
56. The Trust’s first response was that the family had been verbally aggressive to staff and it had a zero-tolerance policy toward such behaviour. Later, the Trust apologised for saying the family had been aggressive and it recognised the family was supporting Mrs K in difficult circumstances. The Trust apologised that this had been seen as aggression.
57. The records show that two staff members separately recorded that the family were verbally abusive on two different occasions. We cannot say exactly what happened or who, if anyone, was at fault. We understand the strength of feeling on the part of Ms KN and her sister. They wanted pain relief for Mrs K as quickly as possible. The staff were under pressure in an ED full of patients awaiting treatment.
58. We can see that there was frustration on both sides. Without underestimating the upsetting experience for Mrs K and family, we think the Trust’s apology and explanation of events is reasonable in the circumstances.