Is There No Pity in the Clouds

That Sees the Bottom of My Grief?

Shakespeare

I have always had an extremely high opinion of Surgeons and Consultants and believed that the rest of the Medical Profession were doing their best.

 Regarding the rest of the Medical Profession, I no longer believe this.

Although I have had the pleasure of meeting some outstanding people, namely some nursing staff, and Paramedics in the Ambulance Service, in my experience of this  particular ward for the Elderly where my mum was transferred this counts as one of the ugliest experiences of my entire Life, and I have seen some ugly situations!

As for the following statement -as far as I am concerned this has been a Mega-Failure! –  and this includes my mother because she knew what was happening to her in that Ward!

  • The GMC Good Medical Practice-Maintaining Trust in The Profession.

I have however, watched television programmes such as King’s College Hospital A&E Department and deem the medics who work there to be Wonderful People – but, there again, what are the Wards like, as I have also watched programmes at this same hospital illustrating a new batch of student doctors arriving, which showed some dedicated people and some I would not ever ‘Let Loose’ on ‘Joe Public’ At All?

  • In fact the day junior doctors start on Wards in August is known historically as Black Wednesday!

Nevertheless I am still so very grateful that there are still real human beings who are not so far detached from Humanity, working in the NHS.

Thinking mum was in safe hands; am I a fool or am I a fool? and was being checked over for her little ailments, I had no idea she was being given all of these Drugs and this was just the Start, and thinking she was safe and knowing she was receiving fluid for her dehydration, I left her reluctantly that night.

  • To recant what had already been given on the 30th:

At 6.30pm mum was given:

1.2G Augmentin IV

500mg Clarithromycin PO

10.00-12.00pm mum was given:

500mg Clarithromycin PO

40mg Clexane SC

5mls Carbamazepine PO

2.5mg Salbutamol NEB

0.5mg Atrovent NEB

1 drop each eye Latanoprost

  • I hope all of you amateur detectives out there are alert today!

~Act Five~

  • On 31st at 4.32am the results from Another Arterial sample was produced.
  • At 7-9am mum was given:

1.2G Augmentin IV

625mg Augmentin PO = Overdose of Clavulanic Acid.

500mg Clarithromycin PO

2.5mg Salbutamol Neb

0.5mg Atrovent Neb 40mg Prednisolone PO

5mls Carbamazepine PO.

FIRST OVERDOSE!

  • The doctor who wrote the 625mg Augmentin prescription initialed and cancelled the first 1.2G Augmentin prescription, YET FAILED to observe that this first dose of 1.2G had been given at 7-9am, when writing the second one and circling this for 7-9am which was also given.
  • If nurses were not so intimidated in-house then they in turn could flag up these facts, essentially creating another person who could observe anything amiss, but they must keep within their own remit.  It is they who administer the drugs to patients.
  • N.B. On a Patient Forum:

Prednisolone should be 5-10mg.

Staying on 10mg will eventually shut down your Adrenal Glands.

  • At 12.00 mum’s blood pressure soared to 173/92 in TAZ awaiting transfer to another Hospital.

After a double dose of Clavulanic Acid with two lots of Augmentin this is no surprise!

She was given Nasal Drops @ 12.00pm – another Drug which she had never had in her life before, which begs the question ‘Why were her nasal passages blocked?’

Why are these things not observed? No one observed that her blood pressure may have soared because of anything amiss? Or even checked this? 

Oh, there’s been a sudden change, did we do or give something to bring about this change?

At 12.15pm she was nursed in TAZ while awaiting her transfer to another Hospital.

  • At 13.00 her B.P. had dropped to 143/65. At 13.00 she tolerated lunch, with no mention of assistance with gobbling.
  • At 1.45pm the ambulance came to transfer her in a chair.

Her discharge sheet was ticked including NOK/Contact informed, case notes, x-rays, nursing notes, and drug form.

