A Patient s and Family s Story

A Patient’s and Family’s Story Mr Dennis Riley was our patient. He was admitted to QMC on two occasions and died during his second admission, on 12th ...
Author: Emery Walton
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A Patient’s and Family’s Story Mr Dennis Riley was our patient. He was admitted to QMC on two occasions and died during his second admission, on 12th June 2013. A clinical account of these admissions is outlined below. Following Mr Riley’s death his family had a number of observations about his and their experience of our care. They raised a series of questions which we discussed with them on 21st October 2013. They are anxious that their concerns and our responses are shared with the Trust Board. Mr Riley’s Medical History Mr Dennis Riley was admitted from his home as an emergency on 11th April 2013 with progressive heart failure (at least moderately severe) and pulmonary emboli. He developed Norovirus on 24th April and was nursed in a side room. Discharge was planned for 29th May. A few days before discharge he complained of pain in one eye. No diagnosis was made or specific treatment given. He required only a little help with personal care and was able to walk, but had a history of falls. Mr Riley was readmitted via ED on 2nd June 2013 with eye pain, facial swelling and general deterioration. The diagnosis was of ophthalmic herpes zoster for which treatment was started (acyclovir antiviral). He was catheterised for urinary retention against a history of previous prostate surgery, inactive prostate cancer and mild chronic kidney failure. He had reasonably controlled heart failure and less well controlled atrial fibrillation (AF). He had a fever: an additional diagnosis of lung infection was made and treated with antibiotics. A falls risk assessment was undertaken. Mr Riley remained short of breath from AF and heart failure. His kidney function deteriorated a little (as expected with treatment for his heart failure). He was cared for in a side room because of the shingles. Overnight 7th/8th June Mr Riley was found by nursing staff on the floor by his bed. He was complaining of pain in his right hip & leg. Clinically and on X-ray (8th June) he had sustained a hip fracture. On the evening of 8th June he was listed for hip surgery, dependant on satisfactory blood tests and heart & lung function, and transferred to the trauma orthopaedic ward. On the 9th June the consultant orthopaedic surgeon considered Mr Riley’s blood results and heart/lung function too poor for surgery. He was seen by a Consultant Orthogeriatrician and 2 Anaesthetists to maximise his well-being prior to surgery. Mr Riley was assessed as having a very limited chance of survival with or without surgery. By 11th June Mr Riley was considered as fit for surgery as he could be, and at 15.00 he underwent fixation of his fracture by a Consultant under spinal anaesthesia. There were no immediate perioperative complications; though Mr Riley’s blood pressure was a little low (this was not unexpected given his heart and lung problems). On return to the ward he was stable but unwell. His blood pressure drifted down and did not respond to treatment. Mr Riley died 02.00 12th June (he had earlier agreed that resuscitation should not be attempted in the event of cardiorespiratory cessation). After discussion with the coroner a death certificate was issued.

Meeting with Mr Riley’s Family A meeting was held with Mr Riley’s family on Monday 21st October 2013 when we addressed each of their 44 questions. Across the several wards and departments where Mr Riley had been looked after and across the majority of his families concerns ‘communication’ was either partly or completely the main issue – lack of explanations, no explanations, poor documentation, not contacting the family, and not maintaining our own standards of values and behaviours. We apologised for the poor communication and for the shortcomings in our care of their father. The specific questions and our responses were as follows: 1.

Why did Mr Riley get Norovirus?

Norovirus, sometimes known as the winter vomiting bug, is the most common stomach bug in the UK. The virus is very infectious. The virus is in the stool and vomitus of infected people (and in the stool of people who carry the virus without symptoms). It is spread by touching a contaminated surface and then ingesting the virus from the hands, or by direct ingestion of contaminated food or drink (or aerosol with virus particles). Mr Riley was the only case of Norovirus on the ward. It is therefore not possible to say where of how he contracted the virus. Norovirus typically causes a combination of vomiting and diarrhoea. Mr Riley had diarrhoea but no vomiting. It is possible that Mr Riley’s diarrhoea had another cause (e.g. antibiotic or laxative use) and that norovirus was an incidental finding (i.e. he carried the virus). 2.

Why did staff who brought lunches not wear gloves and gowns even though everyone else did?

