12. Before we decide if we should conduct a detailed investigation of a complaint, we look at whether there are signs the organisation has got something wrong. We do this by comparing what should have happened with what did happen. If we consider something has gone wrong then we look at the impact this had and what has been done to put things right.
Admission
13. Miss H says she and her mother arrived at hospital at approximately 11am. She says her mother was unwell, but mobile and talking. Miss H complains her mother was still waiting for staff to admit her at 1.30pm as she was not 'clerked in correctly'. She says once the nurse had taken her mother's observations the Trust transferred her directly to a resuscitation room.
14. A resuscitation room is a dedicated space in ED designed for the immediate assessment and treatment of critically ill patients.
15. The Trust accepted Mrs W was waiting longer to be seen in ED than she should have been. It said human error meant Mrs W's journey through the department was not tracked properly.
16. RCEM guidance says EDs should triage patients within 15 minutes. A senior clinician should perform the triage and identify the most unwell patients. They should make a rapid and detailed clinical assessment and start appropriate investigations and treatment.
17. Sepsis guidance sets out how staff should manage sepsis when they first suspect it. This is reflected in The Sepsis 6 Care Pathway in place at the Trust. The pathway says within one hour of suspecting sepsis they should:
• ensure a senior clinician attends the patient • give them oxygen if required • take blood tests • give antibiotics directly into the patient’s vein (IV) • give IV fluid • measure urine output.
18. Nurses directed Mrs W to the Trust’s enhanced care hub when she first arrived at ED at 11.04am. Mrs W then returned to ED at 12.34pm and a triage nurse saw her five minutes later.
19. Once triaged, the nurse sent Mrs W to the resuscitation area. A senior doctor saw Mrs W there at 1.10pm. They took a sample of blood for tests and requested an X-ray at 1.13pm. They gave her IV antibiotics and oxygen at 1.30pm and started to record her urine output. Staff also gave Mrs W IV fluids.
20. Staff did not record these actions on the specific Sepsis 6 Care Pathway sheet in Mrs W’s medical records. Miss H is concerned this means they did not happen. Having considered the entirety of Mrs W’s medical notes we are satisfied they contain sufficient evidence and documentation to conclusively say staff did take these actions.
21. Our adviser explained when Mrs W arrived in ED her triage was delayed by 1 hour and 10 minutes. This is a lot longer than the 15 minutes set out in guidance.
22. We consider the delay to Mrs W’s triage was a failing. We have therefore looked at the impact of this and what the Trust has done to put things right.
23. Miss H believes the delay meant her mother’s sepsis treatment was too slow. She feels this led to her mother’s death, which has caused her a significant amount of distress.
24. Our adviser explained once triaged, the clinician identified Mrs W’s sepsis immediately. They acted promptly and performed all the steps set out in the Sepsis 6 Care Pathway. It is likely these steps would have been taken approximately one hour sooner had the delay not happened.
25. Our adviser said there is a link to early sepsis treatment and improved chances of survival. However, it is not just the timing of treatment that is important but also the extent of it. In this instance Mrs W was not suitable for the most intensive treatment because of her underlying health problems.
26. Consequently, we consider that regardless of when doctors started Mrs W’s sepsis treatment it is unlikely it would have significantly improved her chances of survival. This means we do not believe Mrs W would have lived had things happened differently.
27. We recognise how traumatising this event has been for Miss H and understand this remains a source of distress for her. We hope that in time this information can bring her some form of comfort.
28. Although we cannot link the failing to the most significant impact Miss H has told us about, we still consider that something did go wrong. This has resulted in some distress to Miss H. We consider this is limited to the small delay and that nothing would have changed the sad outcome.
29. We have looked at what the Trust has done to put things right.
30. Our Principles say organisations should act to stop the same problems happening again. They should also apologise when things go wrong. In some circumstances this apology may take the form of financial remedy.
31. The Trust’s complaint response identified the failing set out above. It reviewed the process for moving patients between different departments and reminded staff about how the process works. It also shared the learning it took from Miss H’s complaint.