  • I was not informed until I phoned to ask how mum was!
  • At 12.35am mum was given:

1G Paracetamol

I shall never know for certain what the cause of her pain was, but given all of the above, especially the Clexane in her stomach, or even the pain in her wrist veins, or even hunger pains, possible headache, is it a wonder?

  • At 12-2pm mum was given: (actual time 13.00).

2.5mg Salbutamol Neb

0.5mg Atrovent Neb.

On the morning of 31st I was anxious to phone to find out how mum was but delayed this call in order to give the nursing staff time to attend to patients.  When I did phone I was told she was being transferred to another Hospital, and although concerned I merely thought it was because of the shortage of beds the night before, necessitating the long wait.

Was I Wrong, Wrong, Wrong?

In fact her transfer was such that I could not go to the Hospital she was in to reassure her or anything else, and if I had not phoned when I did then I would have arrived to find her gone and either in transit or arrival at the other Hospital.  I could even have sat with her in TAZ.

This was not the first time that TAZ had failed to update me, as mum had been left there several years before when I was arranging transport myself, and mum had been sitting in TAZ for hours in her nightdress!  It never occurs to them to notify anyone at all!  I thought she would still be in her bed in the ward until the pre-arranged time that I had given to come for her.

Such is the care and concern displayed towards the elderly and/or those who care about them.

Absolutely Disgusting Disregard!

Once again a missed opportunity for humanity to show it’s face and more potential harm inflicted on an older person who as far as they are concerned Do Not Know what is happening or why their loved ones have not appeared.

Blood Pressure?  Who Gives a Damn?

Hang in There!

 In the words of the Late Al Jolson

‘You Ain’t Heard Nothing Yet’

It Gets Worse ~ Much Worse

And Then Some!

~Act Six~

I arrived at the other Hospital just after mum had arrived at 14.30pm

As I walked through the ward door I met a Nursing Sister who asked me what was wrong with my mother and I told her she was sent by the G.P. to be assessed for oxygen for occasional use if required at home.  Remember, neither of us knew anything about the G.P’s diagnosis or letter.

Why tell the patient? They don’t need to know?

Her reply came back ‘Did her G.P. not give her Oxygen’? with a complete look of puzzlement on her face indicating surprise that she hadn’t.

This was the first time I even considered that something might be amiss regarding what we had been told by the G.P.

This person was obviously, alert, awake, professional and ‘on the ball’ so the fact that I never saw her again probably meant that she did not last there, or possibly did not like being there.  Her calibre would not suit the ambiance of the ward.

The first notes written by the Ward Manager had ‘MEWS (modified early warning score) awaited’.

As soon as I saw mum settled I approached the Ward Manager to ask her if she would like me to bring in mum’s liquid Carbamazepine; which I knew to be expensive in liquid form;  and told her it was kept in the fridge, plus her eye drops (refridgerated also).  She abruptly declined my offer.

This female was decidedly unfriendly to say the least, and thinking she may have been under pressure I shrugged this off.  She then proceeded to complain that No Records had been sent with my mum.  This caused me some concern as I was concerned to know how mum could be treated without her details, or even that she would be given something which was contradictory to her well being, but when I expressed my concerns she became very defensive and almost angry; and while pondering her hang-up manner I immediately reassured her by saying ‘I’m not annoyed at you, I’m annoyed at the other Hospital’s carelessness’ (not knowing, of course that it was not their fault).  Another nurse witnessed this welcoming scenario!   This reassurance made no impact on her attitude at all, and I walked back to mum’s bedside worrying about the records and how this would be resolved for mum’s safety.

This Ward Manager was not remotely interested in the fact that I told her mum could not swallow tablets, as will be illustrated further.

The records show that this Ward Manager scored out most of the other Hospitals notes Ward Number and Time and replaced these with her own Ward Number and Time of 2.30pm.

Written in large letters on this original record sheet was ‘Allergic to All Citrus Fruits’.

