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Barking, Havering and Redbridge University Hospitals Trust Pneumonia

Mortality Review - Final Report

APY Consulting Ltd

February 2017

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Contents Executive Summary 5 Introduction 6 Background 6 Reviews Undertaken 7 Analysis of Case Notes 9 Phase One 10 Description of Data 10 Patients not Suitable for Study 10 Age/Sex breakdown 10 Month Patient Died 10 Summary of when 15 Patient 1st dose antibiotics

were given more than 4 hours after admissions 11 Antibiotics Prescribed 14 Summary of Deaths 14 Conclusions 14 Recommendations 15 Phase Two Description of Data 16 Availability of Patient Episode Reports 16

Patients not Suitable for Study 16 Summary of 7 Patients not suitable for Study 16 Age/Sex Breakdown 17 Month Patient Died 17

Length of Stay 18 Time of Various Stages in the Admission Process 18

Time between First Contact and Examination in the MRU 19 A&E stays less than 4 hours 20 Number of Occasions 1st dose Antibiotics

Given in A&E Department 20 Time between Admission and

Administration of Antibiotic in A&E 20 Number of Times 1st Dose Antibiotics Outside Four Hours 21 Times from Admission Note in MRU to Post Take Review Greater than Twelve Hours 21 Time Interval between 1st and 2nd doses of Antibiotics 21 Mandated items 21 Summary of 17 Patients Whose Care fell Outside Guidelines 22 Antibiotics Prescribed 24 Summary of Deaths 24

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Conclusions 24 Recommendations 26 Phase Three 27 Description of Data Forms 27 Availability of Patient Episode Reports 27

Patients not suitable for Study 27 Age/Sex Breakdown 28 Length of Stay 29 Times of Various Stages in Admission Process 29 Time to 1st Dose Antibiotics 30 Time to 1st Dose Administration in A&E and MRU 30 Summary of the 11 Patients whose 1st Dose Antibiotic Administration Fell Outside the 4 Hour Guidelines 31 Time for 1st Dose Antibiotics in A&E Department 32 Mandated Items 33 Comparison of Patients < 5 Days Stay with Patient >10 Days Stay 33 Antibiotics Prescribed 34 Summary of Deaths 34 Conclusions 35 Recommendations 35

Phase Four 37 Description of Data 37 Availability of Patient Episode Reports 37

Case Notes not suitable for Study 37 Age/Sex Breakdown 38 Length of Stay 39 Comparison of Patients < 5 Days Stay with Patients >10 Days Stay 39 Summary of Findings noted during Hospital Stay 40 Low Haemoglobins 43 Summary of Deaths 44 Conclusions 44 Recommendations 45

Additional Comments 46 Patient Episode Report 46 Case Notes 46 Issues around the Use of a Paper Based Clinical Record

for Data Storage and Collection 46 Case for Electronic Support of the Care Process 47

Final Conclusions 48 Comment on the Review 48 Comment on the Findings 48

Next Actions 50

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Recommended Way Froward 50 References 51 Appendicies 52 Phase 1

Appendix 1 - Case notes reviewed in this phase 1 52 Appendix 2 - Data abstracted from the case note in phase 1 52 Phase 2 Appendix 1 Case notes reviewed in this phase 2 54 Appendix 2 Data abstracted from the case note in phase 2 55 Phase 3 Appendix 1 Case notes reviewed in this phase 3 55 Appendix 2 Data abstracted from the case note in phase 3 56 Phase 4 Appendix 1 Case notes reviewed in this phase 4 57 Appendix 2 Data abstracted from the case note in phase 4 58 Appendix 3 National Mortality Case Record Review Programme: Using the structured judgement review method: Data collection form.

Structured Judgement forms and data 59

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Executive Summary APY Consulting were commissioned to perform a quality audit on patients dying from pneumonia at BHRUHT. There was some anxiety in the Trust that the quality of care for these patients was not as good as it should be. Though the review did reveal some problems, on the whole the standard of care was judged to be good. The review was divided into four phases. In each phase data was extracted from the case notes and entered into a spread sheet where further analysis could be performed. Each phase reviewed a different aspect of the clinical records, although because of its importance, time to administration of first dose antibiotics was reviewed in three of the four phases. Phase 1 was an exploratory phase, establishing what data was available and where that data resided in the record. Time to administer the first dose of antibiotics was calculated and the antibiotics used were listed. Phase 2 undertook a more detailed study of the times drugs were administered. These ranged from first contact with the hospital to administration of 1st does antibiotics. Six times for each patient were looked at. From these various intervals were estimated such as the time spent in the A&E Department, the interval between review in the MRU and the Post Take assessment, also time for 1st dose antibiotics was estimated. Mandated data items were looked for including the CURB65 score. This last item is of great importance given that the Trust’s antibiotic policy for pneumonia depends upon it. However it was only calculated for approximately 6% of the patients reviewed. Phase 3, it was noted that a high proportion of patients died within a few days of admission and a cohort of these were compared with those who survived more than 10 days to see if data other than the CURB65 score could indicate which patients were of greater risk of dying. Further review of the administration of 1st dose antibiotics in the A&E Department and the MRU found that the A&E Department’s time to administration was much shorter than when the MRU was responsible. Again the CURB65 scores were rarely calculated. Phase 4 looked at the whole time the patient was cared for and found that 4 patients out of 43 reviewed, developed fluid overload and most likely went into heart failure. Clarithromycin was given orally in situations where intravenous administration was more appropriate. There were 3 occasions where the decisions of the medical attendants were judged to be wrong. Another cohort of patients dying within 4 days was compared with those surviving longer than 10 days. There were no absolute discriminating factors, however it was seen that the survivors had a more vigorous response to their pneumonias. There is evidence of some systematic problems and the ones to be noted are:

1. Time interval for first dose antibiotics greater than four hours when the antibiotics are not given in the A&E Department

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2. The almost universal lack of calculating the CURB65 score and hence the non-compliance with the Trust antibiotic policy

3. The lack of action taken on low haemoglobins 4. The lack of use of the Trust guide lines for the treatment of pneumonia 5. The development of heart failure after intravenous fluids

Introduction APY Consulting was invited by BHRUHT to conduct a review of deaths from pneumonia during the 12 months from July 2015 to June 2016. There was some evidence that these deaths had increased during this time and there was a concern that delivery of a high level of care within the Trust was being compromised.

Background Whilst there is always an interest in hospital mortality, this interest was increased in the UK by a study done in 2012 (1). Helen Hogan set out to ascertain the extent of and reasons for preventable deaths in hospitals. The investigation, under the title of Preventable Incidents, Survival and Mortality Study or PRISM, was conducted by review of the clinical record for patients who had died. It was suggested that the PRISM II tool should be used for the BHRUHT study. Review of this tool – a set of questions to be answered - suggested that it was not possible to answer all the questions without extensive knowledge of the Trust. For example the names of its consultants and their specialties, the consultants and medical staff working within the respiratory division, the names of the wards and the type of patients they were designated for. The reviewer was given the patients’ clinical notes. These contain only partial data on the patients’ conditions. No radiological or laboratory evidence was provided, except what was hand written in the notes. Hence it was not possible to make a full assessment of omissions or delays in organising appropriate investigations. Hogan’s work showed that errors in clinical monitoring (this was either not ordering indicated investigations or not acting on the results) were the commonest cause of deficiencies in care. Many years of experience from the reviewer has shown that caution is required in accepting the accuracy of clinical information recorded in the notes. It is not that staff set out to mislead but their ability to discern the correct clinical state and even to consistently record the same data items vary from individual to individual. For example, one of the questions in the PRISM II set is about the presence of confusion and if present was it due to dementia or delirium. The term dementia appears frequently in the reviewed notes but the condition can vary from mild memory loss to someone confined to

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bed unable to recognize their spouse. The uncertainty of the severity of the condition and whether it puts the patient at risk is not conveyed by the answer to the question. The nature of the task set suggested another approach to the assessment of care quality was required. The reviewer was asked to make judgements on a group of patients who had died of one common condition: pneumonia. This condition has attracted much attention and there are widely accepted guidelines as to its management. In essence these come down to four or five items such as a chest x-ray for diagnosis, oxygen and appropriate antibiotics for treatment and an overall assessment of prognoses reflected in the CURB65 score. These items are all reflected in hard data except for the presence/absence of confusion. This suggested that other hard data items could be looked at and in particular the time when various events occurred. To take two examples, it is well recognized that patients should not spend longer than four hours in the Emergency Department and that antibiotics, if required, should be started as soon as possible and certainly within four hours. A national review of preventable deaths undertaken by the Royal College of Physicians is under way and this depends substantially on the work done in Yorkshire by Professor Alan Hutchinson (2). The Yorkshire methodology depends heavily on what they term Structured Judgement. This is the reviewer’s assessment of the care process and it depends wholly on his or her view of the care process as revealed in the patient’s record. If there is an obvious omission of care then that is straight forward but not if there is just the feeling that things are not going well for some other reason. This project has a different set of characteristics from the national review and the method used, arrived at by a process of reflected evolution, is deemed appropriate.

Reviews Undertaken Phase One The PRISM II Review (2013) Form supplied by the Trust based on the work done from the London School of Medicine and Tropical Hygiene was used initially. A full review was often found to be difficult. Physically the case notes were often problematic to handle, some being 15cms thick, the data sheets were often not filed in chronological order and occasionally vital documents were missing. To do a full review, where possible, was taking upwards of an hour per set of case notes. At least half this time was spent identifying the clinical material which related to the final admission. There was also the learning process of becoming familiar with the various data sheets and where particular data items could be found. The ability to assess the quality of care was compromised by the difficulty of finding the appropriate data.

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It was agreed by BHRUHT to reduce the number of data items sought to make the process manageable and one quality item was sought and that was the time to administer the first dose of antibiotics. On this measure 15 of the 54 case records looked at in phase one found that the interval was above the four hours recommended. Phase Two Given the experience in phase one it was agreed to concentrate on hard data to measure the quality of care. In practical terms this came down to two sets of data: time of various stages of care and the presence of mandated data items. The admission process, if the patient is handled by both the A&E Department and the MRU, involves six timed stages. These are listed in the Phase 2 section. From these times various intervals can be calculated and at least two are subject to guide lines. These guidelines are used as measures of care quality. Generally clinical data is recorded on preprinted forms. These forms as well as acting as a data store also suggest the data items which should be collected. For the purpose of this review these were termed ‘Mandated Items’. Omission of these items, in particular the CURB65 Score is regarded as an omission of care. In practice the extent which an omission affects the quality of care has to be carefully judged and it can vary from almost none to very significant. Phase Three For the Phase three study a method similar to that used for Phase two was repeated. The analysis focused on the administration of first dose antibiotics in the A&E Department, strengthening the evidence for the findings around this item when combined with results from Phase two. In addition those patients who died in less than 5 days after admission or survived for longer than 10 days were compared. Data from NEWS was included in this analysis. It was hoped to find pointers to decide on admission, whether or not patient might survive at least four days. The aim was to provide extra care for the potentially short survival patients. Phase Four The reviews of Phases one, two and three can be characterized as a process audit focusing on the early stages of admission. Apart from the final diagnoses, very little data has been reviewed on the progress of patients. It was suggested that a review of the whole patients’ stay be undertaken to get a sense of how the patients progressed, the intervention of other agencies such as physiotherapy, palliative care and ITU was considered. To facilitate this approach the ‘Structured Judgment’ data forms used in the National Investigation into Preventable Mortality run by the Royal College of Physicians were used. The aim was still to undertake a process audit but to add a judgement dimension to the care delivered and hence move closer to the objectives of the national project.

