Time taken by ED to diagnose and treat 14. Ms A says the Trust took too long to diagnose her daughter following her admission to the ED, she says it left her for three hours without treatment and took too long to intubate her.
15. The BMJ guideline outlines a trauma team should assemble rapidly in response to a major trauma alert. They should carry out a rapid assessment of the patient's airway, breathing, circulation and disability. Initial investigations should include imaging and blood gas analysis.
16. The NICE QS74 recommends a CT scan is completed within one hour of a patient with a significant head injury attending the ED. The NICE NG39 guidance outlines they should use rapid sequence induction of intubation as the definitive method of securing the airway as soon as possible.
17. The clinical records show the trauma booklet completed by the trauma team contains a very clear record of the initial assessment and treatment of Miss A following her admission. We can see the trauma team received an alert 4.29pm, indicating Miss A was due to arrive by helicopter within 25 minutes. The booklet shows a full trauma team was in place by the time Miss A arrived in the ED at 5.16pm. The notes then record in logical order the initial assessment and treatment of Miss A.
18. The trauma booklet and anaesthetic records documents that Miss A was intubated within 10 minutes of her arrival to the ED, this is in line with the NICE NG39 guidance. The trauma booklet also outlines how Miss A had a CT trauma scan to within 30 minutes of her arrival, this is in line with the NICE QS74. This showed she had suffered a significant head injury, bleeding on the brain and had pressure around the brain.
19. We can also see the trauma team completed an assessment of Miss A’s airway, breathing, circulation and disability (level of consciousness), they also carried out a series of blood tests. Miss A was treated with neuroprotective measures (treatment to reduce the pressure around the brain in a patient with a severe head injury), had a transfusion of intravenous fluid and blood, was catheterised and had a plaster cast put on her leg all within 90 minutes of her arrival. This is in line with the BMJ guideline on carrying out appropriate investigations and providing appropriate trauma treatment to a patient and our clinical advice supports this view.
20. During our conversations, Ms A explained to us that when she arrived at the ED, she saw her daughter lying on a hospital bed, was in a neck brace, had a plaster cast on her leg and was awaiting treatment. She has provided us with a witness statement from another party to corroborate her recollection.
21. We do not doubt Ms A’s recollection of the care and treatment her daughter received. When investigating this point we paid particular attention to what Ms A told us and looked to see if there was any evidence in the medical records which we could use to support her account. We have been unable to identify any records or any other supporting information which would allow us to challenge or criticise the information provided by the Trust.
22. We appreciate how disappointing this will be for Ms A. It is important that any findings we make and any failings we identify are supported in the evidence available to us and we have to acknowledge where there is a lack of evidence to support a complaint. For this reason, although we do not dispute what Ms A has said, we have not seen any indication of failings in the care provided to Miss A.
23. Our ED adviser explains that Miss A was treated in a rapid and efficient manner giving her the best chance of a positive outcome from her extremely severe injuries. Sadly, her head injuries were too extensive for treatment to have been effective.
24. Ms A has explained to us how devastating it was for her to see her daughter in the ED following the accident and how much of an impact this continues to have on her. We do not underestimate how much of an impact this had on her and understand how difficult it has been for her to discuss this with us. We have seen no indication of any delay to treatment of Miss A in the ED and our clinical advice supports this view. We hope this provides Ms A with reassurances about the time taken to treat her daughter in the ED.
Time to operate 25. Ms A says the Trust took too long to operate on her daughter following her admission.
26. The RCA audit standard set the target for 95% of patients with a significant brain injury to be transferred to a neuroscience unit within four hours of injury. It explains that surgical evacuation of haematomas (procedure to treat pooling of blood in the brain) is time critical and a maximum of four hours from injury to surgery is the commonly accepted target.
27. The records show Miss A was in the road traffic accident at approximately 4pm, she was admitted to the Trust by air ambulance at 5.16pm and was transferred to the operating theatre at 6.40pm and the operation started at 7.20pm. The Trust therefore operated on Miss A three hours and 20 minutes after her initial injuries which is in line with the RCA audit standard of operating within four hours from the time of injury.
28. We recognise Ms A’s concerns over the time taken by the Trust to operate on her daughter and understand why this is an important part of her complaint. We are truly sorry to hear of the ongoing worry this causes Ms A. Reassuringly we have seen no indication of any delay in the time taken by the Trust to operate on Miss A, we hope this provides Ms A with some assurances over the timeliness of the Trust’s operation during her daughter’s admission.