The Consultant at the other Hospital had written:

  • ‘Not Acutely Unwell’!

~Act Seven~

  • The next person to complete observations on my mum was the FY2 who would ‘Treat’ her until her Death!

At 3.30pm this FY2 completed a pro-forma Admission Document beginning with: date of admission 30th, date of transfer31st:

Reason for Admission:

Exacerbation of COPD.

  • Transferred from Home accompanied by the G.P.’s name. Plus FY2’s own Consultant’s name.   
  • Admitted from left blank!   *Which should have read ‘Home’

Therefore this should have been:

Admitted from Home

Transferred from…other Hospital !

Then the G.P’s name

Then the Consultant’s name

By writing that the Transfer was from Home, this Consultant would never know that mum was transferred from the other Hospital, so would not contact them to *verify any of the patient’s details for any reason, especially given that there were No old notes, hence he would never be aware that the previous Hospital Consultant had stated:

  • ‘Not That Unwell’.

The only words he would see would be ‘Home, G.P. and his own Name’.

In reading the list of drugs which the second FY2 completed under d on the pro-forma; which had only been given since entering the first Hospital;  the second Consultant could only be under the impression that mum had been on all of these Drugs by her G.P.  and must have been unwell for some time!

He most certainly would be completely unaware that the first Hospital Consultant concurred with his own observation that mum was:

  • ‘Not Acutely Unwell’!
  • When he wrote his own doctors Review, plus Creps … plus  ‘Continue as above’, he could only have been referring to the drugs listed on the admission pro-forma (prescribed mainly by  the first Hospital FY2)  and copied by his own FY2.
  • The Question Arises:  Would he have written ‘Continue as above’ had he known that this list had Not been prescribed by mum’s G.P. but by another FY2?

Were the correct details written by this FY2, the other Hospital’s observations would have shown she had virtually Copied everything written by the A&E Triage Nurse, plus the other FY2’s notes, and the only original thoughts from this FY2 were tiny amounts of data from the results of the Haemo. test and her own Problem List:

No Old Notes. (Taken from the first Hospital’s FY2 notes).

This certainly confirmed that No old notes were available to either Hospital, but since this FY2 had copied most of her observations from the Triage nurse plus the other FY2 at the first Hospital, and by completing a misleading document and confirming ‘No old notes’ the only person reading this would be her own Consultant?

  • This copying was to become a common occurrence, throughout mum’s time in that ward with this FY2.

Action Plan:

  • All of the problem details were taken from both the other FY2’s notes and the Triage nurse’s notes, along with the results of WCC 14 taken from Haematology in the other hospital, CRP 188 on admission taken from Biochemistry in other the hospital.
  • Confusion, Hx of dementia (both taken from Triage nurse’s notes) confusion likely related to LRTI.
  • 1) Past Medical History:  Dementia, COPD,  LVH, Hypertension, Elipepsy, Recurrent UTI’s, Macular degeneration (All taken from the Triage nurse).
  • 2) Under Allergies had been written:
  • Severe Allergy – Anaphylaxis.
  • FY2 FAILED to write ‘Citrus Fruits – Anaphylaxis’ and left this box blank!
  • N.B. This was impossible to miss as it was sandwiched between the Triage Nurse’s notes:
  • 1) Past Medical History
  • 2) Allergies
  • 3) Drug History
  • N.B.  It is absolutely Mandatory for anyone working in the NHS to write down Allergies as they can be Life threatening.

Medications on admission:

  • 3) Carbamazepine 5ml BD – 100mg/5ml, Latanoprost eye drops – 2 drops, both eyes nocte, Chlorpheniramine Maleate Sol. 2mg/5ml -10ml 4-6 PRN?, Frusemide (wrong spelling-again_ 40mg 00. (All taken from the Triage nurse, apart from PRN which was written by the first FY2 but applied to an inhaler 2 puffs prn spacer, and Did Not apply Ever to Piriton(Chlorpheniramine Maleate Solution)!
  • These 3) all came under Drug History on the Triage nurses notes, but were listed under Medications on Admission on FY2’s Admission pro-forma.