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Analysis of the Case Notes Review Method Phases One to Four The following documents were examined for information on the standard of care for all phases: RAT clinical record (for patients admitted via A&E Dept.), Emergency Medical Clerking Proforma, (for patients admitted through the Medical Assessment Unit, MRU), Notification of Death to GP’s, Essential Patient Assessment Planning Evaluation Booklet, Drug prescription Chart and daily progress notes. For occasional patients who developed hospital acquired pneumonia whilst under surgical care the daily surgical progress notes were examined. Where possible, care delivered was assessed against the ‘Guidelines for the Management of Community Acquired Pneumonia in Adults Update 2009: A Quick Reference Guide.’ Published by British Thoracic Society 2009 (3).

Data Not Provided Type of pneumonia for review was not defined. Names of consultants with specialties, names of wards with specialties, coded diagnoses for each patient, radiology reports, laboratory investigations and microbiology findings were not provided. No guidelines for selecting appropriate patients for review were provided.

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Phase One Description of Data Phase 1 Number of records 81 Number of Full Review (60 items) 41 Study numbers 1-40 Number of Limited Review 1(26 items) 21 Study numbers 41- 62 Number of Limited Review 2 (28 items) 19 Study numbers 63-81 Reason for change from Full to Limited review Examination of the records reveal substantial number patients who did not meet the study criteria, that is death from pneumonia

Patients not suitable for study 27 Reasons with study numbers

Patient did not have Pneumonia Def: No evidence for the diagnosis of pneumonia in the last admission 34, 41, 44, Patient Discharged Def: Patient discharge from hospital at end of last admission 49, 51, 55, 56, 57, 58, 59, 60, 61, 62, 66, 69, 70, 71, 77, 79 Not suitable - reason not recorded 15, 16, 19, 20, 20a, 23, 24, 25

Case Notes suitable for study 54

Age/Sex Breakdown

Basic Demographic Data Males 24 Females 25 Not Recorded 5 Total 54 Average age total group 82 years

Month Patient Died April 16 May 7 June 8 July 0 Aug 10 September 2 Not recorded 11

Total 54

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Summary of 15 Patients When 1st dose Antibiotics were given outside the 4 hourly Guidelines Study Record Number

Summary of Care Nature of Problem What

13 Issues are detailed below. Patient had a significant infection with WCC 26,000 Note this patient had 2 problems

Patient admitted at 13.20 1st dose of antibiotics not given till 22.00. Antibiotics should be given ASAP and certainly with 4 hours

B6

13 Patient was having iv infusions. It was noted by nursing staff that arms were swelling. Suggesting infusion was going into the tissues. As antibiotics were given iv possible correct dose was not administered.

Antibiotics delayed B6

22 Patient admitted with 1 wk history of SOB, diagnosis of CAP made, 1st does antibiotics not given till 22.00. Patient condition continued to deteriorate, family wanted her to be kept comfortable

Delay in giving 1st does antibiotics, Amoxicillin given at 22.00, 21/06/16, Clarithromycin not given till 08.00 22/6/16

B6

26 Admitted with increasing SOB, 2 previous admissions with same symptom over pasted 2 months. Started with Co amoxiclav changed to Tazocin after 3 days. Felt pulmonary fibrosis was progressing rapidly. Condition not improving.

Patient seen at 16.00. 1st does of co amoxiclav not given till 22.00

B6

28 Admitted from nursing home, not well for past few days, had seizures. No respiratory symptoms. WCC raised some basal shadowing on CXR. Had seizures secondary to previous CVA on the ward, developed LVF. Principle diagnosis was sepsis associated with a UTI. Overall condition gradual deterioration.

Admitted 18.00 30/04/16 Written up for clarithromycin 1st does not given till 08.00 on 1/5/16 Delay 1st antibiotic dose

B6

32 Not well for 3 days cough with white sputum. Recent treatment for a chest infection, On LTOT hypoxic,

Patient 1st seen at 09.10. Antibiotic started at 18.00.

B6

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dehydrated, hypotensive, metabolic acidosis. CXR R basal consolidation. Reviewed for ITU but it was felt ward car was better. Some initial improvement but metabolic acidosis worsened said to be due to sepsis and AKI. Felt intubation and ventilation was not appropriate. Idiopathic pulmonary fibrosis was main problem.

33 2/12 difficulty in opening mouth seen by a dentist, should have been seen at QH but no appointment sent. Recently chesty, more confused and hallucinating. CXR show L pleural effusion and R basel shadowing. IV antibiotics prescribed. Mouth was giving biggest problem. Progress notes do not show how patient was responding to treatment

1st seen at 15.22 1st does antibiotics given at 22.00

B6

37 BCC removed Dec 2015 since then increasing SOB, more recently choking on swallowing. 2 wks saw GP because of SOB pneumonia diagnosed but no antibiotics given. SOB worse on day of admission. After 2 days and initial improvement collapsed and later died

Difficult to be sure of exact time of admission probably 1.00am if so 1st dose antibiotics not given till 8.00 am

B6

38 Wide spread bronchiectasis. Medical admission notes missing not able to give full history or initial findings

Difficult to be clear of situation. Patient admitted on 14/04/16 drugs written up on that day but first doses not given to 15/04/16.

B6

43 80 yr old drowsy generally unwell, chest infection diagnosed. Given iv antibiotics. No real recovery remained frail cachectic

Admitted 14.24 1st does antibiotics given 22.00

B6

45 Patient admitted 18.00 on 12/8/16. Drugs written up on 12/08/16? 1st dose 22.00 on 13/08/16. This needs checking as it maybe drug was not given at this time. Tazocin written up 13/08/16 1st dose 8.00

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on 13/08/15

50 Recent diagnosis of pneumonia treated by GP. Patient admitted in a very poor state. Unable to talk, hypotensive, hypoxic. CXR R upper zone consolidation. Patient died after about 6 hrs

Patient admitted 00.50 on XX/04/16. Written up for antibiotics. One dose given but timed at 08.00 according to the chart. This was after he had died

B6

53 Admitted with a few days history of ill health. In spite of treatment condition continued to deteriorate, developed LVF and died after 3 days

Patient admitted at 1.39 XX/08/16. 1st does of antibiotics at 8.00 XX/08/16

B6

68 Bed bound patient with sever dementia seen to deteriorate. CXR confirms consolidation at L base. Pneumonia resolved, patient had Chronic changes LL.

No time given on Emergency Medical Clerking Proforma. In progress notes times at 13.56. 1st dose of antibiotic given at 22.00 6/3/16

73 Severe COPD Some difficulty in establishing when patient was admitted Seems to be 26/04/16 at 18.56 no date given on medical proforma. No antibiotics given in A&E. In this case 1st antibiotics given 8.00 on 27/4/16

B6

80 Admitted critically ill with pneumonia and septic shock multi organ failure Died 2 days later.

Date and time missing from Emergency Medical Clerking Proforma. However post take round timed at 16.30 11/04/16 Prescribed teicoplanin - not given, clarithromycin 1st dose 22.00 11/04/16

B6

All these patients are breeches of the pneumonia guidelines and can be judged to have received less than optimal care.

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Antibiotics Prescribed Each row is one combination of antibiotics prescribed. The number of patients is in the second column.

Antibiotic Combination Number of Patients

Co Amoxiclav 6

Co Amoxiclav, Clarithromycin 16

Co Amoxiclav, Clarithromycin, Tazocin 3

Co Amoxiclav, Tazocin 1

Co Amoxiclav, Clarithromycin, Gentamycin 1

Co Amoxiclav, Trimethoprin 1

Co Amoxiclav, Gentamycin 2

Amoxycillin, Clarithromycin 2

Clarithromycin, Tazocin 1

Gentamycin 1

Gentamycin Tazocin 1

Levofloxacin 3

Teicoplanin 1

Treatment chart missing 5

Data not recorded 10

BHRUHT Summary of Deaths Template Report Phase of Study Amount Case notes reviews undertaken 81

Case notes without problems 39 of 54. 27 cases did not satisfy selection criteria

Case notes showing problems requiring further review

15 out of 54

Further reviews undertaken 15

Preventability of death count All 15 were judged to be 2’s

Narrative See table below - Summary of 15 patients whose care fell outside the guidelines

Conclusions 1. This phase should be regarded as an exploratory or pilot exercise, hopefully to provide

useful information on the main problem but also to refine the review process to make the

task more efficient and purposeful.

2. That one third of the case records reviewed (27 of 81) did not satisfy the criteria for the

study is a cause for concern.

3. No evidence of a consistent failure of care. On the whole the care given was of a high

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standard.

4. Deficiencies in some process items were found, including; failure to calculate the CURB65

score, Trust’s antibiotic policy not adhered to, time of first antibiotic administration outside

4 hour recommendation.

5. Given that there appears to be no regular lapses of care, apart from lack of CURB65 scores,

other reasons for the apparent increase in pneumonia mortality should be sought.

Recommendations 1. Data collection should be refined to make each review phase more manageable and useful.

2. Case notes should be reviewed to ensure patients fulfil criteria for the study.

3. Case notes re-organised so that all information for last admission is gathered together at

front.

4. Determination, recording and coding of the discharge diagnoses should be reviewed to

ensure the data is accurate and reflects the patients’ condition.

5. Short stay patients with a length of stay of four days or less should be reviewed to

determine if they were sent in to hospital to die.

6. A proforma for pneumonia should be developed and used for the management of all

patients where pneumonia is the most significant illness. It should include the ‘Pneumonia

Care Bundle’ to ensure this is used. This completed profroma could then be reviewed at the

post-take round.

7. A twice yearly review of pneumonia in the emergency department, both A&E and MRU

should be undertaken. If the suggested proforma was available in an electronic format the

review would be straightforward and not time consuming.

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Phase Two Description of Data for Phase Two Number of records 60 Number of Full Review 60 Study numbers 100-159 Examination of the records, reveal a number of patients who did not meet the study criteria, that is patients who died from pneumonia.

