17. Mr A raises concerns that his mother, Mrs A, was not accompanied by medical staff to her X-ray and in the period after her X-ray whilst she was waiting for the porter to transfer her back to the ward. Mr A considers that if his mother had been accompanied by a medical professional, faster action could have been taken when she deteriorated, and a different outcome could have been possible.
18. The Trust’s investigation stated Mrs A had not been accompanied by ward staff to radiology because she had stable observations and was not on a cardiac monitor or receiving oxygen. It concluded that Mrs A’s death was not avoidable, as it was felt that the rapid deterioration leading to the cardiac arrest was not caused by Mrs A being left alone for a short period.
19. To determine whether it was appropriate for Mrs A to be left alone following her X-ray, we have first considered if she should have had a medical escort accompanying her to her scan.
20. The Trust’s ‘adult patient internal transfer policy’ says the need for an escort must be appropriately assessed by the nurse responsible for the patients care or the nurse in change of the ward. This should be done using the ‘levels of care’ table within the policy, and this should be documented in the patients record. The levels of care table provides examples of patient groups and the levels of care they require. It ranges from Level 0, requiring a porter only, to Level 3, requiring a registered nurse, doctor, and porter. The relevant section of this table for our investigation is as follows:
“Level 0 patients who require a porter only meet the following criteria:
• Outpatients • Patients who require hospitalisation where needs can be met through normal ward care • NEWS2 score within a normal threshold
Level 0 patients who require a porter and a HCA meet the following criteria:
• Oxygen therapy less than 35% • Intravenous (IV) fluids that do not contain additives • Confused patient not at risk • Confused patients who are at risk or require constant supervision”
21. The policy also says that IV infusions must not be disconnected for any ward transfer, and if a patient is receiving continuous or intermittent infusions then these can be clamped but must remain attached.
22. NEWS2 is a tool used to improve the detection of and response to clinical deterioration in patients with an acute illness. It is an aggregate scoring system which allocates a score to six physiological measurements: respiration rate, oxygen saturation, systolic blood pressure, pulse rate, level of consciousness or new confusion, and temperature. A higher NEWS2 score indicates the patient’s observations are outside of the norm (RCP – NEWS 2).
23. A score of 1-4 is considered low and should prompt assessment of a nurse or equivalent who should decide if a change to the frequency of clinical monitoring or an escalation of clinical care is required. A score of 5-6 is considered medium and is a key trigger threshold which should prompt an urgent review by a doctor or nurse and consideration of an escalation of care. A score of 7 or more is considered high and is also a key trigger threshold. This should prompt emergency assessment by the clinical team or clinical care outreach team (RCP – NEWS2).
24. From reviewing the medical records, we consider Mrs A was a Level 0 patient. This is because we have not identified any indications Mrs A was suffering from any cognitive impairment, and she was not critically unwell. The most recent set of observations were recorded at approximately 1:20pm, and Mrs A’s NEWS was stable with a score of 2. We note she was not receiving any oxygen therapy at the time.
25. The medical records indicate Mrs A was receiving IV fluids earlier that day, the notes from the consultant review at approximately 9am and the nursing notes at 1:05pm state “continue IVF”, which we understand to mean continue IV fluids. We can also see Mrs A had been commenced on a 1 litre bag of IV fluids to be delivered over eight hours at 3:44pm on 31 January 2024.
26. If the IV line was clamped and the infusion was paused, Mrs A would not have needed a trained escort in accordance with the Trust’s policy, however, if it was still running, she would have. We have not seen any evidence of the IV fluids being clamped prior to the gastrografin scan in line with the Trust’s policy. We accept this may have been done and not recorded in the medical records, however, without this information we cannot confirm this was done.
27. We also cannot see evidence that a consideration of the appropriateness of an escort has been recorded within the medical records, in line with the Trust’s transfer policy. Similar to the above point, we recognise this consideration may have taken place, but without a corresponding entry in the medical records it is not possible to confirm the nursing team carried out an assessment of the need for an escort.
28. Based on the evidence we have considered, we consider it is more likely than not that Mrs A should have been accompanied by a HCA as well as a porter, as per the Trust’s policy.
29. Next, we have considered the period between Mrs A being left in the radiology recovery area and being found unresponsive.
30. The Trust’s transfer policy states there must be adequate, appropriate and timely communication between transferring and receiving staff. Additionally, it says portering staff must inform a member of the nursing team when they are collecting and returning patients.
31. Within the Trust’s rapid review report, it identified findings which we consider to be additional contributory factors to Mrs A being alone in the radiology recovery area.
32. The report details that the radiology nurses were not made aware of Mrs A’s presence in the recovery area and were getting changed at the end of their shift. In the absence of constant supervision, patients are usually given call bells to alert staff and summon assistance. The rapid review report notes that on this occasion, Mrs A was not given a call bell.
33. Our initial understanding the timeline of events was that the scan was marked as complete at 5:45pm. Mrs A was then taken back to the radiology recovery area and left by the porter at approximately 5:55pm whilst they went to transport another patient nearby.
