Mrs X complained about the decision not to immediately treat her husband, Mr X, in the ITU department of Glan Clwyd Hospital (“the Hospital”) following his repatriation from Tenerife on 25 February 2014. She believed that, had this been the case, Mr X would have received constant monitoring and any deterioration in his condition would have been identified at the earliest opportunity, which would have given him a better chance of survival. Mrs X said that her husband was not regularly reviewed when on the renal ward. Mrs X also complained that the Health Board lost Mr X’s notes for six months.
Mr X suffered with Chronic Renal Failure (a long term condition where the kidneys do not work effectively) and with other medical conditions. He was a patient of the Hospital’s dialysis unit and had received dialysis three times a week since around February 2012.
Mr X became ill when on holiday in Tenerife, in February 2014. On 25 February, Mr X was repatriated back to the Hospital. A fax was sent to the Hospital which detailed the treatment Mr X had received in Tenerife. On arrival at the Hospital, Mr X was transferred to the AMU (Acute Medical Unit) department, before being transferred to the renal ward. He was not attended by a consultant until 26 February.
All of the clinical renal physicians were away from the hospital that day. An ITU Registrar did not attend Mr X until 11.50am, when it was considered that Mr X may have pulmonary oedema (excess fluid in the lungs). At 1.02pm, Mr X suffered a peri-arrest (when a cardiac or respiratory arrest is imminent). The clinical plan was to increase Mr X’s blood pressure so that he could have dialysis. At 9.30pm, there was a sudden deterioration in Mr X’s condition and he sadly died at 10.00pm. The post mortem noted bronchopneumonia, COPD and damage caused to the kidneys due to diabetes, as the cause of death.
The Health Board carried out a Root Cause Analysis of Mr X’s death. This concluded that his death was not avoidable due to his existing medical conditions and that, whilst he should have been admitted to the ITU department immediately following repatriation, this would not have saved his life. The Ombudsman’s advisers found that the renal team should have been involved in Mr X’s admission to the hospital, to decide when Mr X needed dialysis. They were concerned that the Consultant Physician did not instigate dialysis. The ITU Registrar also did not instigate any dialysis. Mr X was not admitted to ITU until it was too late.
The Ombudsman concluded that there was a lack of responsibility for Mr X on the part of the Consultant Physician. He was critical of the lack of renal physicians on 26 February.
The Ombudsman also noted delays in care. He said that there was a ten hour gap in observations between 10.45pm on 25 February and 9.20am on 26 February when no observations were taken. There was no attendance by a consultant between 8.00pm on 25 February and 9.00am on 26 February. The Ombudsman was concerned about the Health Board’s comments that timings in Mr X’s medical records could not be relied upon, due to the practice of writing retrospectively. The most critical episode of delay, however, related to the failure to provide Mr X with dialysis. The Ombudsman found that Mr X’s pneumonia would not have improved until he had received dialysis and there was no urgency for this to be done. Mr X did not receive any dialysis until 6.00pm on 26 February.
The Ombudsman was critical of the RCA and its lack of objectivity. There was no mention of fluid overload or heart failure being the major causes of Mr X’s death. A further failing is the loss of Mr X’s medical records for six months, without proper explanation.
Recommendations
Renal
a) The Health Board instigates immediate (same day) senior review of renal patient admissions by consultant renal physicians.
b) The Health Board carries out a review of why there was no decision making renal consultant at the Hospital on 26 February, together with an explanation for inpatient responsibilities. A copy of the review should be forwarded to the Health Board’s Medical Director for consideration and any appropriate action be taken within three months of the date of issue of this report. A copy should also be sent to my office within this timeframe.
c) The Health Board reminds all junior doctors and consultants working in emergency and acute medicine of the need to immediately inform renal physicians when a renal patient is admitted. Evidence should be supplied to my office that this has been completed within three months of the date of issue of this report.
d) The Health Board’s renal department draws up clear policies for the management of emergency hospital admissions of renal patients within three months of the date of issue of this report.
Governance
a) The Health Board’s Chief Executive provides confirmation to my office that the Consultant Nephrologist and the Consultant Physician have reflected upon the issues raised in this complaint, with particular reference to the themes set out in the analysis section of the report. An anonymised copy of the complaint, together with this report and the consultants’ reflection on them, should be retained on their appraisal file, which will then be further discussed with their Appraiser and will be retained within the permanent appraisal database. Appropriate training should be supplied to anyone identified to be in need of it within six months of the date of issue of this report. The Health Board should also consider whether any of the issues raised as part of the process of reflection warrant referral of any relevant Consultant to the GMC.
b) The Health Board carries out further investigation as to who was contacted by the air ambulance, the Spanish ITU department and the patient’s wife. It should report the outcome of this investigation to my office within three months of the date of issue of this report.
c) The Head of the Health Board’s ITU department reviews the delay in the attendance of the ITU Registrar on 26 February at 11.50am and provides a report to the Medical Director for consideration containing their findings and any proposed recommendations within three months of the date of issue of this report. A copy should also be supplied to my office within this timeframe.
d) The Health Board completes the work set out in the RCA regarding its review of the management of repatriated or transferred in patients as a matter of urgency. Should the Health Board decide that a policy is required to best manage repatriated or transferred in patients, that work, in addition to the review of the position, should be completed within six months of the date of issue of this report.
Apology
a) The Health Board’s Chief Executive personally apologises to Mrs X for the failings identified in this report, most notably, Mr X’s potentially avoidable death, within one month of the date of issue of this report.
Redress
a) In light of Mr X’s potentially avoidable death, the Health Board’s service failure and the uncertainty caused to the family, it should pay Mrs X the sum of £20,000, within one month of the date of issue of this report. This sum also reflects the distress caused to the family by the manner of Mr X’s death, Mrs X’s time and trouble in pursuing the complaint and the delayed complaint response.
A full copy of the report is available below.