Infection control guidelines are that gloves and gowns (aprons) should be worn by staff who have direct patient contact, or are going to be with the patient for a prolonged period. Gloves and gowns are not needed by staff who are delivering trays or jugs of water to the patient. All staff should undertake hand hygiene on leaving the patients area or room. 3.

Mr Riley wanted the toilet and asked a nurse who was with another patient who said they could not help, asked another nurse who said “not my patient”. Then another nurse came, but at shift change the nurse sitting with the patient went home and left the patient alone.

I apologise that staff responded unhelpfully and inappropriately to Mr Riley’s request for help. A nurse may not be able to leave one patient, but they should explain this sensitively and summon a colleague to help. The unacceptability of Mr Riley’s experience, and our expectation of professional responsiveness, has been re-iterated to all the ward’s nurses. 4.

Why was there not a sign on the door saying Norovirus, as members of the family caught norovirus (within the week of being on Ward F18)?

The alert notices on doors and above patient’s beds strike a balance between protecting the patient and other patients and staff, and the need to keep information about the patient confidential. Infection prevention and control alert notices and

instructions therefore do not generally include a diagnosis (e.g. Norovirus), but do describe the kinds of infection control precautions which are necessary. This is standard practice across the NHS. I apologise if staff did not supplement the sign of the door with verbal information about the diagnosis and the necessary precautions. 5.

Why was the hand cleaning gel container outside the ward empty for 10 days?

I apologise that this dispenser was empty for 10 days. We have been moving the dispensers to inside the ward doors since they are more likely to be used in that position and more reliably replenished. 6.

At 7.30am the family were informed by phone that Mr Riley had had a suspected heart attack while in isolation. At approximately 11.00 am the family were informed that it was not a heart attack.

Mr Riley was reviewed in the early hours of the morning of April 22nd 2013 by the duty doctor. Although Mr Riley had had no pain, a heart attack was suspected because the blood test (Troponin) which signifies a heart attack was high. But this blood test can be elevated in other circumstances (e.g. heart failure, lung clots) without a heart attack. When the consultant reviewed Mr Riley and the blood test they thought that the blood test was best explained by Mr Riley’s established heart failure rather than indicating a new heart attack. Because Mr Riley had been unwell overnight, his family were updated in the morning. They were updated again after the consultant review. The notes describe a conversation between Mr Riley’s son and the doctors about the severity of Mr Riley’s medical condition, the raised Troponin, and how it may indicate a “heart attack” but could relate to the severity of his heart failure. 7.

Mr Riley was not in a position to write – should his reported request not to be resuscitated have been in writing?

At time of his admission, Mr Riley was reviewed by a medical consultant who discussed resuscitation with him and his preferences in the event of a clinical decline. Mr Riley indicated that he would not want resuscitation to be attempted in the event of a cardiorespiratory arrest. This was documented and the form was properly completed by the senior clinician, in keeping with Trust policy (and standard NHS practice). There is no requirement for such a decision to be accompanied by a declaration signed by the patient. Mr Riley’s decision that resuscitation should not be attempted in the event of a cardiorespiratory arrest was confirmed with him on F18. This was described to Mr Riley’s son during the discussion (as above) regarding Mr Riley’s heart failure and possible heart attack. 8.

The family asked Ward F18 staff several times if there had been discussion with Urology at the City Hospital about Mr Riley’s waterworks/prostate. Family told nurses, but nothing happened. Why was nothing done about the waterworks/prostate during the admission even though it says prostate cancer on the death certificate? Why were the family not kept informed about this? Why did neither Mr Riley nor his family know he had prostate cancer?

I apologise that this aspect of Mr Riley’s management was not considered further with his family, especially after they has raised it. During his time on F18 there was no clinical indication for a review by the urology specialist. Mr Riley’s prostate diagnosis was long-established, and was not contributing to the urgent clinical problems of infection and heart failure. The medical and nursing teams did not consider the prostate cancer diagnosis, which had been made several years previously at the time of prostate surgery, a priority for discussion with Mr Riley’s family. The diagnosis is included in many of the letters from urology clinics in the intervening period. I am uncertain whether Mr Riley’s knowledge of this diagnosis was explored during his 2013 admission, but such a conversation with Mr Riley (or with his family) was not a priority for the clinical team at the time. This prostate cancer diagnosis was properly included on the death certificate, but as a secondary finding not as a primary cause of Mr Riley’s death. 9.