34. During our investigation, the Trust has provided additional evidence which confirms the X-ray was timestamped as complete at 5:56pm. On this basis, the timeline changes as it means the porter took Mrs A round to the radiology recovery area later than originally thought, which leads us to conclude she was left alone for approximately two to three minutes before a radiology nurse found Mrs A unresponsive and put out an emergency call at 5:59pm, and a subsequent cardiac arrest call at 6:06pm.
35. The staff statements we have reviewed are consistent with their detail that Mrs A was conscious, responsive, and communicating, and was not actively vomiting in the immediate period before, during, or after the scan.
36. Based on this, we have not identified any change in Mrs A’s needs following the scan that would indicate she required any additional monitoring or constant supervision in line with the Trust’s transfer policy. However, we do consider the radiology nursing team should have been made aware of Mrs A’s presence in the radiology recovery area, and that she should have been given a call bell, in line with the Trust’s transfer policy.
37. In conclusion, we have identified a service failure as the Trust did not follow its transfer policy with regards to providing an escort for Mrs A to and from her scan and in its communication when leaving Mrs A in the radiology recovery area. We will consider the impact of this in the next section of our report.
Impact
38. We consider if Mrs A had been escorted to her scan in line with the Trust policy, it would have meant the HCA waited in the radiology department for Mrs A following her scan, therefore meaning she was not alone for the short period afterwards.
39. We have reviewed the evidence available to us regarding Mrs A’s presentation prior to and following her scan. From this, we understand she was stable in the period leading up to the gastrografin scans and following the scan.
40. Based on the information available to us about Mrs A’s presentation and her co-morbidities, we consider even if Mrs A had been accompanied by a HCA who had waited with her in the radiology recovery area, she would have still deteriorated and gone into cardiac arrest. This event was not caused by Mrs A being left unaccompanied.
41. Despite this, we have taken into consideration whether the emergency call could have been put out any sooner had staff been present.
42. Based on the timeline of events, we consider the presence of a HCA may have only made a couple of minutes of difference in terms of putting out the emergency call.
43. As Mrs A did not have an escort, we have considered if the presence of the radiology nurses in the recovery area would have made a difference to when the emergency call was raised. We consider if the radiology nursing team had been made aware of Mrs A’s presence, it would have mitigated the gap in supervision caused by no HCA being present.
44. However, we must also take into consideration that based upon what we know about her presentation she most likely would not have been constantly supervised following her scan and for this reason we consider it is unlikely this would have had much of an impact on the timing of the emergency call.
45. With regards to the absence of a call bell, we do not consider this has had a notable impact in this case. Mrs A was left for a couple of minutes and the presence of a call bell, if pressed, would likely not have made a meaningful difference to the response time of the nursing team given they found her shortly after the porter had left.
46. Our nursing adviser also explained that based on Mrs A’s clinical status, even without the delay in putting the emergency call, out it is unlikely the outcome of this case would be different. From this, we conclude it is unlikely that if the failings not occurred there would have been a significant difference to the sad outcome of this case. We recognise this will be upsetting for Mr A and his family.
47. Despite this, and as recognised in the Trust’s rapid review report, we recognise Mrs A deteriorated in a period where she was left alone and without any means of calling for help and it is likely this caused her additional distress and anxiety. We also recognise that learning of these circumstances was significantly concerning for Mrs A’s family and these circumstances left them with uncertainty and concern about the care Mrs A received.
48. We have reviewed what actions the Trust has taken in response to the complaint, and whether it has done enough to put things right for Mrs A’s family.
49. In the Trust’s response to the complaint, it has expressed its sincere condolences to the family for their loss. It advised that it had put measures in place to improve the process of patients awaiting transfer back to the wards from the radiology department. It also advised a further formal process was being ratified to support the regular oversight of patients within the radiology waiting and recovery area outside of normal working hours, when fewer staff are around.
50. The rapid review report detailed the following actions which were undertaken as a result of the events which occurred:
• Porters will provide patients with a call bell when in the radiology recovery area • Porters to carry radios from 5:30pm rather than 6pm to enable them to call for assistance, rather than leaving patients unaccompanied • All out of hours patients to be taken directly to the ward whenever possible, and if not possible, they should remain outside the scanning rooms for better oversight by radiographers • Radiology nursing staff to inform porters/radiographers when they are leaving the department, so it is clear the area is no longer staffed • Radiology department assistant to stay with patients in recovery area out of hours if possible, and if no escort is available • All ward patients out of hours to have an escort, unless cleared with radiology/portering supervisors first, especially after 8pm
51. We are reassured these actions will prevent the likelihood of a patient being left alone in the radiology recovery area following scans both without oversight and without any means of calling for assistance.
52. We cannot see the Trust has acknowledged the failing we have identified with regards to not providing Mrs A with a medical escort to her scan. Whilst this did not have a clinical impact on Mrs A, we have identified this likely caused Mrs A additional distress and anxiety as she was alone when she deteriorated. The impact of being left alone has been acknowledged in the rapid review report but has not been formally acknowledged in the Trust’s complaint response to the family.
53. We have also identified this had a wider impact upon Mrs A’s family, and whilst the Trust has expressed its condolences in its response, it has not provided the family with a sincere apology for what went wrong, and the impact it had.
54. Furthermore, the Trust has not identified what action will be taken to ensure the Transfer policy is implemented correctly in the future.