32. The Trust’s complaint response also explained the reasons for the failing to Miss H. It included a written apology for the delay.
33. We are satisfied these are reasonable steps to stop the same problem happening again. However, we consider the written apology does not go far enough. We therefore contacted the Trust and it agreed to pay a £120 financial remedy to Miss H.
34. We believe the amount it has offered Miss H fairly recognises the failing and the impact we have found. With this in mind, we have decided to take no further action on this part of her complaint.
35. Having considered this issue we know why it means so much to Miss H. We acknowledge how sad these events have been and the devastation she has experienced.
Observations
36. Miss H says staff did not check her mother as often as required whilst she was in ED.
37. The Trust explained observation intervals differed depending on the patient's NEWS scoring. NEWS determines how ill a patient is and prompts critical care intervention at the right time. The Trust said when a patient’s NEWS is seven or more then they require regular monitoring, which is what happened.
38. NEWS guidance set out standard intervals for how often staff should observe sick patients. In principle, they say the most unwell patients should be observed more frequently.
39. However, our adviser explained the NEWS system is best suited to ward-based care. This means the observation timings set out in NEWS guidance did not specifically apply to Mrs W in ED. Our adviser said RCEM guidance is most relevant in this instance.
40. RCEM guidance says early warning scores will not typically benefit the care of patients already known to be critically ill and receiving appropriate treatment. This applied to Mrs W. Instead, observations should be timed in response to the individual patient’s condition.
41. When staff were treating Mrs W in the resuscitation area she was under continuous observation. When staff stepped down her care they examined her approximately every 90 minutes.
42. Our adviser explained although Mrs W was unwell, she did not deteriorate significantly when doctors stepped down her care. Our adviser said her condition remained stable and the frequency of observations was reasonable based on her condition at that time.
43. We consider staff took Mrs W’s observations in response to her individual requirements. This is in line with RCEM guidance. Given she did not suddenly deteriorate during this time it demonstrates the observation intervals were appropriate.
44. We hope this reassures Miss H about what happened and goes some way to addressing the understandable distress this has caused her.
Lorazepam
45. Miss H says the lorazepam doctors gave her mother at 9am on 30 January was not necessary. She feels it put her mother at risk and disputes the Trust's account that her mother was acutely distressed at the time. Miss H says her mother was calm when she left shortly before 9am, and there is no record of any distress or observations during this period.
46. The Trust said it gave Mrs W lorazepam because she was experiencing agitation due to her acute illness. It said doctors needed to obtain clinical observations and treat her medical issues so gave Mrs W the lorazepam.
47. Care of Dying Adults in the Last Days of Life says doctors should manage a patient’s breathlessness, anxiety, agitation and delirium. It recommends using a tranquiliser drug, like lorazepam, to do this.
48. BNF guidance from the time explains the standard dosage for a patient like Mrs W was 0.5 to 2mg. It advises caution as lorazepam can significantly affect someone’s ability to breathe when given with drugs like morphine. Therefore, it should only be given when necessary and in the lowest possible dose for the shortest duration.
49. We understand Miss H’s concern about what happened and accept her mother was calm whilst she was there. However, after Miss H had left her mother’s medical notes show she was agitated, confused, and removed her oxygen mask. Staff gave her 0.5mg of lorazepam to calm her down so they could complete their observations and deliver necessary care.
50. Our adviser explained giving the lorazepam was a reasonable course of action to take. They added once the observations were completed and care was given, the effects of lorazepam were no longer necessary. Therefore, doctors gave Mrs W flumazenil shortly after to reverse any potentially dangerous effects.
51. We consider it was appropriate to give Mrs W lorazepam to address agitation she was experiencing at the time. As doctors gave her the smallest dose set out in guidance and reversed the effects shortly after, we are satisfied they demonstrated appropriate caution.
52. We acknowledge this has been an exceptionally upsetting series of events for Miss H. Her mother’s death has been understandably devastating, and the fact she had reason to complain has only made this worse.