Availability of Patient Episode Reports The Trust supplied a set of ‘Patient Episode Reports’ (PER) along with the case notes to be reviewed. The PER contained some demographic information of the patient and the dates of the last admission, though in many cases these were incorrect. Most important was the set of coded diagnoses for the last admission. Matched one of the 60 medical records 34 Did not match any of the supplied Medical Records 26 Total 60

Patients not suitable for study 7

Summary of 7 Patients not suitable for Study Study No Hospital Id Reason

105 XXXXXX Died pneumonia XX/04/15 outside date range

110 XXXXXX Last admission in notes 29/04/14. Comment - there exists 2 extra sets of notes. Requested but did not arrive

119 XXXXXX No pneumonia

124 XXXXXX Discharged 18/02/16, No later admission

136 XXXXXX No record of last admission, which was 2-9th Jan 2016. ? another set of notes

141 XXXXXX Unable to find clinical details of last admission 5-11th Jan 2016

158 XXXXXX No clinical information after 2014. Patient died XX/02/16. ?another set of notes

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Note The following record was not totally suitable but there was enough to cover some items

137 XXXXXX Substantial part of clinical notes missing. Patient included in study using what was available


Age/Sex Breakdown

Basic Demographic Data Males 25 Females 28 Total 53 Average age total group 81 years Males 81 Female 81

Day Patients Admitted Mon 9 Tues 9 Wed 12 Thurs 3 Fri 10 Sat 5 Sun 5 Total 53

Month Patient Died Jan 16 Feb 16 March 20 Aug 1 Total 53

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Length of Stay Length of Stay days Number

1 7

2 9

3 4

4 4

5 3

6 5

7 4

8 1

9 2

10 and more 13

Not recorded 1

Total 53

Number of patients staying 4 days or less was 24, almost 50% of the records reviewed. The number of short stays suggests that for some patients at least they are sent in to die rather than to have any realistic chance of recovery.

Times of Various Stages in the Admission Process There are several admission routes from presentation at the hospital to the ward. The commonest is presentation and assessment in A&E Department, then transfer to MRU for a medical opinion, then transfer to ward. At various stages the time is noted. These are listed below. Seven times were extracted if the data was available. These were:

Time Source

1. Time of first contact with the hospital

From the A&E record, latterly this was the RAT record

2. Time when A&E officer prescribed a1st dose antibiotic

Prescription sheets forming part of the A&E record

3. Time when the first dose antibiotics were administered in A&E Dept.


4. Time when the Emergency Medical Clerking Proforma in the MRU was started

From the EMCP form

5. Time of Post Take Review From the EMCP form

6. Time of administration of 1st dose antibiotics by Ward Staff or the

Treatment Chart

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MRU staff

7. Time of administration of 2st does antibiotics by Ward Staff or the MRU staff

Treatment Chart

From these it is possible to determine 1. Time patient spent in A&E before transfer to MRU( time 4 minus time1) 2. Whether 1st dose given in the A&E Department (time 3) 3. If antibiotics given in the A&E Department then time between prescription and

administration (time 3 minus time 2) 4. Time interval between contact with the hospital and administration of 1st dose

antibiotics (time 3 minus time 1 or time 6 minus time1) 5. Time between entry to MRU and Post Take Review (time 5 minus time 4) 6. Time interval between 1st and 2nd administration of antibiotics (time 7 minus time 3)

Time between First Contact and Examination in the MRU The interval is first contact with hospital, noted on the A&E form and the time on the Emergency Medical Clerking Proforma. This last time is written on the front page of this document. This duration should represent the time spent in A&E with the proviso that the patient was seen immediately after transfer to the MRU. If the patient was not seen immediately the time in the MRU to examination will form part of this duration.

Study Number Duration from A&E Registration to EMCP start Breech if greater than 4 hrs

Duration to 1St Dose

Duration from EMRP start and 1st dose

101 6.54 15.04 8.10

103 4.07 11.37 7.30

117 4.33 11.23 4.50

127 4.25 Not recorded

128 7.47 0.13 Dose given in A&E Dept

145 6.50 15.04 8.14

Total No 6

These times represent A&E breeches. An interesting feature is that 4 of the 6 had delayed 1st dose antibiotics time. In all cases except case 128 the first does occurred after transfer to the MRU.

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A&E stays less than 4 hours – Time between 1st Contact with Hospital and examination in the MRU The following are examples where the duration in A&E was less than 4 hours. Given to demonstrate the time intervals to 1st dose antibiotics when A&E durations are acceptable

Study Number Duration from A&E Registration to EMCP start

Duration to 1St Dose

Duration from EMCP start to 1st dose antibiotics (column 2 minus column 3)

104 1.28 12.28 11.00

106 2.15 6.05 3.50

112 2.45 0.00 -2.45

116 3.47 2.50 -0.57

120 2.55 11.05 8.10

122 1.30 2.17 0.47

125 1.45 0.22 - 1.23

126 3.00 0.44 - 1.58

128 16.58 0.13 -16.45

Negative times indicate that 1st dose antibiotics were given in the A&E Department. These negative intervals (column 4) are the time between administration of 1st dose antibiotics and transfer to the MRU.

Number of Occasions 1st Dose Antibiotics given in A&E Department

Antibiotics given on 13 occasions or 25% of 53 patients reviewed

Time between Admission and Administration of Antibiotic in A&E Time between 1st contact with hospital (col 2) and giving of antibiotics (col 5)

Study No 1st Contact with

hospital A&E Prescription A&E Administration Duration

112 18.30 18.45 0.15

116 9.02 12.48 3.46

122 12.50 14.08 15.07 2.17

125 9.00 9.30 0.30

126 13.08 14.10 1.02

131 13.04 14.45 1.41

133 7.19 7.45 0.26

138 12.59 13.15 0.16

140 14.41 14.50 0.09

142 19.51 21.00 1.09

143 8.05 11.40 14.00 5.55

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144 13.34 15.25 1.51

150 4.11 8.00 3.49

The interval between admission and 1st dose antibiotics is very much shorter when antibiotics are given in the A&E Department. On only one occasion was it outside the 4 hour recommendation (case143)

Number of Times 1st Dose Antibiotics outside Four Hours

Time greater than 4 hours

Number of Breeches Study numbers

4 – 5 hrs 3 100, 149, 157

More than 5 hrs 14 101 102, 103, 104, 106, 117, 120, 137, 143, 145, 147, 151, 155, 156

Total 17

Nearly one third of patients reviewed were administered 1st dose of antibiotics outside of four hours. A record of the number of occasions that date and time was not recorded. It is generally felt that the post-take round should take place less than 12 hours after the patient’s admission. The number of times this did not occur is listed.

Item Number

Number of records 53

No date 4

No time 12

Interval between entry to MRU and Post Take round > 12 hours

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7 out of 41 which is 17%

Time Interval between 1st and 2nd Doses of Antibiotics All second doses of antibiotics were administered within an appropriate time range.

Mandated Items Items printed on the ‘Emergency Medical Clerking Proforma’ (EMCP) are expected to be addressed. These included the following items listed in the first column:

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Item Number missing

Not possible to assess/No record

Total number of records suitable for counting/analysis

Date 1 2 50

Time 3 2 48

Post take date 10 3 40

Post Take Time 2 4 47

O2 sats 4 1 48

Mental Test Score 21 4 28

CURB65 47 1 5

The CURB65 numbers are of particular significance because they were almost universally ignored and more importantly the Trust guide lines for antibiotics in community acquired pneumonia are dependent on the CURB65 scores. A contributing feature to the lack of these scores may be because the CURB65 material was printed on the last page of the form. None of the other requirements printed on this page were fulfilled.

Summary of 17 Patients When Care Fell Outside The Guidelines Study Record Number

Diagnoses at Death with other comments

Nature of Problem Time to administration 1st dose antibiotics in hours and minutes

What

100 LRTI , R/O PE 4.04 B6

101 Pneumonia, schizophrenia

15.04 B6

102 Pneumonia, hematemesis pressure ulcer, AF. Death due to upper GI hemorrhage Pneumonia not relevant to death

11.58 B6

103 Co morbidities present COPD,T2DM,IHD,pacemaker, CCF

11.37 B6

104 Pneumonia, Interstitial lung disease, Diabetes

12.28 B6

106 Lobar pneumonia, pleural effusion, IHD, Asthma,

6.05 B6

117 Lobar pneumonia, COPD, Respiratory Failure, Pleural Effusion, AF

9.23 B6

120 Lobar pneumonia, Syncope, AF, IHD, 11.05 B6

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HTN

137 Bronchopneumonia, Respiratory Failure, CKI, Anemia, Spina bifida, UTI

19.03 B6

143 Lobar pneumonia, Ca lung, Metastasis, Anemia, Respiratory Failure, T2 DM 1st dose A&E, Patient admitted with pain L chest, thought to be due to metastatic disease

5.55 B6

145 Lung Ca, LRTI Pat presented A&E then went home returned later in the day. 1st dose 8 hrs after first presentation

11.58 B6

147 CAP, HTN, TIA 9.07 B6

149 Pneumonia, Respiratory Failure, ARF, Alcoholic Hepatic Failure, CCF 1st dose given stat at 18.00 outside 4 hrs, changed to Tazocin Alcoholic liver disease main prob. Associated with Sepsis from chest infection led to death.

4.15 B6

151 Lobar Pneumonia hypothermia, hypotension, CKI, Dementia

11.47 B6

155 Pneumonia, Oedema, Pleural Effusion, RA

14.58 B6

156 Glioblastoma, CAP 12.09 B6

157 Bronchopneumonia, COPD 4.28 B6

All these patients are breeches of the pneumonia guidelines and can be judged to have received less than optimal care.

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Antibiotic Combination Number of Patients

Co Amoxiclav, Clarithromycin 25

Co Amoxiclav 9

Tazocin 4

Levofloxacin 4

Co Amoxiclav, Gentamycin 3

Clarithromycin 1

Clarithromycin, Levofloxacin 1

Amoxicillin, Clarithromycin 1

Teicoplanin 1

Clarithromycin, Tazocin 1

Treatment chart missing 3

BHRUHT Summary of Deaths Template Report Phase of Study Amount Case note reviews undertaken 60

Case notes without problems 36 of 53. 7 cases did not satisfy selection criteria

Case notes with problems requiring further review

17 out of 53


Preventability of death count All 17 were judged to be 2’s

Narrative See table below - Summary of 17 patients whose care fell outside the guidelines

Conclusions

1. Several types of pneumonia have been found in patients whose case notes were reviewed.

Apart from Community Acquired Pneumonia (CAP) there was also bronchopneumonia in

patients with COPD and Hospital Acquired Pneumonia. This mixture weakens the relevance

of using guidelines for Community Acquired Pneumonia as the guide lines for judging the

quality of care. No patient with pneumonia should come to harm if those guidelines are

followed.

