title-4473811

2008-07-20T14:19:16+02:00

Teaching Hospital. The Royal Free Hospital London. NW3

'...the last straw in a catalogue of errors.'

Non-diagnostic x-rays ? Late fluid balance assessment
Failure of Urology Consultant to re-visit patient
Misuse of antagonists ? Sub-standard respiratory monitoring
Alteration in ITU operation anaesthetic record

A twenty-three year old male patient at the Royal Free Hospital should have survived.
The treatment he received was unprofessional. Professor Carol Black, Chief Medical Officer of the Royal Free, admitted; "the treatment was poor"....

After admittance to A&E with injuries which were not life threatening, the patient was subjected to sub-standard treatment which led to a cardiac arrest 60 hours later and was transferred, in a coma, to the ITU.

Four days later an ill-judged orthopaedic operation was performed. The patient died during this operation.

Mr. J. C. Faux (Consultant Orthopaedic Surgeon, Preston) wrote:- "I agree with Mr. P J Smith. (Consultant Urological Surgeon, Bristol) that none of this unfortunate patient's injuries were life-threatening and he should have survived."

The treatment, from being alert and in pain from a kidney injury in the A&E to cardio-respiratory arrest, involved serious medical errors.

Lionel had other injuries; mild concussion; a fracturedwrist; a fractured arm; a broken rib and a pneumothorax.The fractured arm was diagnosed as a dislocation.

The pneumothorax was not discovered until forty hours had elapsed. Why the mis-diagnosis? Why the delay? The x-rays, after transfer from A&E, for 60 hrs leading up to the cardio- respiratory arrest, were non-diagnostic.

'These x-rays are of such poor quality apart from the ones on the 2nd of September (A&E) that they are unacceptable by clinicians for diagnostic purposes and it indicates a poor standard of radiography and one must question why the radiologists allow such poor quality of films to be produced'. Mr W.A.D. Downie. (Consultant Surgeon Emeritus. Sheffield.)

Over the initial sixty hours Lionel endured increasing respiratory difficulties (due to the unobserved pneumothorax and a broken rib) which were exacerbated by respiratory depressant drugs.

Without the aid of a reasonable standard of x-rays, a junior doctor attempted to 'pull' what he assumed was a dislocation of the elbow but which was, in fact, a complex fracture.

He administered Diamorphine and Diazemuls without the assistance of an anaesthetist. He left the scene, admitting that the 'manoeuver had failed’. He did not return. Ten minutes later Lionel had almost stopped breathing. A huge single dose of narcan was injected as an emergency measure.

Although laboured respiration was noted later by the junior doctors, Lionel was administered
further respiratory depressant drugs. The junior doctors were unaware of the re-narcotisation
effects of Diamorphine; the short life of Narcan and the correct dosage of this drug, and its
association with the development of pulmonary oedema.

A Urology consultant, Mr R J Morgan, assessed the kidney injury. He ordered an I VP and later, a scan. After examination of the scan he diagnosed that the kidney haemorrhage had stabilised and concluded that the injury should be treated 'conservatively'.

He did not re-visit Lionel. Months later when I questioned Mr R J Morgan and asked him why he did not re-visit the patient, he stated; "I cannot think why I did not re-assess the injury!"

Lionel was massively over-infused during the sixty hours before the cardio-respiratory arrest. The reason? The fluid balance charts were virtually unreadable.
Examination of these charts led another consultant expert to comment:- “The delayed assessment of this man's fluid balance is pathetic for any hospital in this country. He was then 'effectively drowned' by intravenous infusions causing generalised oedema. At the same time he had increasing pneumothorax producing respiratory distress.”
Mr. J.C. Faux. Consultant Orthopaedic Surgeon. Preston.

The Day before the Cardiac Arrest. During the early evening there was an assessment by a junior doctor Dr. R.O.P. King. He noted a marked lowering of the level of consciousness and wrote that this may be caused by:- (a) Hypoxia (b) Intracerebral contusion. No change or revision of treatment is suggested.

An hour later Dr Christina Ramage (Registrar-Dept of Anaesthesia) made an assessment. Most likely because she was unable to interpret the fluid balance charts, she ordered a 'fluid
challenge'.The results of this test (although indicating over-infusion) were not acted upon.

