This case featured in the Ombudsman's Annual Report for 2012
Background
I received a complaint from a man who was very distressed after he received a phone call from his mother telling him she was dying and that he was to come to the hospital. The hospital was the Mid-Western Regional Hospital, Dooradoyle, County Limerick. He received the call at noon and arrived at the hospital at 13.30. The man was not briefed by medical staff of the seriousness of his mother’s condition until approximately 17.45, over four hours after he arrived at the hospital. His mother died that night at 23.40.
The delay in advising the man of his mother’s condition had serious implications for the rest of the family - who live in the UK - as they did not have sufficient notice of their mother’s condition to allow them make the necessary travel arrangements to be at her bedside before she passed away.
While the man was concerned about the impact on the family of receiving news from their mother about her deteriorating condition rather than from nursing staff, he was primarily concerned that there was a failure to provide convincing evidence that his mother was seen by a member of the medical team between 9.00 and 17.45 on the day of her death (thus making it impossible for the family to be informed of their mother’s serious condition and to make arrangements to be present).
Examination
The hospital maintained that the woman’s medical notes were relatively complete, and that they gave a description of the patient’s condition and a medical plan. However, I was not entirely satisfied with the hospital’s initial response. I felt there were deficiencies in its record keeping. The medical notes were not timed and, therefore, the hospital was not able to say if the patient was seen between 9.00 and 17.45 on the day in question.
My examination focused on the reasons why there was a failure by hospital staff to contact the family. It appeared the reason may have been linked to a delay by medical staff in examining the woman.
The purpose of keeping good records in a clinical environment is to provide accurate, current, comprehensive and concise information concerning the condition and care of the patient. Good record keeping also provides evidence of the care required, interventions by professionals and the patient’s response.
I drew the hospital’s attention to the fact that all records should be timed, especially where the condition of the patient is changing or liable to change frequently.
I also pointed out that the HSE’s ‘Code of Practice for Healthcare Records Management - Recommended Practices for Clinical Staff’ states:
“It should always be clear from the patient record what time an event occurred and what time a record was written. The time (24 hour clock) and date (day/ month/ year) are noted against each clinical entry. All entries must be accurate in relation to date (day/ month/ year) and time.”
I noted that the hospital, as part of its review, had confined its examination to the patient’s medical notes and formed the view that it was not possible to say if the patient was reviewed medically between 9.00 and 17.45.
I needed to get some appreciation of the extent of the medical review and the timing of that review. Therefore, rather than examine the medical notes in isolation, I reconciled the nursing notes with the medical notes of the same date. This process gave me a broader view of the situation as it was unfolding on the day in question.
From my examination, it appeared to me that, on the balance of probability, the patient was not seen by the medical team in the period 10.00 to 16.30 on the day she died.
Outcome
The hospital agreed that the documentary evidence supported my view.
In relation to the failure to contact the next-of-kin and the hospital’s inadequate recognition of the impact this had on the family, the hospital drew up and introduced a written policy on “Contacting the next of kin when a patient’s condition deteriorates”, shortly after the incident.
I welcomed the hospital’s response to this point. However, I asked the hospital to consider whether it felt an apology was warranted for the distress that was caused to the family as a result of:
- the apparent delay in reviewing their mother by the medical team,
- the consequent delay in advising the next of kin of the seriousness of their mother’s condition and
- the impact this delay had on the family, thus denying the family the maximum opportunity to try to reach their mother in her last hours.
Following my request, the hospital offered a sincere apology for the hurt and distress caused to the family. It also regretted that the family did not have the opportunity to be with their mother before she died.
As a result of this complaint the hospital put in place a number of measures that directly address the issues highlighted by my complainant, namely:
- It initiated a guideline on contacting the next of kin when a patient’s condition deteriorates.
- It introduced, as part of the Acute Medicines Programme for all nursing staff, an early warning scoring system for the recognition of deteriorating patients.
- It commenced a programme of education and training with the focus on a system called COMPASS using MEWS (Modified Early Warning Scores). The MEWS incorporates an escalation flow chart for informing a doctor and requesting a review by the doctor.
- It included a session on the HSE’s Code of Practice for Healthcare Records Management as part of its induction training for all new Interns (junior doctor).
The family was happy to receive the clarification and apology from the hospital. It welcomed the revised training and emphasis on good healthcare record management. It also hoped that other families would be spared the heartache that it endured in trying to get reliable responses from the hospital to its genuine distress.