2. Fewer patients were admitted on Saturday and Sunday. We can only speculate about the

reason for this. However the role of ‘out-of-hours’ services should be looked at.

25

3. The judgement that 17 patients received less than optimal care is based on when the first

doses of antibiotics was given. In most cases this information was taken from the Treatment

Chart. This chart specifies four times during the day when drugs are routinely administered;

8.00 13.00, 18.00 and 22.00. The prescriber is not limited to these times and other times can

be hand written onto the chart. However it seems likely that the antibiotics were prescribed

without any further instruction given on when they should be administered. As a result the

antibiotics would be administered during one of the routine drug rounds.

This leads to two possibilities: firstly waiting for one of the routine rounds may have delayed

the giving of the antibiotics and secondly the antibiotics may have been given outside one of

the four suggested times but the treatment chart was not amended to show the actual time

of administration.

4. It can be seen that when antibiotics are prescribed and administered in the A&E Department

the time to 1st dose administration is significantly reduced.

5. One of the principle objectives of this study was to record the time when various activities

occurred as listed in the table (Times of Various Stages in the Admission Process - page 18)

and calculate intervals between various events such as the time spent in the A&E

Department and time to first dose of antibiotics.

6. 17 out of 53 case notes suggest time to first dose of antibiotics of over 4 hours. This is 32%, a

high proportion.

7. 6 out of the 53 case notes suggest the patient breeched the 4 hours wait in A&E

recommendation. This is about 11%. Data on time spent in A&E is collected separately to

make it possible to look at this finding in more detail.

8. There are several mandated actions printed on EMCP. On the whole these are adhered to

but the two principle deficiencies are calculation of the Mental Test Score (MTS) in patients

in over 65’s and CURB65 score for all pneumonia patients. The CURB65 score is almost

universally ignored.

9. For 17% of the relevant case notes examined, the post-take round occurred 12 hours after

admission to the MRU.

10. The Trust’s guidelines for antibiotics in Lower Respiratory Tract infections are written

according to the CURB65 scores. In practice these scores were rarely calculated. Therefore

strictly speaking the Trust guidelines were never used. The most common regime used was

oral co-amoxiclav with clarithromycin, used in 25 of the 53 patients. This particular

combination is not amongst those given in the guidelines. The second most common regime

was co-amoxiclav as a single agent used in a further 9 patients, also not amongst the Trust’s

suggested regimes.

26

Recommendations 1. In the selection of case notes for review it would be helpful to try and achieve a more

homogenous group by excluding certain types of pneumonia such as those associated with

COPD or hospital acquired pneumonia.

2. All first does administration antibiotics should be prescribed as and given as ‘stat’ doses.

Though this will involve writing the prescription twice, once for stat and once for regular

administration, it will ensure there is no delay in waiting for the routine drug rounds to

occur.

3. If pneumonia is diagnosed or strongly suspected in the A&E Department, antibiotics should

be prescribed and administered in the A&E Department rather than referring the patient to

MRU for them to administer.

4. Education on the importance of the 4 hour rule to 1st dose antibiotic administration is

required.

5. The 4 hour rule should be printed on both the A&E clinical form (RAT form) and the

Emergency Medical Clerking Form.

6. If the MTS (Mental Test Score) is regarded as important then further action is required to

ensure it is calculated.

7. The CURB65 score is one of 5 similar clinical scores printed on the final page of the EMCP.

This form should be redesigned. One suggestion is that the final page becomes the seventh

page after the clinical findings page and before the Diagnosis, Management Plan and

Investigation Results page. Hopefully making the CURB65 assessment more obvious

8. The Trust guidelines for lower respiratory tract infections have either to be rewritten

omitting the need for the CURB65 score or significant action should be taken to get

prescribers to calculate and use this score. Being appreciative of getting Doctors to follow

particular lines of action with the regular audits necessary to monitor the use of the CURB65

score, we would recommend that the use of the CURB65 scores be abandoned and two

options presented. One for all cases of pneumonia. The second for all cases of pneumonia

except those that are severely ill or immunocompromised for which a second regime should

be suggested.

27

Phase Three Description of Data Forms The data taken from the medical records is held in 3 Excel spreadsheets.

Sheet 1 is the complete set of data taken from all 66 medical records and the associated Patient Episode Reports. The data is a mixed of numbers, dates and text. Sheet 2 Contain a selection which it was felt might define the nature of the patients and the response to their illnesses. It consists of 3 types of data a. source of patient i.e. Home or Care Home, and mobility. Then b. the six NEWS items used to identify patients with possible sepsis, and finally c. three laboratory tests WCC, Urea and CRP. All this data came from the patients’ medical records. Sheet 3 the data from two groups of patients, extracted from sheet 1. The groups were a. those who died within 4 days and b. those who survived longer than 10 days. The hope was to try and identify pointers which on admission would place the patient in one of these two groups.

Number of records 66 Number of Full Review 66 Study numbers 200-265 Examination of the records reveal a number patients who did not meet the study criteria, that is death from pneumonia

Availability of Patient Episode Report The Trust supplied a set of ‘Patient Episode Reports’ (PER) along with the case notes to be reviewed. The PER contained some demographic information, of the patient and the dates of the last admission, though in many cases these were incorrect. Most importantly was the set of coded diagnoses for the last admission Matched one of the 66 medical records 52 Did not match any of the supplied Medical Records 14 Total 66

Patients not suitable for study 14

Reasons with study numbers

Study No Hospital Id Reason

202 XXXXXX Record of last admission 31/12/15 to 5/1/16 missing

213 XXXXXX No evidence of pneumonia. Last admission was for nephrostomy

214 XXXXXX No evidence of pneumonia died from

28

mesothelioma

218 XXXXXX Last clinical record 2013 ?Another set of notes

219 XXXXXX Last clinical record July 2015 patient discharged to care home

224 XXXXXX Last clinical record June 2015 ?Missing file

227 XXXXXX Last clinical record June 2015 patient died in July 2015 ?Another set of notes

228 XXXXXX Last clinical record Sept 2015 died Oct 2015

229 XXXXXX Last clinical record Oct 2014. Not known if he has died

237 XXXXXX Records end at April 2015 patient died in July 2015 ?Another set of notes

238 XXXXXX No evidence of death or pneumonia

239 XXXXXX Died xx/07/15 No notes after Jan 2013

240 XXXXXX Died Oct 2015 No clinical records after Aug 2015

265 XXXXXX Last clinical record 2013. Nothing since Patient died xx/01/16


Age/Sex Breakdown

Basic Demographic Data Males 27 Females 25 Total 52 Average age total group 84 years Males 81.5 Female 86.4

Day Patients Admitted Mon 10 Tues 10 Wed 6 Thurs 8 Fri 10 Sat 3

29

Sun 5 Total 52

Month Patient Died Jan 17 Feb 3 March 2 June 2 July 14 October 13 November 1 Total 52

Length of Stay Days Number of

Patients

1 6

2 8

3 2

4 5

5 3

6 3

7 3

8 3

9 4

10 0

>10 days 15

Stays less than 5 days are 40% of total

Times of Various Stages in Admission Process Seven times were recorded if the data was available. These were:

Time Source

1. Time of first contact with the hospital From the A&E record, latterly this was the RAT record

2. Time when A&E officer prescribed a 1st dose antibiotic


3. Time when the first dose antibiotics were administered


4. Time when the Emergency Medical From the EMCP form

30

Clerking Proforma was started

5. Time of Post Take Review

6. Time of administration of 1st dose antibiotics by Ward Staff or the MRU staff

Treatment Chart

7. Time of administration of 2nd does antibiotics by Ward Staff or the MRU staff

Treatment Chart

Time to 1st Dose of Antibiotics The times to first dosage of antibiotics was divided into those prescribed in the A&E Department and those prescribed in the MRU. MRU responsible for 1st dose 12

No of times MRU administration > 4 hours 11 A&E responsible for 1st dose 27

No of times A&E administration > 4 hours 0 No data 8 Other reasons for no times 5 Total 52

Time to 1st Dose Administration in A&E and MRU Time between first contact with hospital and administration of 1st dose antibiotics

Study No A&E (hrs.mins) Study No MRU (hrs.mins)

201 0.10 200 5.52

203 1.23 205 14.30

207 0.21 206 6.41

208 1.18 215 9.36

211 0.36 221 5.38

212 0.18 226 13.08

216 0.15 230 3.00

217 0.02 234 10.01

222 1.16 235 15.43

225 0.30 236 21.48

242 0.19 249 5.36

244 0.36 251 7.11

245 0.36

246 0.13

247 3.51

248 1.14

252 2.53

254 1.01

31

255 1.05

256 1.34

257 0.58

258 1.16

259 3.11

260 1.06

261 2.17

263 3.08

264 0.56

A&E Average = 72 mins (1.12) hrs.min MRU Average = 594 mins (9.54) hrs.min

Summary of the 11 Patients when 1st Dose Antibiotic Administration Fell Outside the 4 Hour Guidelines Study Record Number

Diagnoses at Death with other comments

Time to administration of 1st dose antibiotics

What

200 Lobar pneumonia, UTI, ARF, CRF, CCF, Cellulitis T2 DM, Pressure ulcer, AF,

5.52 B6

205 Pneumonia, AF, HTN 14.30 B6

206 Pneumonia, COPD, UTI, Anaemia, thrombocytopenia, CCF, HTN, Osteoporosis, Polymyalgia Rheumatica

6.41 B6

215 Pneumonia, Constipation, Acute MI, CCF, HTN

9.36 B6

221 Lobar pneumonia, Bronchiectasis, Interstitial Pul fibrosis

5.38 B6

226 Lobar pneumonia, ARF, CRF, Paralytic Ileus, Volvulus, Asthma, HTN

13.08 B6

234 Pneumonia, Bronchiectasis, Falls, ARF, AF

10.01 B6

235 Pneumonia, ARF, Thrombocytopenia, Mantle cell lymphoma, Osteoporosis

15.43 B6

236 Pneumonia, Pleural Effusion, CRF, Decubitus ulcer, AF, COPD,

21.48 B6

249 Patient Episode Report missing 5.36 B6

32

251 Lobar pneumonia, COPD, CCF, Pleural Effusion, ARF, CRF, Colitis, Acidosis T2DM

7.11

All these patient are breeches of the pneumonia guidelines and can be judged to have received less than optimal care. All the breeches occurred in patients whose antibiotics were prescribed in the MRU.

