The Healthcare Safety Investigation Branch’s latest report relates to a 58-year-old woman who was transported to an emergency department (ED) by ambulance with severe abdominal pain, 13 days after surgery for a perforated duodenal ulcer.
Initial observations in the ambulance and ED showed a rapid heart rate and low blood pressure. In ED the blood pressure decreased further. She was admitted to a surgical ward after seven hours in ED. She deteriorated two and a half hours later and, despite being transferred to ICU she died a few hours later.
HSIB had been notified anonymously about this event. Specific concerns were raised relating to limited recognition and response to the seriousness of the patient’s condition.
The watchdog investigated given problems in recognising and responding to deteriorating patients continues to be a major source of "severe harm and preventable death in hospitals".
With regard to the event in question, HSIB found that:
- There were interrelated and systemic contributory factors that influenced decision-making and explained why the patient’s deterioration was not sufficiently recognised or responded to.
- The staffing structure of the ED was not best for ensuring patients were seen by the right person in the right time frame.
- Information about the patient was dispersed across a variety of documentation and clinical staff.
- There tended to be a focus on the latest physiological observations which falsely reassured staff.
- Information that was communicated was eroded at each stage of the care pathway.
- Escalation was not optimal due to the availability of staff.
- One Trust policy differed from that recommended by the Royal College of Physicians.
- There was some ambiguity as to which specialty had clinical responsibility.
Nationally they made several findings too, including that there are multiple organisations producing publications and guidance on this topic but the large number of publications and guidance is likely to add complexity and make it difficult for trusts and staff managing a deteriorating patient.
Two safety recommendations:
- The Royal College of Physicians National Early Warning Score (NEWS) group to evaluate the implementation of NEWS 2.
- NHS England and NHS Improvement to expand the remit of the Cross System Sepsis Programme Board to include physical patient deterioration.
Three safety observations:
- NEWS 2 is not intended to be a standalone tool. It is intended to be combined with other relevant charts, results so staff should be trained in this approach.
- There may be benefits to including historical data from NEWS 2 during a patient handover.
- Trusts to ensure they are using the latest version of NEWS 2 charts and protocols.
You can read a summary of the key findings, safety recommendations and observations at pages 38 – 39 of the report.
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