Dr Ramage noted:-'Percussion note stony dull all down left side and at right base - Air entry absent left side and at right base - Clinically bilateral pleural effusions despite left side chest drain - Left effusion is greater than right'. Dr Ramage suggested re-administering 60% Oxygen and monitoring respiration on the grounds of respiratory rate and arterial blood gases.

There is only one arterial blood gas analysis for the following 17 hours. (I was informed that The Royal Free do not execute this test overnight.)

One hour later At 18.00hrs (Sunday) the patient is examined by Dr Richard Garlick.
(Registrar-Neurosurgery) who recorded further deterioration and orders a CT (brain) scan.

A scan is performed later that night. There is no recorded assessment of the result of this scan
although it reveals the possibility of early brain swelling due to over- infusion. (since the date of this report is shown as the following day, it is possible that it was not assessed until after the cardiac arrest). Dr Garlick does not record any notes about the result of this scan.

During the 17 hours before the cardio-respiratory arrest, respiratory monitoring was
unprofessional. There was no overnight arterial blood gas analyses. (The patient remained on 60% Oxygen during this period) Dopamine was administered. No E C G was in place. No senior doctor visited.

On that night the pulse rate rose from 88 at 7pm. to 130 at midnight; and the respiration rate rose from 14 to 39 breaths per minute. These values are recorded. There is no reaction from the clinical team.

The overnight nurse's notes indicate that a junior doctor visited Lionel. This doctor did not
write notes concerning the patient's progress.

Three hours before the arrest a nurse scribbled in her notes; 'patient gasping'. There is no evidence of a doctor's arrival on the scene. Thirty minutes before the arrest there is a request for 'urgent' arterial blood gas analysis. The results were available an hour later...after the cardiac arrest.(The results reveal a very high level of PaCO2).

5 minutes before the arrest a nurse 'suctioned' without resorting to essential hyperoxygenation.
This was the last straw in a catalogue of errors that led to cardio-respiratory arrest.

I have no conception of the cardio-pulmonary resuscitation standards of the Royal Free Hospital.

Lionel was transferred to the I T U in a coma. In the I T U there was an E E G report which
stated:- 'A fairly marked abnormal record compatible with widespread cerebral insufficiency. The pattern could be related to a diffuse cerebral oedema in which case it is potentially recoverable'. There was little progress noted for the first forty-eight hours in the ITU.

A day later there was some progress. On the morning of the fourth day an I T U consultant wrote:

'Respiratory System; Gases improved. For weaning (from ventilator)
Central Nervous System; Eye Movements. Moving right arm Markedly raised level of
consciousness.'

Much later that day the surgeons decided to perform an orthopaedic operation to reduce the
fractured arm. Mr Nigel L Trimmings was the surgeon; the anaesthetist was a Dr Mark V Lynch. It is noteworthy that the consultants do not refer in their case-notes to the planning and execution of this operation at this particular time.

However, I was told; "something went wrong". Lionel died during the operation. There is scant reference in the case notes as to exactly what 'went wrong'. There was, however, a crisis.

There is an obligation for doctors to report a perioperative death. These details should be
forwarded to CEPOD:- 'The Report of a Confidential Enquiry into Perioperative Deaths'.
Furthermore, on the operation anaesthetic sheet there is a visible alteration in the entries for
end-tidal EtCO2. Where the end-tidal EtCO2 is being held at a constant 4.2 to 4.0 kPa for the first half-hour, it suddenly drops to 3.0kPa. (This figure is altered to 3.9 kPa)

Possibly, the Royal Free surgeons were not too keen on the idea of CEPOD examining this
anaesthetic sheet.

Lionel was kept on the ventilator for a further seven days. I can only assume that the reason for this was to distance the death from its actual date and signing the death certificate a week later.

There might be two reasons for this.
1. Death a week later puts the incident out of the orbit of CEPOD investigations since they require reports of death occurring with twenty-four hours of an operation.

2. The pathologist's Post Mortem report would not accurately reflect the true clinical situation,
after seven further days of ventilation, which would have been apparent earlier.