29. We can see no indication of any significant delay in the time taken by the Trust to operate on Miss A following her admission, and our clinical advice supports this view.
Decision to turn off life support machine 30. Ms A says the Trust failed to involve her in the decision to turn off her daughter’s life support machine on 18 November, despite her being her next-of-kin.
31. The AMRC code of practice section 7.2 explains that for patients who have suffered brain death, withdrawing ventilatory assistance following a discussion with the patient’s relatives or relevant others may be the most appropriate course as being in the best interests of the patient.
32. The records show doctors conducted brain stem tests and identified there was no brain-stem function, they diagnosed her as having suffered brain-stem death at 4.28pm on 18 November. Miss A remained on a mechanical ventilator after this diagnosis to breathe for her. Our critical care adviser explains that as the Trust doctors had diagnosed Miss A as having suffered brain-stem death, the ventilator was not actually providing life support to her at this time, only mechanical breathing for her body.
33. Ms A tells us how she does not accept the conclusion of brain death. We are very aware of Ms A’s strength of feeling in respect of this and we respect this being her belief.
34. Our adviser explained that that determining brain death is an appropriate part of clinical decision-making.
35. We know this will be very difficult for Ms A to read and we are very sorry for the inevitable upset this will cause. Whilst we do respect her views, it does remain that clinical evidence shows us there were appropriate investigations undertaken, which gave clear support for the diagnosis of brain death. Because of this, our critical care adviser explains the decision to turn the ventilator off was a clinical decision and there was no legal requirement for this to have involved Ms A with this.
36. The records detail a discussion between the doctors and Miss A’s family and friends on 18 November at 7.51pm in which the doctors outline that Miss A was now brain dead and the decision has been made to extubate her (remove the breathing tubes). The notes say the family accepts this and did not wish to ‘drag things out’ for any longer. Overall we can see this conversations is in line with the AMRC guidance on discussing withdrawal of ventilatory assistance and our clinical advice supports this view.
37. We have seen evidence the Trust’s decision to turn off the ventilator machine and how it communicated this to Miss A’s family was appropriate.
Record keeping 38. Ms A says the Trust failed to keep accurate records during her daughter’s admission.
39. The GMC guidance on record keeping explains clinicians should keep clear, accurate contemporaneous and legible records at the time the events happen. They must also record clinical findings, investigations proposed, provided or prescribed, information shared with patients, decisions made, actions agreed and who is creating the record.
40. We can see the records clearly record the clinical findings and investigations carried out by the Trust from the time of Miss A’s admission in the ED, until her sad death. They document the information shared and discussions held with Miss A’s family and friends and the actions agreed about her treatment and prognosis, this is in line with the GMC guidance. We also sought clinical advice about the standard of record keeping by the Trust during Miss A’s admission. Our ED adviser explains there is no evidence of poor record keeping in this case. They explain the documentation available is in fact very good given the complexity of Miss A’s assessment and treatment and the urgency with which she was treated.
41. We understand Ms A has specific concerns about the times recorded within the clinical records about her daughter’s arrival to the ED and the time in which it recorded she had a plaster cast applied to her leg. We have carefully considered the evidence to see if there is anything to support that the Trust recorded inaccurate timings in respect of these points. The trauma booklet details a clear time of arrival into the ED following the earlier trauma call and we have no reason to dispute this. We can also see it also outlines, in minutes from the time from arrival, the time the plaster cast was applied. We have seen evidence to support the view the records were made after the time of each event. We understand this is likely to be frustrating for Ms A and understand her strength of feeling in respect of this. We have seen no indications of a failing in respect of the Trust’s record keeping during Miss A’s admission, and our clinical advice supports this view.
42. Overall we have seen no indications of a failing in respect of the care and treatment the Trust provided to Miss A during her admission.
43. We extend our sincere condolences to Ms A for the devastating circumstances surrounding the death of her daughter, we understand how much of an impact her death continues to have on her. We hope our findings provide her with reassurances over the care and treatment provided to her daughter during her admission.
44. Complaints gives us valuable insight into the organisations we investigate. We do not underestimate how difficult it must have been for Ms A to have shared her experience with us. We are very grateful to Ms A for bringing her complaint to our attention.