Time for 1st Dose Antibiotics in A&E Department Time between 1st contact with hospital (col 2) and administration of antibiotics (col 5)

Study No 1st Contact with hospital

A&E Prescription

A&E Administration

Duration

201 16.10 16.20 16.29 0.19

203 20.37 21.50 22.00 1.23

207 12.44 12.40 13.05 0.21

208 11.42 No data 13.00 1.18

211 20.02 20.30 29.38 0.36

212 16.32 16.45 16.50 0.18

216 11.50 12.00 12.05 0.15

217 10.13 10.36 ?10.13 0.02

222 14.14 No data 15.30 1.16

225 17.55 18.10 18.25 0.30

242 11.48 12.07 12.07 0.19

244 23.14 23.11 23.50 0.36

245 08.59 09.00 09.35 0.36

246 23.49 No data 00.02 0.13

247 19.44 21.40 23.35 3.51

248 16.21 17.11 17.35 1.14

252 18.37 No data 21.30 2.53

254 14.29 14.50 15.30 1.01

255 09.52 10.45 10.57 1.05

256 09.21 10.20 10.55 1.34

257 23.12 23.55 0.10 0.58

258 16.42 17.10 17.58 1.16

259 08.52 11.50 12.03 3.11

260 10.34 11.36 11.40 1.06

261 22.53 23.10 01.10 2.17

263 06.59 10.07 No data 3.08 min time

264 18.09 18.50 19.05 0.56

33

The interval between admission and 1st dose is very much shorter when antibiotics are given in the A&E Department.

Mandated Items CURB65 scores were the only mandated item checked in phase 3. Of the 52 records reviewed only 3, around 6%, had a CURB65 score.

Comparison of Patients < 5 Days Stay with Patient >10 Days Stay In the hope of finding markers for those patients who might die within 4 days or less, two groups of patients were defined. Those who died in 4 days or less (21 patients in rows 3 -23 in spreadsheet 3) and those who died after 10 days or more (14 patients in rows 26-39 in spreadsheet 3).

Demographics Data Item Died < 5 days (%) Died after > 10 days (%)

Males 10 9

Average Age 80 78

Female 11 5

Average Age 89 81

Care Home/Nursing Home

4/14 (29%) 0/9 (0%)

Immobile or needing physical assistance

3/10 (30%) 3/8 (38%)

NEWS (National Early Warning Signs) Data Item Died < 5 days (%) Died after > 10 days (%)

WCC > 12.0 or <4 8/15 (53%) 3/11 (27%)

Temp <36 or >38.3 2/18 (11%) 2/10 (20%)

HR >= 90 11/20 (55%) 7/12 (58%)

RR >=20 13/19 (68%) 10/10 (100%)

Urea >= 10 7/10 (70%) 5/11 (45%)

1st dose > 4 hrs 7/11 (63%) 6/11 (55%)

Antibiotic regular 14/21 (67%) 8/13 (61%)

Antibiotic for sicker patients

7/21 (33%) 5/13 (39%)

These values have no absolute worth. The data sources are too unreliable and the numbers too small. However they could be used as a screening tool to determine if further

34

investigation is worthwhile. The denominators vary, reflecting the inconsistent data recording. The percentages are used to reduce the fractions to a standard format. It has not been possible to predict who will die quickly and who will persist. Those who died in less than 5 days tend to be older possibly from a Care/Nursing Home, WCC abnormal, respiratory rate normal, urea raised. Not enough data was available to calculate the CURB65 scores.


Antibiotic Regime Numbers

Amoxycillin 1

Co Amoxiclav 6

Co Amoxiclav/Clarithromycin 18

Clarithromycin 1

Levofloxacin 9

Levofloxacin/Clarithromycin 2

Tazocin 5

Tazocin/Clarithromycin 1

Tazocin/Gentamycin 1

Gentamycin 1

Gentamycin/Co Amoxiclav 1

Gentamycin/amoxicillin 1

Cefixime 1

Doxycycline 1

Treatment Chart missing 2

Not recorded 1

BHRUHT Summary of Deaths Template Report Phase of Study Amount Case reviews undertaken 66

Cases without problems 41 of 52

Cases with problems requiring further review 11 out of 52


Preventability count All 11 were judged to be 2’s

Narrative See table Summary of 11 patients whose care fell outside the guidelines

35

Conclusions 1. The Patient Episode Reports contain a long list of diagnoses. Often listing conditions which

are barely mentioned in the patient’s record. It is not clear how these lists are compiled, or

how the order relates to the importance of the conditions.

2. Weekend admissions are less than week day as previously noted.

3. Short lengths of stay, less than 5 days predominate. This may well reflect severity of illness.

However it has not been possible to prove this from the case notes.

4. In broad terms the antibiotics used can be divided into two groups, those that are given to

averagely ill patients such as amoxicillin, co-amoxiclav, clarithromycin and those used on the

sicker patients tazocin, levofloxacin. Gentamycin was used for one patient with urinary tract

infection where a gram negative organism was suspected.

5. The time difference in administration of 1st dose antibiotics between the A&E Department

and the MRU is once again revealed. On average the time difference for administration

between these two groups is approximately 8 hours 30 minutes.

6. The A&E Department has a better record both for the prescription and administration of 1st

dose antibiotics.

7. CURB65 scores not calculated and therefore not used.

8. On the patient characteristics available and reviewed it was not possible to predict which

patients were likely to die soonest. The CURB65 score would be helpful for this analysis.

Recommendations (same as for phase two)

1. In the selection of case notes for review it would be helpful to try and achieve a more homogenous group by excluding certain types of pneumonia such as those associated with COPD or hospital acquired pneumonia.

2. All first does administration antibiotics should be prescribed as and given as ‘stat’ doses. Though this will involve writing the prescription twice, once for stat and once for regular administration, it will ensure there is no delay in waiting for the routine drug rounds to occur.

3. If pneumonia is diagnosed or strongly suspected in the A&E Department, antibiotics should be prescribed and administered in the A&E Department rather than referring the patient to MRU for them to administer.

4. Education on the importance of the 4 hour rule to 1st dose antibiotic administration is required.

36

5. The 4 hour rule should be printed on both the A&E clinical form (RAT form) and the Emergency Medical Clerking Form.

6. If the MTS is regarded as important then further action is required to ensure it is calculated.

7. The CURB65 score is one of 5 similar clinical scores printed on the final page of the EMCP. This form should be redesigned. One suggestion is that the final page becomes the seventh page after the clinical findings page and before the Diagnosis, Management Plan and Investigation Results page.

8. The Trust guidelines for lower respiratory tract infections have either to be rewritten omitting the need for the CURB65 score or significant action should be taken to get prescribers to calculate and use this score. Being appreciative of getting Doctors to follow particular lines of action with the regular audits necessary to monitor the use of the CURB65 score, we would recommend that the use of the CURB65 scores be abandoned and two options presented. One for all cases of pneumonia. The second for all cases of pneumonia except those that are severely ill or immunocompromised for which a second regime should be suggested.

9. Short stay patients: we get the impression that some patients are sent in to die. A small number survive only one or two days. Perhaps it might be better if these patients, if they

could be identified, were proactively managed in the community.

37

Phase Four This phase differs from the other three in that the whole medical, but not the nursing record is reviewed and the focus is on identifying issues on the progress of the patient. To this end the ‘Structured Judgement’ forms (4) to be used in the National programme on preventable Mortality (RCP 2017) were used to hold the data. The format was kept but the form was truncated to fit this study. See Appendix 3 Phase 4

Description of Data The data taken from the medical records is held in 3 Excel spreadsheets:

Sheet 1 is the complete set of data taken from all 47 medical records and the associated Patient Episode Reports. The data is a mix of numbers, dates and text. Sheet 2 contains a selection of data points which it was felt might define the nature of the patients and the response to their illnesses. It consists of 3 types of data a. source of patient i.e. Home or Care Home, and mobility. b. the six NEWS items used to identify patients with possible sepsis. c. three laboratory tests WCC, Urea and CRP. All this data has come from the patients’ medical records. Sheet 3 the data from two groups of patients, extracted from sheet 1 from Phase 3 and Phase 4. The groups were a. those who died within 4 days and b. those who survived longer than 10 days. The hope was to try and identify pointers which on admission would place the patient in one of these two groups.

Number of records reviewed 47 Study numbers 300-346 Examination of the records revealed a number of patients who did not meet the study criteria, i.e. death from pneumonia.

Availability of Patient Episode Report The Trust supplied a set of ‘Patient Episode Reports’ (PER) along with the case notes to be reviewed. The PER contained some demographic information, of the patient and the dates of the last admission, though in many cases these were incorrect. Most importantly was the set of coded diagnoses for the last admission Matched one of the 47 medical records 47

Case Notes not suitable for study 4

Reasons with study numbers Study No Hospital Id Reason

302 XXXXXX Last IP visit 31/1/14 for loose stools patient died XXXXXX of pneumonia

306 XXXXXX RAT, EMCP and progress notes all

38

missing

320 XXXXXX Progression of patient not clear. Seems likely patient was admitted from haematology OP. Patient has AML. None of usual admission forms i.e RAT and EMCP used. Progress notes from 8 Oct 15 to XXXXXX present when she died. Treated with Tazocin and Clarithromycin plus usual drugs. No adverse incidents. Lack of usual information reason for rejection

341 XXXXXX No evidence of final admission. Patient IP 2/06/15 Discharge to Care Home 4/06/15.


Age/Sex Breakdown

Basic Demographic Data Males 22 Females 21 Total 43 Average age of total group 83 years Males 80.4 Female 85.3

Month Patient Died Jan 9 Feb 2 March 5 July 9 Aug 2 Sept 1 October 9 Nov 1 Dec 5

Total 43

39

Length of Stay Days Number of

Patients

1 3

2 1

3 4

4 4

5 8

6 0

7 3

8 0

9 1

10 4

>10 days 15

Total 43

Stay less than 5 days are 28% of total Stay more than 10 days are 35% of total

Comparison of Patients < 5 Days Stay with Patients >10 Days Stay In the hope of finding markers for those patients who might die within 4 days or less, two groups of patients were defined. Those who died in 4 days or less (21 patients in rows 3 -23 in spreadsheet 3) and those who died after 10 days or more (14 patients in rows 26-39 in spreadsheet 3).

Demographics Data Item Died < 5 days (%) Died after > 10 days (%)

Males 8 7

Average Age 85.6 79.8

Female 6 6

Average Age 83.8 86.7

Care Home/Nursing Home

3/14 (21%) 0/11 (0%)

Immobile or Needing Physical Assistance

9/14 (64%) 0/9 (0%)

NEWS (National Early Warning Signs) – should be phase 4 only Data Item Died < 5 days (%) Died after > 10 days (%)

WCC > 12.0 or <4 5/14 (36%) 8/13 (62%)

40

Temp <36 or >38.3 3/14 (21%) 1/11 (9%)

HR >= 90 5/14 (36%) 11/11 (100%)

RR >=20 8/14 (57%) 7/10 (70%)

Urea >= 10 9/14 (64%) 8/12 (67%)

These values have no absolute worth. The data sources are too unreliable and the numbers too small. The denominators vary reflecting the inconsistent data recording. The percentages are used to reduce the fractions to a standard format. It is not possible to predict who will die quickly and who will persist. Those who died in less than 5 days tended to be from a Care/Nursing Home and need more support for Activities of Daily Living. There is a feeling that those who survived longer are likely to have a more vigorous response to their infection. For example the WCC, HR and RR all tend to be higher in the survivor group, though all the patients ultimately died.