Why were there delay in seeing a doctor (e.g. for 2 hours on the 24 April 2013 at 7.00 pm)?

Mr Riley was reviewed by a Senior House Officer at 16.06 on 24 April. The same Senior House Officer reviewed him again at 18.30. There was not an undue delay in the doctor’s attendance or review: I am sorry if you were left with the impression that there was. 10. Mr Riley’s family told staff several times that he needed 4 or 5 blankets to keep warm but this did not happen. Mr Riley’s preference for several blankets was recorded on the nurse handover sheet. I apologise that despite this there were occasions when he was not given this number of blankets. The wards nurses have been reminded that they can get blankets from the linen room (or other wards) if there are insufficient on the ward. 11.

D58. Why no one went to him when your father was shouting for help, and why he was thirsty and cold.

I apologise that Mr Riley had to wait for a long time for assistance, could not always reach his drinks, (and was thirsty), and did not always have the number of blankets he liked (and was cold). The unacceptability of Mr Riley’s experience, and our expectation of professional responsiveness, has been re-iterated to all the ward’s nurses. We have recently introduced ‘hourly rounding’ in which each patient is checked by a nurse regularly (typically hourly during the day and two hourly during the night). To support this for the side-rooms on D58 we are building a small nursing station adjacent to them, and the ward is now using a side-room check list for each sideroom door. 12.

You had to ask for a beaker on several occasions.

Beakers and jugs of fresh water are usually given out twice a day by the ward waitress. I apologise if Mr Riley was not given a beaker or jug reliably and consistently. We have discussed this with the nursing and catering staff. Access to drinks is one specific aspect of hourly rounding [see 11].

13.

No one helped your father with eating and drinking.

I apologise if Mr Riley did not receive adequate help despite his care plan describing that he was to receive assistance when he was not able to manage himself. His food intake (and meals delivered) was recorded, though this could have been done more consistently. 14.

How often was your father seen by nursing staff?

The nursing records suggest the nurses changed Mr Riley’s position at approximately 2-hourly intervals. He would also have been seen during medication rounds (up to four times a day), when observations (pulse, blood pressure and temperature) were taken, and during meal times. 15.

On informing a nurse that your father was cold and that you could not find his buzzer you felt that nothing was done.

As part of ‘hourly rounding’ each patient’s buzzer is checked. I apologise that the nurses did not act more promptly to give Mr Riley a buzzer in his reach and to respond to your observations that he was cold. 16. You informed a doctor that you felt that your father had been abandoned in a side room. I apologise if the doctor did not explain the reasons for moving your father into ‘isolation’ in a sideroom, and reassure you that he would receive regular review of his clinical problems. Mr Riley developed shingles and it was necessary to isolate him from other patients. 17.

One member of the nursing team said he had pneumonia and another said that he hadn’t.

I apologise if there was inconsistent description of Mr Riley’s diagnoses. The nursing and medical staff have been reminded of importance of clear and consistent communication with patients and relatives, perhaps especially when there is more than one diagnosis and/or uncertainty about which is most important. 18.

Why was Mr Riley not on a low bed?

At the time of admission to D58 Mr Riley’s ‘falls and bed rails’ assessment did not indicate a need for a low bed, but did indicate that bed rails should be used. When Mr Riley was found by the night staff standing next to his bed (7th June) despite the in-place bed rails, the ‘falls and bed rails’ assessment should have been repeated. This might have indicated that a low bed should now be used. I apologise for this shortcoming. 19.

You were told that your father climbed over the bed sides and fell, but do not believe this as he could not move.

Mr Riley’s fall was un-witnessed. The bed sides were up when the nursing staff entered the room. From experience patients who have difficult moving can nonetheless sometimes manoeuvre themselves in the bed, and may be able to get over or around bed sides.

20.

How long was Mr Riley on the fall before he was found?

Nursing staff had been in Red Bay (next to Mr Riley’s side room) when they heard a noise from Mr Riley’s side-room. They responded within a few seconds to the noise, and found Mr Riley on the floor. 21.

Your father missed his hot meal when he had to go for an x-ray, and you had to feed him.

