- Brighton and Sussex University Hospitals Trust warned patients at risk from failings in care
- Patient was not given prescribed fluids and staff failed to read her notes or check tests
- Trust has since introduced a new handover process form and way of working for consultants
An NHS trust has issued a safety alert to all staff and introduced a new working model for acute medicine consultants following a patient’s death last year.
Brighton and Sussex University Hospitals Trust has been warned other patients could be at risk after Kamla Ram-Henman died in June last year following multiple failings in her care.
Last month, the trust was rated “good” by the Care Quality Commission, having previously been rated “inadequate” by inspectors.
Mrs Ram-Henman died within 24 hours of presenting at the trust’s accident and emergency department. An inquest into her death in October heard she was given just half a litre of fluids in the 24 hours before her death, despite her being seriously dehydrated and despite A&E staff prescribing fluids and potassium. Doctors giving evidence at the inquest told the coroner she should have had at least four litres of fluids.
She was transferred to a ward during handover period. A senior coroner investigating her death said it was wrong for hospital staff to assume “she should simply be put in a bed and left until the morning ward round”.
Mrs Ram-Henman also had only one set of bloods done. The coroner was told more should have been ordered, which would “undoubtedly have shown her deteriorating condition and would have acted as an additional reminder of the failings in her care”.
Other concerns cited by the coroner were:
- Mrs Ram-Henman received only half a litre of fluids in her entire 24-hour admission and was given no potassium despite this being requested when she was in A&E;
- A fluid chart was started but inaccurately completed with no attempts to record or measure outputs, meaning staff were unaware of how dehydrated she was becoming;
- An electrocardiogram which showed abnormalities linked to low potassium levels was ordered but not seen by the doctor who requested it, and the signature on the ECG was illegible;
- A second ECG was not requested and should have been;
- When she was transferred from A&E to a ward, Mrs Ram-Henman’s notes were not read so the failure to give fluids and potassium was missed; and
- The next morning, a doctor wanted her to be given medication, intravenous fluids and to have a computerised tomography scan. None of this was done before her death two hours later. It was another failure to recognise she had not received the fluids prescribed in A&E.
Mrs Ram-Henman was later found to have a large gastric ulcer which had perforated.
Senior coroner Veronica Hamilton-Deeley concluded that, while there was no guarantee Mrs Ram-Henman would have survived had her care been better, there was a risk of death to other patients if similar failures in care were repeated.
In response to the coroner, the trust revealed it had shared a copy of its incident investigation with Mrs Ram-Henman’s family.
Since the death, the trust told HSJ it had issued a trust-wide safety alert to warn staff not to use a “one-only” section of the drug chart to prescribe fluids and infusions. This had become “habitual” for staff but the trust believes a new electronic prescribing system, due in the next 18 months, will prevent the problems happening again.
It has also introduced a new telephone handover form, which includes prompts for staff on drains, lines and medication issues.
A new model of working has also been implemented for acute medicine consultants, where one is responsible for covering calls and another consultant is responsible for seeing patients when requested. This will mean more time for consultants to review patients and follow-up clinical plans.
George Findlay, chief medical officer and deputy chief executive, said the trust had apologised to Mrs Ram-Henman’s family and taken a number of steps to “ensure that we learn from this tragic event”.
Coroner’s report; statements to HSJ