Summary of Findings during Patients’ Stay The findings from the review of the medical records are presented here. In phase four the emphasis was on continuing care in contrast to the admission process and the first 24 hours reviewed in phases 1, 2 and 3. The findings are presented in two tables. They are summaries of the findings given for convenience. The full information will be found in the compilation of Structured Judgment Data Sheets contained in the final report. The first table is a very truncated view of the findings the second table gives more detail.

Brief Summary of Structured Judgment Data Sheets Minor Possibly Significant Significant

301 No diagnostic or problem list

305 Pressure sore on heels 301 Transfusion required

307 – PER did record main problem GI bleed

312 Heart failure said to present –little evidence

304 Fluid overload CCF no treatment

311 Fall whilst monitored with nurse’s plan

317 Oral not iv clarithromycin given

311 Fluid overload CCF developed



319 Fluid overload



322 Not admitted when indication there


324 Fluid overload

343 Poor monitoring patient had collapse

Low Haemoglobins see note 344 Dr did not attend patient

41

after tables when requested to by nurse

Extended Summary of Structured Judgment Data Sheets Study Number

Findings Comment Impact

301 A&E admitting officer did not put a diagnostic or problem list at the end of his/her admission note

No impact None

301 Hb 72, not transfused, should have been given

Would have given some symptomatic relief

Symptoms increased

304 On day 6 bilateral diffuse creps noted and generalised peripheral oedema. Seems very likely patient had developed CCF CCF must be a possibility by day 6. A CXR would have been helpful and diuretics if heart failure confirmed. The pulmonary oedema must have increased the SOB, which diuretics would have relieved

Whether more active treatment in a frail demented95 year old is indicated is a problematic. The relatives were happy to see their mother kept comfortable

Symptoms increased

305 Nursing issue, investigated by Nurse managers. Patient developed pressure ischemia of both heels. Presumable due to lack of turning and heel protection. Incident Report prepared by nursing management

No impact None

307 CXR result ‘suggestion of possible infection in L base’ Chest was judge clear on numerous occasions. On 7th day was said to sound chesty PER should have GI bleeding as first cause of death

Coding issue Main cause of death not recorded

None on course of illness

311 Day 5 went into heart failure, bilateral creps, peripheral oedema,

Diagnoses not stated in notes

Some symptomatic distress to patient

42

JVP not seen. 500 mls fluid given overnight Term heart failure not used, patient given furosemide

311 Day 4 fell backwards Assessed for falls and a prevention plan in place

Falls in spite of protocol for falls followed. Laceration of scalp occurred

No influence on course of disease

312 Heart failure diagnosed at initial assessment but little evidence for it.

None

317 Clarithromycin given orally rather than iv. A breach of Trust guidelines on antibiotic administration

Unlikely to have made any difference

None

319 Fluid overload after iv administration. Basel creps suggestive of LVF. Settled with furosemide

Does not seem to be any problem with the patient. Died 14 days after fluid overload

None

319 CURB65 was 5. Which indicates iv antibiotics. Clarithromycin given orally

Not following Trust guidelines

None

322 Patient with end stage AML present in OPD with pneumonia. Given oral therapy and asked to come back in 2 wks. No better when next seen admitted for further treatment

Patient should have been admitted at presentation

Slight

324 Admitted with pneumonia went into pulmonary oedema with iv fluids

Issue is the monitoring of the fluid and decision on how much to give and the rate

Slight


An administrative issue which might indicate

None

43

a deeper problem

327 A&E admitting officer did not put a diagnostic or problem list at the end of his/her admission note MRU EMCP form no date or time

These might be signs of a poor practitioner

None


These might be signs of a poor practitioner

None

340 Patient given oral clarithromycin rather than by iv as recommended in the Trust guidelines

Failure to follow Trust guidelines on treatment of community acquired pneumonia

None

343 Poor monitoring of patient who had some form of collapse, cause not stated

May have contributed to death

344 Doctor refused to attend a patient after a request from ward staff

Always a dangerous thing for one professional to refuse a request from another one.

Not likely any further medical attention would have prevented the death

Haemoglobin Analysis

24 out of the 42 haemoglobins noted were outside the normal range

Significant number of anaemias. Only a few of these were attended to

Causes of all anaemias should be found and treated where possible

All these patients outlined in the tables can be judged to have received less than optimal care.

Low Haemoglobins Though the reviewer did not have access to laboratory information some laboratory results and radiology findings were written in the case notes. Some of this data was recorded in sheet 2 of the Excel file for phase four. It was noted that low haemoglobins were relatively common occurring in 24 out of 42 patients (57%). Broken down by gender 14 (58%) of the men and 10 (42%) of the women had low haemoglobins.

44

There was little evidence in the case notes that many of these were investigated. It might be argued that as 13 of these died within 4 days there was little opportunity for investigation and treatment, also there were two cases of acute myeloid leukaemia, but that still leaves 9 patients where there was the opportunity. It may be that review of all the laboratory results would reveal that some/many of these were investigated.

BHRUHT Summary of Deaths Template Report Phase of Study

Amount

Case reviews undertaken 47

Cases without problems 27 of 43

Cases with problems requiring further review 16 out of 43


Preventability count All 16 were judged to be 2’s

Narrative See table Summary of 16 patients whose care fell outside accepted guidelines

Conclusions

1. The most significant finding was the number of patients who went into heart failure due to

i.v. fluids. 4 out of 43 patients reviewed with a further possible one.

2. Anaemia is a common problem amongst this group of patients; 24 out of 42 patients or 57%.

From the progress notes, it seems that only a few of these were investigated. Not having

access to the full patient record it was not possible to say definitely if this was the case.

3. There are a few examples of errors of judgment. We would highlight case 301 where

transfusion was required, 322 where patient was not admitted when admission was

required and 344 where the Doctor on call did not comply with a request to review a

patient.

4. Trust guidelines on antibiotic usage in community acquired pneumonia and other types of

pneumonia were almost universally ignored.

5. The monitoring and review of nursing care seems substantial which is to be welcomed as

two issues were picked up as a result (patient 305 pressure sores on heels and patient 343

NEWS score of 7).

6. Whilst absence of a diagnostic and/or problem list after initial examination of patients may

seem a trivial error, especially in patients with clear cut conditions, it may often be

symptomatic of a deeper problem of lack of knowledge, training or experience.

45

7. Coding of IP conditions seems satisfactory, although there are occasional lapses, such as not

including significant conditions. These may not be highlighted in the patient record.

Recommendations 1. More care in prescribing i.v. fluids with particular attention to the amount and the rate of

infusion is required.

2. Better monitoring of elderly patients given i.v. fluids is needed.

3. More information is required on the management of patients with anaemia.

4. Guidelines with suggested recommendations from the Heamatology department should be

drawn up for initial investigation of patients with anaemia.

5. Trust guidelines on antibiotic usage require revision. Whilst a policy of antibiotic

administration based on CURB65 for pneumonia is the rational approach, action is required

to see it is carried through. Consider such points as education in and awareness of the policy

and monitoring to see if it is adhered to.

6. Assessors of Doctors in training should be aware of the problems noted here in the writing

of admission notes.

7. The points made around the Patient Episode Report in the final report we will submit should

be made known to the coding staff at BHRUHT.

46

Additional Comments Patient Episode Report The Trust supplied a set of ‘Patient Episode Reports’ (PER) along with the case notes to be reviewed. The PER contained some demographic information, of the patient and the dates of the last admission, though in many cases these were incorrect. Most importantly was the set of coded diagnoses for the last admission Lobar pneumonia appears quite frequently in these reports. Pure lobar pneumonia is a relatively uncommon form of pneumonia. Coding instructions should be checked to make sure they actually reflect the patient’s diagnoses. Also occasionally significant diagnoses were not mentioned for example in patient 307 who either died from a GI bleed or whose condition was seriously affected by GI bleeding the condition was not mentioned. Patient 324 had a very low sodium and heart failure neither of which was mentioned, 325 AF not listed.

Case Notes The case notes as presented to us are not fit for purpose. The case notes have two broad functions. Firstly to act as a support for the management of patients on the ward and in the out-patients department. Secondly to act as a repository of patient data enabling analysis for management or clinical purposes. The sheer bulk of some of the records argues against their usefulness in clinical areas and their disorganisation of content argues against their usefulness as a data source. BHRUHT should consider electronic technologies to support clinical care and data storage. Not necessarily a full electronic clinical record but more than appears to be available at the moment.

Issues around the Use of a Paper Based Clinical Record for Data Storage and Collection

Stages in Using Paper Medical Record as an information source

Possible Faults Comment

Identification of patients who died from pneumonia within the defined time interval

Patient diagnoses are incorrect. The categorisation of pneumonia as the principle illness

Coding errors and assessment of the relevance of a particular diagnosis

Pulling the notes Wrong set of notes pulled. Not the whole record is pulled

Mistakes in the medical record library

Transporting the medical record from medical record library to

Cost and difficulty in transportation

The sheer bulk and size of the medical record

47

reviewer introduces difficulties in transportation, be it from one part of the hospital to another or from one hospital to another

Identifying the section of the case notes where the sought after data item should be found

Relevant section, form or sheet may be missing. Relevant section, form or sheet may be overlooked by reviewer

Paper record is clumsy to handle, the sections are not always in the appropriate order or correct place in the record. Even if the record is complete it may take a reasonable length of time to find the item required

Data item May be missing or entered incorrectly

There can be a significant error rate in recording data not absolutely germane to patient care

Transcribing the data item Error in transcription Always a possibility when collecting data items

Case for Electronic Support of the Care Process

1. The case for having digital support for patient care is overwhelming and widely understood. As it is possible to provide electronic support for virtually every aspect of medical record keeping the decision is not whether to use but what to use

2. Aspects of hospital care supported by electronic means. Major electronic records include the following, patient administration including patient index, IP patient admission, OP booking, medical record tracking, case note recording, ordering and results reporting on all types of laboratory, radiological and specialist investigation, prescribing and administration of drugs, noting for nurses, PAMs and other types of staff, records for specialties and special interests.

3. The key decision is what if any types of noting should be provided. It is well recognised that professional staff can be reluctant and a few can be hostile to typing rather than writing. It is perfectly possible to have a record system that contains all major types of medical information except that which is normally hand written.