Since admission:       Medications stopped –  Furosemide

d.

  • Clexane 40mg S/C, Prednisolone 40mg PO, Clarithromycin 500mg BD, Augmentin 625mg, Atrovent neb, Salbutamol neb. (these were all taken from the first FY2 plus the other Hospital doctor who prescribed the 625mg Augmentin).
  • One note was *exacerbation +/- cardiac failure, copied from the Triage nurse’s notes (which he had taken from the GP including >Amoxicillin + Frusemide 20mg bd this latter fact which FY2 FAILED to note.

General:

Sitting in chair  (FY2’s own note.)

  • Does Not Look Very Unwell ! (Fy2’s own note)
  • This is a Triple Whammy Confirmation of mum being Not that Unwell.
  • No Peripheral Oedema. (Triage nurse)
  • Air entry poor. (Opposite of first FY2)
  • Resp. no dullness. (Opposite of first FY2)
  • Mild creps (L) base, otherwise clear (similar to first FY2)

ABDO/GUS

  • Soft, non tender (First FY2)
  • No manes/organomegaly (Opposite of first FY2)

CNS

  • Moving all 4 ? + mobilising reasonably with 1.  CN 11-x11 Intact. (other FY2)
  • Vision macular degeneration (Triage nurse)
  • Hearing  (ticked.)

FY2 then entered the results of the Biochemistry test.

Problem list:

  • LRTI.  Increased confusion. (taken from first FY2 notes).

Management Plan:

A.

DVT Risk:  Moderate (circled).

DVT prophylaxis:  LMWH (circled).

B.

1) Continue Abx, & Prednisolone.

2) If  Sats. (oxygen saturation)  remain OK on 2L, try without O2.

  • Yet, on the following 2nd of the month, mum’s Sats. were 99% on 2L but she was not taken off O2!

3) Continue nebs and review to revision?

4) Bloods mane – monitor CRP + WCC.

5) Mobilise with physio.

6) Oral fluids.

7) Need old notes.

8) Urinalysis.

  • Almost every one of the above list was taken from the first FY2’s observations.
  • FY2 made no observation about the first FY2’s  ‘IV fluids-clinically dry but needs careful fluid balance.
  • ‘ Yet she wrote down almost everything else?
  • Would this not be important?

*It was not until 6.30pm that another doctor wrote a fluid chart.

  • FY2 made no mention of any of these observations in her Doctors notes.
  • At 3.30pm mum’s blood pressure had dropped to 110/60.
  • At 4-6pm mum was given:

625mg Augmentin PO

5.00mg Salbutamol Neb (Doubled)

0.5mg Atrovent Neb

This FY2 had doubled the Salbutamol, after writing a prescription for 2puffs 4 x day then scoring through it , writing a prescription for 2.5mg Salbutamol Neb prn, and 0.5mg Atrovent prn, and scoring through these completely, then writing another in error, scoring through this and finally writing 5mg.

  • The FY2 FAILED to observe the doubling of the Augmentin,  nor the deadly effects of what had been prescribed for a person:
  • ‘Not That Unwell’  ‘Not Very Unwell’  ‘Does Not Look Very Unwell’.

*Another doctor wrote a fluid chart to begin with N. Saline at 6.30pm.

  • This was the same doctor who started prescriptions for 1G Paracetamol at *10-12pm then 4 x day ongoing.
  • At 9pm mum’s blood pressure was 104/55.
  • At *10-12pm mum was given:

1G Paracetamol Disperse (written by other doctor).

625mg Augmentin PO

500mg Clarithromycin PO

40mg Clexane S/C

5mg Salbutamol Neb

0.5mg Atrovent Neb

5mls Carbamazepine PO

1 drop Latanoprost ea. eye.

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