I apologise that Mr Riley missed this meal. We do not store hot meals on the ward for longer than 30 minutes for food safety reasons. We try to avoid X-Rays (and other tests) at mealtimes. However there are occasions when the test takes priority, as it did for Mr Riley. I am sorry if the alternative was not satisfactory. Typically we encourage relatives to assist patients who need help with eating because most patients feel more comfortable (and eat more) with a family member helping. 22. What is the ratio of nurses to patients and does this allows for the side rooms to be cared for? On D58 (up to 28 patients) there should be at least 4 trained nurses and 2 auxiliary nurses on duty during the day. This means each trained nurse looks after 7 patients (including 1 side room), and each auxiliary nurse looks after 14 patients. At night there are 2 trained nurses and 2 auxiliary nurses. 23.

On the 26 May 2013 (on B50) Mr Riley complained of stabbing pain in his eye. He was still complaining of this the following day. His daughter and son both pointed this out to staff, but no one came to see him. On the morning of discharge (29 May) he was still complaining of the pain, but no one did anything about it.

Mr Riley’s eye pain was not documented until 05.00 on 29th May. The nursing records describe that on 26th May Mr Riley complained of no pain, and that on 27th May he complained of pain in his knees (for which Ibuprofen gel was applied by nursing staff).. At 0500 Saturday 29th May the nursing staff gave one dose of Codeine phosphate (30 mg) for pain relief after Mr Riley complained of pain in his eye. I apologise that the clinical team did not acknowledge or assess Mr Riley’s eye pain when it was earlier drawn to their attention. There is no documentation of further eye pain. Mr Riley was transferred to the discharge lounge at 08.30. On 31st May Mr Riley had pain in his right eye and was taken to the Accident and Emergency Department, where he was diagnosed with right ophthalmic shingles. Mr Riley’s eye pain on B50 was indeed likely due to shingles. However this diagnosis may be extremely difficult to make in the early stages of the infection when the pain is often increasing in intensity, but intermittent and unaccompanied by any signs (i.e. there is no rash or redness). 24.

Mr Riley described to his family that nurses had taken him to a shower, poured water over him and then put him back to bed without drying him. His daughter reported this to the Deputy Ward Sister who said she would speak to the nurses concerned and get back in touch. Mr Riley’s family heard no more. A nurse on B50 was rough with Mr Riley.

After discussion with ward staff the Deputy Ward Sister formed the view that the nurses had not behaved roughly or insensitively in showering Mr Riley, but that his report was in the context of flashback episodes form his wartime experiences which occasionally caused him considerable distress (so much so that he was referred to the liaison psychiatry service). I apologise that the Deputy Sister did not discuss this further with Mr Riley’s family. If this remains a concern, the hospital will of course explore this again with them. 25.

You thought that the bedside handover between nurses was wrong as it breached confidentiality: other patients (and visitors) could readily overhear.

Just as with near bed or door notices there is a balance between confidentiality, the need to communicate important information, and the need to involve patients in their own care. Nursing shift handovers now do indeed predominantly take place at the bedside. This gives patients and relatives an opportunity to be involved in the exchange of information between and with nursing staff. When we have asked our patients, somewhat to our surprise they prefer to be so directly involved, rather than have the handover at some distance from them (and other patients) when they are unaware of what is being said (and whether it is correct or what they understood). At the time that Mr Riley was a patient on B50 this type of handover had only very recently been introduced onto the ward and the nurses were learning the right amount of information to discuss (and what to leave out as too sensitive). 26.

Nurses seemed to be arguing between themselves about the workload, and who should do what. A patient soiled himself and the nurses told him off. This put off Mr Riley from asking for help. A urine bottle was on Mr Riley’s table. The nurse only begrudgingly moved it when asked. A patient shouting for help was told off - ‘if you don’t shut up we won’t come and see to you’.

I shared the ward sister’s shock at these descriptions. This is such unprofessional conduct that if substantiated it would prompt disciplinary. The Director of Nursing would welcome the opportunity to discuss this further with you when we meet. Meantime a number of ward staff have undergone refresher ‘Values and Behaviours’ training, and the consequences of such behaviour for individual nurses have been made clear. I apologise that nurses gave the impression that they were arguing about who does what. 3 nurses had joined the ward shortly before Mr Riley’s stay. There may have been robust explanation and discussion with them about expected nurse tasks and duties. 27.