4. A hybrid system consisting of full support for all aspects of the medical record except for the hand written notes is possible.

5. Given the immense benefits that electronic prescribing systems bring in keeping

48

patients safe, it could be argued that institutions that do not have such systems need to consider their use urgently.

6. An electronic record could be a component part of a shared record across a health and social care economy, driving system wide integration and facilitating population health management.

Final Conclusion Comment on the Review In general a good standard of care was delivered. Patient admission assessments were reviewed by Consultant staff and treatment was done promptly, although there were some issues with the time interval for first does antibiotics, Ward care seems good with daily reviews often more than once, availability of specialist staff to review problems in care such as respiratory, and cardiology, the assessment by ITU staff for failing patients. Additional care provided by nursing, physiotherapy, occupational therapy and palliative care teams seemed to be generally available. Changes in the patient’s condition are monitored and action taken where necessary. There appears to be close contact and discussion with relatives particularly over DNR orders and other end of life issues. All these factors give reassurance that appropriate care is delivered In the review of any set of patient records, mistakes are almost certain to be found, errors of omission and of commission. It is a consequence of human involvement. The key question on errors should be is this a systematic problem or the result of random events. Here almost all errors can be attributed to random events. But organization issues should be reviewed to minimize random events including education, training, monitoring and reviews. There is evidence of some systematic problems and ones to be considered include:

1. Time interval for first dose antibiotics greater than four hours when the antibiotics are not given in the A&E Department 2. The almost universal lack of calculating the CURB65 score and hence the non-compliance with the Trust antibiotic policy 3. The lack of action on low haemoglobins 4. The lack of use of the Trust guide lines for the treatment of pneumonia 5. The development of heart failure after intravenous fluids

Comment on the Findings Pneumonia in these hospital patients stemmed from three sources

1. Principle cause for admission and hospital care 2. An additional condition to other major problems such as Cancer, Pulmonary fibrosis,

COPD 3. A complication of the hospital stay

Each of these types of pneumonia was represented in the patient records reviewed. It could be argued that the British Thoracic Society guidelines were not relevant in all cases.

49

However they are an unexceptional and systematic way of dealing with pneumonia. It seems reasonable to use them as a guideline for all types of pneumonia reviewed. The principle purpose of the review was to determine if deaths due to pneumonia were associated with reduced standard of care. There is no evidence of a significant and consistent deficiency of care in the management of these patients That is not to say there are no deficiencies or areas where improvement could not be made. Within the limits of the study, which can be characterised as an assessment of care based on a review of the hand written material in the patient notes. The notes consist almost entirely of documents which should be filled in. Apart from blank sheets of paper for clinical progress notes the style and type of data going into the patient record is predetermined. This format makes it relatively easy to determine what happened to the patient. From this it is possible to make three points. A significant number of times the first dose of antibiotics was not given with the 4 hour period, CURB65 scores should be calculated for every patient with pneumonia and from the score and the Trust guidelines on antibiotic usage the treatment determined. Antibiotic usage did not seem to accord with Trust guidelines. The crucial question is what difference did this make to the patients and it is very likely there are other deviations from recommended care. We would judge very little on this basis. It can be said the standard of care in virtually all cases was satisfactory. It is difficult to comment on the antibiotic usage because the guidelines for antibiotics in Community Acquired Pneumonia are written in terms of the CURB65 scores which in most cases were not calculated. Also we are dealing with several different types of pneumonia including those caused by aspiration, and hospital acquired, for which the antibiotic recommendation are slightly different. It is possible to say that co-amoxiclav was used in almost two thirds of the patients (Phase Two 34 of 53 patients) and the co-amoxiclav clarithromycin combination in almost half (25 of 53). The main thrust of the antibiotic policy in pneumonia was satisfied. None the less unless the guidelines were followed it cannot be said the best treatment was given on a consistent basis. Several of the patients had short stays, dying a few days or even a few hours after admission. This raises the possibility that some patients are sent to the hospital to die. It has been stated, possibly unfairly, that some institutions refer patients when it is felt their condition is critical.

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Next Actions Recommended Way Froward for BHRUHT

1. Qualitative information gained from questionnaires is a valuable source of insight in studies of mortality, especially when combined with case note reviews. These were not made available for this project but must be completed.

2. We understand that during the time period after that dealt with in this report i.e. August 2016 to January 2017, there was a step increase in Mortality rates as measured by SHMI.

3. This suggests deaths should be reviewed during the six month period August 2016 to January 2017 to ascertain why this increase has occurred. A patient cohort study should be commissioned to compare the nature of patients who presented in 2014 with those presenting in 2016.

4. A change in coding practice needs to be excluded to ensure this was not the reason for the increase in Mortality as reported by BHRUHT.

5. The objective would be to identify if patients are now older, frailer and more acutely ill as this could potentially help explain the increase in mortality.

6. A wider study of mortality across other conditions for example: sepsis, respiratory failure, urinary tract infections, acute myocardial infarction, chronic obstructive pulmonary disease is needed.

7. The Royal College of Physicians estimate that between 10% to 15% of patients have some sort of problem in their care and around 3% of deaths might have been avoided.

8. The Royal College of Physicians have suggested that reviewing adult deaths from a wider group will help identify issues and provide enhanced opportunity for learning and improvement.

9. There is a clear need to extend the work undertaken to examine Trust wide issues such as patient flow, discharge to assess, bed occupancy rates, A&E waiting times, staff and patient surveys, to ascertain their impact on mortality rates.

10. Investigating system wide issues such as early screening in primary care and proactive management of patients in community care would also help understand external factors that may well be influencing mortality rates at BHRUHT. Early intervention is key with the pneumonia pathway.

11. Consideration should be given as to whether there is a microbiology issue such as a change in type of organisms or a change in virulence of organisms.

12. Peer review via internal workshops and external benchmarking provide an opportunity for reflection and challenge and would be beneficial for BHRUHT to undertake.

51

References

1. Hogan, H (2014) The Scale and Scope of Preventable Hospital Deaths. PhD thesis, London School of Hygiene & Tropical Medicine. DOI: 10.17037/PUBS.01776586

2. Hutchinson, A., Coster, J.E., Cooper, K. L., et all (2010) comparison of case note review methods for evaluation quality and safety in health care. Health Technology Assessment, 14(10), pp1-170. ISSN 136-5278

3. Lim, W.S., Baudouin, S,V., George, R.C., et all British Thoracic Society guidelines for

the management of community acquired pneumonia in adults : update 2009 (2009) Thorax 2009;64:iii1-iii55 doi:10.1136/thx.2009.121434

4. Using the structured judgement review method: Data collection forms, Royal College of Physicians, National Mortality Record Review Programme. 2016

52

Appendicies Phase One Appendix 1 List of patients whose case notes were reviewed

Satisfied selection criteria Study No Hospital No Study No Hospital No Study No Hospital No Study No Hospital No

1 XXXXXX 17 XXXXXX 37 XXXXXX 63 XXXXXX











12 XXXXXX 33 XXXXXX 50 XXXXXX 80 Not recorded

13 XXXXXX 35 XXXXXX 52 XXXXXX

14 36 XXXXXX 53 XXXXXX

Did not satisfy selection criteria 15 XXXXXX 41 XXXXXX 60 XXXXXX




20a XXXXXX 55 XXXXXX 69 XXXXXX





Phase One Appendix 2 Data Items Reviewed 1st Set for 41 case notes

53

Timestamp Any problem in healthcare Health care fell below acceptable standards

Review Date Was death avoidable if problem had not occurred

Reviewer Summary of care

Box Number Description of problem I: what should happen, what did happen

Study Number Where did problem occur

Hospital Id Type of problem

Was patient suitable for the study? Contributory factors

Age at Death Description of problem II: what should happen, what did happen

Gender Where did problem occur

Stay days Type of Problem

Confusion or Memory Problems Contributory factors

Month Admitted Strength of evidence for avoidable death

Day Admitted Give reasons to support Q16

Time Admitted Strength of evidence for avoidability

Month when died How long was life reduced

No of wards on When time to avoid death

Admitted from Time to avoid death on a ward

Type of Admission Ways to avoid future deaths

If Yes was a diagnoses made Overall Quality of Care

Was patient mentally ill Give details on overall quality

Learning disability present End of Life:

Co-morbidities present Condition before current admission illness

Intrusive/invasive procedures not in patients best interest (CRP included)

Was patient 1st seen in A&E or other ED End of Life discussion with family/friend

1st ward placement Details of any end-of-life care which might help relief

If sub specialty which one Were judgments limited by lack of subspecialty knowledge

Was ward appropriate Were patient records adequate

Ward specialty at death Specify deficiencies records

If sub specialty which Ward where patient died

Was the ward appropriate Diagnosis on death

Main diagnosis on admission see sheet Antibiotics

Reduced Data Collection 1

Timestamp Description of problem I: what should happen, what did happen

Review Date Where did problem occur

Reviewer Type of problem

Box Number Contributory factors

54

Study Number Description of problem II: what should happen, what did happen

Hospital Id Where did problem occur

Was patient suitable for the study? Type of Problem

Month Admitted Contributory factors

Month when died Give reasons to support Q16

Main diagnosis on admission see sheet Strength of evidence for avoidability

Final diagnosis How long was life reduced

Antibiotics Were patient records adequate

Summary of care Specify deficiencies records

Reduced Data Collection 2 Above plus age and sex

Phase Two Appendix 1 List of patients whose case notes were reviewed Satisfied selection criteria Study Number

Hospital Id Study Number Hospital Id Study Number Hospital Id







107 XXXXXX 122 Not known 137 XXXXXX







Study number

Hospital Id Study number Hospital Id

145 XXXXXX 152 XXXXXX







Did not satisfy selection criteria

55

105 XXXXXX

110 XXXXXX

119 XXXXXX

124 XXXXXX

136 XXXXXX

141 XXXXXX

158 XXXXXX

Phase Two Appendix 2 Data Items Reviewed

Time stamp Time Post Take Review

Review Date Co-morbidities present

Reviewer Post take Diagnosis

Box Number Diagnosis at death

Study Number O2 Sat

Hospital Id MT Score

Pat Episode Report CURB65

Was patient suitable for the study? Antibiotics 1

Why not suitable Antibiotics 2

d.o.b. Time 1st dose

Age at Death Time 2nd dose

Gender Overall Quality of Care

Stay days Give details on overall quality

Month Admitted Were patient records adequate

Day Admitted Specify deficiencies in records

Month Died Did healthcare Health care fell below acceptable standards

Time RAT Comment

Admin Drug in A&E

Time EMCP

Phase Three Appendix 1 List of patients whose case notes were reviewed Satisfied Selection Criteria