The Consultant-in Charge, Mr Lionel Gracey, did not visit Lionel during the initial sixty hours in the general ward. He appeared in the I T U, after the cardio-respiratory arrest (before the
operation). He said; "I expect a ninety-five per cent recovery.... Of course your son must return here for removal of a blood clot around the kidney".

This statement was made to mollify the anxious parents. One can only conjecture what went
through Mr Gracey's mind as he examined the junior doctors' and nurses notes'. One does not
know who ordered the orthopaedic operation. The patient might or might not have survived. He might have survived with paralysis. He might have left the Royal Free in a wheelchair. The
operation put paid to that outcome.....His chance of survival was eliminated.

The Coroner's verdict..?Blood loss due to traumatic injury to kidney'
After the Inquest the Consultant-in-charge, Mr Lionel Gracey said;
"Death due to severe head injury". (I did not believe either conclusion)

If the patient had survived the orthopaedic operation, would he wake from the
coma? If he woke from the coma, would he be paralysed - a quadriplegic? Would
he be a constant stimulus to the parents, in the coming months, to question the
medical treatment? Would the parents seek legal advice? If the treatment is proved
to be negligent; the Health Authority will be liable to provide for the patient for
many years to come.

The Health Authority would suffer adverse publicity and face an immense bill for
damages. The prestige of the hospital would suffer. The reputations of the negligent
doctors would suffer. The newspapers and TV would carry the story.

If the patient is now in a coma and the doctors realise that there has been negligent treatment.......will the patient wake from the coma?

If the patient is subject to a borderline orthopaedic operation in Intensive Care..will
the patient wake from the coma?

I was not enthusiastic, years later, when I was invited to a meeting to discuss the
case-history at the hospital. I did not wish to hear that trauma care had improved when the subject of improving trauma care had been aired many years before Lionel arrived at the Royal Free. I did not want to hear; "we must learn lessons from this".

What lessons? Should it be that the Royal Free, a Teaching Hospital, are required to learn:-

1. that a kidney injury should be re-assessed within 24 hours

2. that x-rays should be of diagnostic quality;

3. that trainee doctors should not anaesthetise without the guidance of an anaesthetist;

4. that respiratory depressant drugs should not be administered to patients whose respiratory status is compromised, without extremely close monitoring;

5. that trainee doctors should not administer Narcan if they are unaware of the countless warnings that are published concerning the correct dosage and administration of this drug;

6. that fluid balance sheets should be scrupulously maintained;

7. that the drug Dopamine should only be administered with regard to the guidelines of its manufacturer..'Dopamine should only be used under the direct supervision of physicians to whom facilities for regular intensive monitoring of cardiovascular and renal parameters, in particular, blood volume, myocardial contractility, cardiac output, Electrocardiography, urine flow rate, blood and pulse pressure are available.'; and that the use of this drug is associated with increased pulmonary oedema;

8. that Oxygen should be administered continuously and not intermittently;

9. that 60% Oxygen should not be administered over a period of many hours without serial blood gas analyses;

10. that nurses should be taught that suctioning without prior hyperoxygenation is
dangerous and can result in cardiac arrest.

A scenario is devised for the next of kin:- The 95% recovery statement. The Coroner's verdict. The verdict of the Consultant-in-charge. The post-inquest meetings at the hospital. The absence of case-notes at these meetings.
The Consultants probably thought it unlikely that these case notes would ever be examined in detail.... 'The next of kin would have an uphill struggle to bring a legal action..what possible evidence of negligence will be available to them? The patient died - the claim is meagre -will they get Legal Aid?... unlikely'

The Consultant-in-charge had, in the I T U, a patient in a coma which was directly attributable to negligent treatment in the Orthopaedic ward from which he had been transferred. The patient was showing some neurological reactions. These were variable. One could not accurately predict the outcome.

If the patient surfaced from the coma he might probably have neurological deficits.
There most likely would be an intense inquiry which would examine the questionable
progress of a patient who had arrived at the hospital with injuries which were not
life-threatening and who was now in a coma.

There would be an aftermath. The parents might react unfavourably towards the Health Authority if their son left the hospital paralysed... in a wheel-chair.

The parents would have time to regain their composure...time to think about the outcome...If their son dies they will be traumatised..they may never regain their composure.

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Young Life Wasted at Teaching Hospital

title-4473811