The floor was dirty and had not been cleaned for a few days.

The ward floor as cleaned each morning by the ward cleaner. If an area is soiled outside the ward cleaner’s normal working hours, it is the responsibility of the nursing staff to remedy the situation themselves or to contact the domestic supervisor, who is available by hospital bleep. I have ensured that all ward staff and the cleaning staff managers are aware of your observations and of the options should a floor be reported dirty.

28.

There was a soiled bag of clothes near Mr Riley’s bed not belonging to him. This was there for five days.

I apologise that Mr Riley had this experience. The bag belonged to the patient in the next bed and was awaiting collection by the patient’s relatives. Unfortunately there was no room to keep the bag in the patient’s bedside locker. In future when patients have soiled clothing awaiting collection it will be stored well away from bed areas. 29.

Used urine bottles on the window sill for 2 days.

I apologise that this happened. All beds now have urine bottle holders which attach to the bed and are easily accessible for patients. Ward staff have been made aware that bottles must not be left on window sills or tables. 30.

On Monday 2 June 2013 Mr Riley went to the eye clinic for a long time in a wheelchair and came back distressed (he had been sitting in a wheelchair for so long).

I apologise that Mr Riley had such a long wait, and that the reason was not explained to him at the time. He spent some three and a half hours in the department. That afternoon was unusually busy and patients were waiting much longer than they do on a typical day. Mr Riley had been sent to the Eye Emergency Clinic. Patients in the clinic are seen according to clinical priority established by the triaging specialist nurse. Mr Riley was triaged within a few minutes of his arrival. Regrettably there was then a longer interval than usual until he was seen (because other patients had higher clinical priority for emergency or urgent assessment and treatment. If the referral is not so urgent, or the patient cannot reasonably wait in a chair, the clinical team can request assessment on the ward by the duty Ophthalmologist. We will ensure that wards are made more aware of this option. 31.

Nurses on D57 said that they did not know what was happening, but then looked in the notes and said eye ointment had been prescribed 5 times a day. Initially they said he could go home and if his son had not been there, the family feel Mr Riley would have been discharged.

I apologise that there was confusion about plans for Mr Riley’s discharge. The notes describe a plan to admit Mr Riley into a side room under the care of Healthcare of the Older Person (HCOP) for further assessment and treatment. Mr Riley had a physiotherapy assessment on 3 June (11.30) and was considered safe to walk using a walking frame. However it was noted that Mr Riley would need additional support at home and that a referral to social services would be required to ensure a satisfactory discharge. 32.

Initially was told going to ward C53 – sent back to D57. Then told ward D58. Took 15 minutes to find out. Did he ever go to C53, if yes why was he moved so many times?

I apologise that there was uncertainty about this transfer. Mr Riley needed a sideroom (isolation from other patients because he had shingles). Such a room was provisionally identified on C53, but Mr Riley was subsequently transferred from D57 to D58 at 21.52 on 3rd June.

33.

The corridor outside Ward C6 was full of old boxes and condemned equipment. This did not give a lot of confidence. Why was it so untidy?

I apologise that the corridor was untidy. There is a shortage of storage space in the QMC building and some materials have to be stored in corridors (in specialist containers). We have regular days when larger items should be disposed of and are collected. We are considering how best to monitor the corridors to prevent exactly the kind of build-up of discarded materials you encountered. 34.

On 9th June 2013 Mr Riley’s daughter called the ward several times for an update. Sometime between 3.05pm and 5.00pm a decision was made to cancel the planned operation, but Mr Riley was nil by mouth from the evening of the 8th June 2013. Did he have anything to eat on 9th June 2013? Did the nurses keep a record of what he had to eat through this time? It seems to his family that he went at least 24 hours without any food.

Mr Riley had a ‘Build-up’ drink on the afternoon of 8th June on D58. There is no record of his eating or drinking anything after then on that day. He was transferred to C6 at 22.00 in anticipation of an operation the following day. On 9th June (C6) Mr Riley was not offered breakfast of lunch (he was nil-by-mouth). An intravenous infusion was commenced at 10:15 to maintain hydration. The planned operation to repair his fractured hip (sustained in a fall on 8th June) was cancelled at 16:30hrs (because his blood remained too thin after warfarin). At 17:00 (the ward supper time) he was offered pasta bolognaise (he ate one quarter) and a yogurt and ice cream (he ate all). 35.

On the 10th June 2013 a doctor was rather rude when telling the family that Mr Riley was very poorly. Why was he not more sympathetic?

I apologise if the doctor was insensitive in describing Mr Riley’s very poor clinical condition and prognosis for survival, and the very considerable risks of hip fracture surgery. 36.

Mr Riley was given fish pie even though his family had made it clear that he did not like fish, this was documented on the “About Me” and also on the board on Ward C6.

I apologise that Mr Riley was given fish pie. The nurses have been reminded to check the ‘About Me’ documentation regularly. 37.

On the 11th June 2013 a nurse commented that “we will make sure he won’t climb out of bed”. The family found this offensive in particular because what had happened on D58.

I apologise for the insensitivity of this remark, but I am satisfied that this was not intentional. 38.

Told at 9.05pm that he was fine and sitting up, but at 3.05am the family got a telephone call to say that Mr Riley had passed away. What happened during this time as the family wonder whether there was an opportunity missed for them to be present with him?

Following Mr Riley’s operation (15.15 – 1740) Mr Riley’s blood pressure was quite low. His blood pressure was monitored frequently in recovery. By 2100 his blood pressure had improved to a level at which he could return to the ward. This clinical course was not unexpected given Mr Riley’s pre-existing heart failure and general condition. At 22.00 Mr Riley’s blood pressure was again recorded to be a little low. The duty doctor was contacted and he gave a verbal order at 22.30 for 500mls of fluid to be given intravenously (a verbal order was given because the doctor was busy in the emergency department). Mr Riley’s blood pressure did not improve and a second verbal order for 500mls of IV fluid was given at 0015 by the same duty doctor (who was still in the emergency department). The duty doctor assessed Mr Riley on C6 at 01.00. He spent approximately 40 minutes with Mr Riley as he received further intravenous fluids. Mr Riley’s BP improved, although his condition remained poor. The nursing staff continued to Mr Riley’s blood pressure which remained relatively stable to 02.00. At 02:10hrs the staff nurse went to review the intravenous infusion and found Mr Riley unresponsive with no signs of life. Mr Riley was not for attempted resuscitation (with a valid form). The doctor was informed and confirmed death at 02.45. At 03:00 the staff nurse phoned Mr Riley’s family to inform them that Mr Riley had died. I apologise that you were not informed of this sequence of events, particularly of Mr Riley’s deterioration shortly after he returned to the ward from recovery. His condition did seem to have stabilised by 01.00 (after the intravenous fluids). 39.

The doctor who explained the operation was very good. Told 60:40 chance of success, but nurses did not keep them well informed about why the operation was taking so long.

I apologise that his family were not informed during the period Mr Riley remained recovery before his return to the ward. It is not standard practice for theatre to give the ward updates unless the operation does not go as expected. This was not the case with Mr Riley. Recovery do let the ward know when a patient is likely to return to the ward and did contact C6 several times to explain that Mr Riley was remaining in recovery until his blood pressure had improved. I am sorry if you were not forewarned that his stay in theatre or in recovery might be prolonged. 40.

Mr Riley’s daughter was told by PALs that the Ward Sister would telephone on Wednesday 12th June, but she did not receive a call.

I apologise that there was a breakdown in communication between PALs and the Ward Sister, and that as a result Mr Riley’s daughter did not receive a call back.

41.

On the death certificate it says several things and we would like answers to the following: a. How did Mr Riley get sepsis? b. Did Mr Riley have pneumonia near the end or indeed throughout his time on Ward C6? c. The death certificate also says “chronic kidney disease”. How did he get this?

It was agreed that the likely ultimate cause of death was sepsis (1a on the death certificate). Sepsis is the body’s response to severe infection characterised by failure of the vital organs (heart, lungs, and kidneys). This failure of vital organs (notably the heart) was the cause of the low blood pressure experienced by Mr Riley in the hours after his operation. The sepsis (failure of vital organs) was though most likely secondary to a combination of pneumonia (lung infection) (1b on the death certificate) and congestive heart failure (1c on the death certificate). Pneumonia is a common feature in patients who have a fractured femur and may develop rapidly, because the lungs do not expand as well as normally and hence secretions can build up and become infected either because of relative immobility or because of an anaesthetic (however skilfully this is delivered, and whether a general anaesthetic or other type), or because the fracture itself is a serious very serious injury and reduces the effectiveness of the body’s defence against infection. It is very unlikely that Mr Riley had pneumonia throughout his time on the ward, much more likely that this developed after his fall and fracture, and especially in the hours during and after his operation. The congestive heart failure describes the pre-existing weakness of Mr Riley’s heart. He had required treatment for this (including fluid in his lungs) for some time. Mr Riley’s blood tests suggested that he had mild chronic kidney disease – the kidneys had deteriorated and they were no longer quite so effective at clearing waste from the body’s normal functions, there was no longer a reserve which could be called on if the kidneys needed to work harder (e.g. after severe injury or to clear the fluid which builds up in the body in heart failure. This was not of itself a major problem, but it will have played a part in the speed with which pneumonia and sepsis developed. Its cause was likely multifactorial. Mild deterioration is very common with age, it often accompanies heart failure (because of sluggish blood supply to the kidneys and heart over many years), it can be related to high blood pressure, and it can be caused by obstruction to flow of urine out of the kidneys either at the prostate or bladder or both (which Mr Riley had had in the past). 42.

Who explained what was on the death certificate? Mr Riley’s son did not understand what was said.

The family came in to the bereavement centre and registered the death. Regrettably there is no record of who saw them. The family would normally be shown the certificate and the causes of death in the bereavement centre, before they go through to the Registrar. In cases in which the Certificate is issued on the authority of the Coroner, the Coroner’s Officer will usually have discussed the certificate and causes of death with the family (and well as with the doctors, and sometimes the nurses who were looking after the deceased). At each point up to the Registration the family have the opportunity to raise concerns. I am sorry that Mr Riley’s son’s understanding of the death certificate was not checked by those involved in the certification and registration.

43. Some nurses do not speak English well enough and Mr Riley could not understand them. I am sorry if Mr Riley could not understand all that was said to him all of the time. We endeavour to employ only staff who can communicate to a satisfactory level in English. We had not received similar complaints or observations about staff on the variety of wards on which Mr Riley was looked after. 44. White Boards: could important information be written on this? As described above there are limits to what can be described on such Boards while maintaining an appropriate and safe degree of patient confidentiality. We have worked with the organisations which regulate hospitals and information protection to find the right balance for our patients. Even with patient’s or relatives’ permission it is not good practice to include personal details. Outcome of the Meeting Following the meeting it was agreed with the family that their father’s experience, and the questions they had raised, would be presented to the November Trust Board. There were two points about which we were unable to reassure the family: 1. Whether bed rails had been in place immediately prior to their father’s fall 2. Whether Mr Riley’s poor nutritional intake in the interval between his fall and operation further compromised his ability to withstand the surgery (his appetite had been poor and he was kept nil by mouth for 24 hours before the operation) As a result of the meeting, these additional actions were agreed:ACTION Regarding point 2; food service assistant’s delivering food without using gowns and gloves: A review of this part of the infection control policy and procedure will be carried out and discussed at the monthly infection control meeting.

DATE FOR BY WHOM COMPLETION 22nd November Dr Fowlie to take 2013 to ICOG

Regarding point 8 of the response: Matron Gray will discuss your concerns with ward staff, in particular why they did not advise you about your father’s urology appointment, after you had made a number of enquiries.

End of Oct 13

Matron John Gray

Regarding point 17 of the response: Matron Gray will reiterate to his nursing staff and the matrons responsible for the other wards regarding the importance of providing clear and consistent communication with patients and their relatives.

End of Nov 13

Matron John Gray

Regarding point 34 of the response: Matron Gray will ask the matron for Ward C6 to remind staff to read a patient’s ‘About Me’

End of Oct 13

Matron John Gray

documentation on a regular basis. Regarding point 38 of the response: Matron Gray will remind his nursing staff and the matrons responsible for the other wards to follow up PALS enquiries, to ensure that relatives are kept fully informed.

End of Oct 13

Matron John Gray

Regarding point 40 of the response: Matron Gray will speak to the Bereavement Centre to ensure the staff seek clarification of a relative’s understanding of the patient’s death certificate and if required, arrange for them to speak to a doctor for a detailed explanation.

End of Nov 13

Matron John Gray