Study No Hospital Id Study No Hospital Id Study No Hospital Id









56









Study Number

Hospital Id Study Number

Hospital Id










Did Not Satisfy Selection Criteria Study Number

Hospital Id Study Number

Hospital Id








Phase Three Appendix 2 Data Items Reviewed Time stamp Stay days CURB65

Review Date Month Admitted Antibiotics 1

Reviewer Day Admitted Antibiotics 2

Box Number Month Died Time 1st dose

Study No Time RAT 1st Dose A&E or MRU

Hospital Id Prescribe Drug Overall Quality of Care

PER present Admin Drug Give details on overall quality

Was patient suitable for the Time EMCP Were patient records

57

study? adequate

Why not suitable Time Post Take Review Specify deficiencies records

d.o.b. Co-morbidities present Was Pneumonia main condition

Age at Death Post take Diagnosis Did healthcare Health care fell below acceptable standards

Gender Diagnosis at death

Sheet 2 Extract from Main Sheet Reflecting Patients’ Condition

Study number BP systolic

d.o.b Acute altered mental State

Source Glucose > 7.7

Mobility Hb

Temp > 38.3 <36 WW C> 12 , < 4

HR > 90 Urea

RR > 20 CRP

Sheet 3 Extract from Main Sheet 2 groups, those who died in less than 5 days stay and those who died after a 10 day stay The data items are the same as in sheet 1

Phase Four Appendix 1 List of patients whose case notes were reviewed Satisfied selection criteria

Study number

Hospital Id Study number

Hospital Id Study number

Hospital Id














58


346 XXXXXX

Did not satisfy selection criteria Study No

Hospital Id

302 XXXXXX

306 XXXXXX

320 XXXXXX

341 XXXXXX

Phase Four Appendix 2 Data Items Reviewed Time stamp Gender Overall Quality of Care

Review Date Stay days Give details on overall quality

Reviewer Month Admitted Were patient records adequate

Box Number Month Died Specify deficiencies records

Study No Time RAT

Hospital Id Admin Drug

PER present Time EMCP

Was patient suitable for the study?

Time Post Take Review

Why not suitable Co-morbidities present

d.o.b. Post take Diagnosis

Age at Death Diagnosis at death

Sheet 2 Extract from Main Sheet Reflection patients’ Condition

Study number BP systolic

d.o.b Acute altered mental State

Source Glucose > 7.7

Mobility Hb

Temp > 38.3 <36 WW C> 12 , < 4

HR > 90 Urea

RR > 20 CRP

Sheet 3 Extract from Main Sheet 2 groups, those who died in less than 5 days stay and those who died after a 10 day stay The data items are the same as in sheet 1

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Appendix 3

National Mortality Case Record Review Programme: Using the structured judgement review method: Data collection form Structured case note review data collection Material in bold reflects data collected from the notes Study Number 301 Note all findings, except preventability of death are scored from the following scale Very poor 1 2 3 4 5 Excellent Please circle only one score. Please enter the following.

Item Data

Date of Review 9/01/17

Reviewer DWY

Study Number 301

Storage Box 270

Age at death 97

Date of Death XXXXXX

Sex

Social deprivation indicator (first 3/4 alphanumeric items of postcode):

Date of Admission 2/03/16

Time of Admission 17.20

Specialty Team at Death

Recorded Cause of Death

Type of Admission 1 Emergency 2 elective 3 1

Did patient have learning Disabilities No

Did patient have Dementia No

Structured case note review data collection Phase of care: Admission and initial management (approximately the first 24 hours) Please record your explicit judgements about the quality of care the patient received and whether it was in accordance with current good practice (for example, your professional

60

standards or your professional perspective). If there is any other information that you think is important or relevant that you wish to comment on then please do so. Patient reviewed in A&E Dept, identified crackles in chest, no diagnosis/problem list written. Referred to MRU. CXR showed R consolidation. In MRU Sepsis, neutropenia CAP diagnosed, Tazocin 5 days then Co amoxicillin. C Diff found on 5th day. Please rate the care received by the patient during this phase. Score 5 Phase of care: Overall assessment Please record your explicit judgements about the quality of care the patient received overall and whether it was in accordance with current good practice (for example, your professional standards). If there is any other information that you think is important or relevant that you wish to comment on then please do so. Care generally good however 2 points

1. A&E doctor of SHO grade did not write any diagnoses or a problem list 2. Transfusion should it have occurred given Hb was 72 in a patient with myeloma

Please rate the care received by the patient during this phase. Score 4 Please rate the quality of the patient record in enabling a good quality of care to be provided. Score 5 Assessment of problems in healthcare In this section, the reviewer is asked to comment on whether one or more specific types of problem(s) were identified and, if so, to indicate whether any led to harm. Were there any problems with the care of the patient? (Please tick) Yes (please stop here) If you did identify problems, please identify which problem type(s) from the selection below and indicate whether it led to any harm. Please tick all that relate to the case. Problem types 1. Problem in assessment, investigation or diagnosis (including assessment of pressure ulcer risk, venous thromboembolism (VTE) risk, history of falls) Yes Did the problem lead to harm? No

61

2. Problem with medication / IV fluids / electrolytes / oxygen (other than anaesthetic) Yes Did the problem lead to harm? Yes 3. Problem related to treatment and management plan (including prevention of pressure ulcers, falls, VTE) Yes Did the problemlead to harm? Yes Avoidability of death judgement score We are interested in your view on the avoidability of death in this case. Please choose from the following scale. Score 6 Score 6 Definitely not avoidable Please explain your reasons for your judgement of the level of avoidability of death in this case, including anything particular that you have identified. The patient was severely anaemic due to multiple myeloma. With a HB of 72 there was bound to be symptoms of fatigue, SOB, perhaps not even feeling well. A transfusion whilst not affecting the overall prognosis would have made the patient feel better. Symptomatic harm which will have occurred

Study Number 304

Structured case note review data collection Material in bold reflects the data collected from the notes Note all findings, except preventability of death are scored from the following scale Very poor 1 2 3 4 5 Excellent Please circle only one score. Please enter the following.

Item Data


Reviewer DWY

Study Number 304

Storage Box

Age at death 95


Sex F

Social deprivation indicator (first 3/4

62

alphanumeric items of postcode):

Date of Admission Dec 2015



Recorded Cause of Death Pneumonia



Did patient have Dementia Yes

Structured case note review data collection Phase of care: Please record your explicit judgements about the quality of care the patient received and whether it was in accordance with current good practice (for example, your professional standards or your professional perspective). If there is any other information that you think is important or relevant that you wish to comment on then please do so. 5 Phase of care: Ongoing care Please record your explicit judgements about the quality of care the patient received and whether it was in accordance with current good practice (for example, your professional standards or your professional perspective). If there is any other information that you think is important or relevant that you wish to comment on then please do so. Chest initial clear CXR on admission and No progress notes day 2-5. On day 6 bilat diffuse creps noted and generalised peripheral odema. Seems very likely patient had developed CCF. Another CXR was indicated and diuretics. Please rate the care received by the patient during this phase. Score 3 Phase of care: Overall assessment Please record your explicit judgements about the quality of care the patient received overall and whether it was in accordance with current good practice (for example, your professional standards). If there is any other information that you think is important or relevant that you wish to comment on then please do so. CCF must be a possibility by Day 6. A CXR would have been helpful and diuretics if heart failure confirmed. Whether more active treatment in a frail demented 95 year old is indicated is a problematic. The relatives were happy to see their mother kept comfortable However the pulmonary oedema must have increased the SOB, which diuretics would have relieved.

63

Please rate the care received by the patient during this phase. Score 3 Please rate the quality of the patient record in enabling a good quality of care to be provided. 2 progress note missing for days 2 to 5. Score 3 Assessment of problems in healthcare In this section, the reviewer is asked to comment on whether one or more specific types of problem(s) were identified and, if so, to indicate whether any led to harm. Were there any problems with the care of the patient? (Please tick) Yes If you did identify problems, please identify which problem type(s) from the selection below and indicate whether it led to any harm. Please tick all that relate to the case. Problem types 1. Problem in assessment, investigation or diagnosis (including assessment of pressure ulcer risk, venous thromboembolism (VTE) risk, history of falls) Yes Did the problem lead to harm? Yes 2. Problem with medication / IV fluids / electrolytes / oxygen (other than anaesthetic) Yes Did the problem lead to harm? Yes 3. Problem related to treatment and management plan (including prevention of pressure ulcers, falls, VTE) Yes Did the problemlead to harm? Yes Avoidability of death judgement score We are interested in your view on the avoidability of death in this case. Please choose from the following scale. Score 4 Score 4 Possibly avoidable but not very likely (less than 50:50) Please explain your reasons for your judgement of the level of avoidability of death in this case, including anything particular that you have identified. 4 days of chest symptoms, CXR clear, no signs, provision diagnosis of LRTI. Bilateral creps developed Given 5 days antibiotics. Pul odema is a possibility another CXR indicated. Because of frailty and no response by Day 6 decided to keep patient comfortable died on D10. A likely sequence of events patient was admitted with sepsis cause unknown. This settled on antibiotics. Heart failure then developed.

64

The patient is likely to have developed heart failure which is imminently treatable. It is difficult decision to say it should be treated. Would we be prolonging dying rather than saving lives. Cases notes were deficient in that clinical progress notes were missing for D2 – D5.

Study number 305 Structured case note review data collection Material in bold reflects the data collected from the notes Note all findings, except preventability of death are scored from the following scale Very poor 1 2 3 4 5 Excellent Please circle only one score. Please enter the following.

Item Data


Reviewer DWY

Study Number 306

Storage Box 330

Age at death 73


Sex M






Type of Admission 1 Emergency 2 elective , 3 1



Structured case note review data collection Phase of care: Admission and initial management (approximately the first 24 hours) Please record your explicit judgements about the quality of care the patient received and whether it was in accordance with current good practice (for example, your professional standards or your professional perspective). If there is any other information that you think is important or relevant that you wish to comment on then please do so.

65

Patient admitted after a fall. Noted to have multiple problems, PEG feeding after CVA, CABG 20 yrs ago. Cachectic, IDDM not well controlled. Pneumonia diagnosed. Please rate the care received by the patient during this phase. Score 5 Phase of care: Overall assessment Please record your explicit judgements about the quality of care the patient received overall and whether it was in accordance with current good practice (for example, your professional standards). If there is any other information that you think is important or relevant that you wish to comment on then please do so. Principle issue was control of diabetes, Seen regularly by the Diabetic Nurse. On day 16 developed hypoglycaemia BM < 1. Had a fit then respiratory arrest, pCO2 was 19. The cardiac arrest was resuscitated fairly easily. His chest problem of collapse consolidation with effusion gradually worsened. 1L fluid aspirated at one point Not responding to antibiotics. Under review by Respiratory consultant, had BiPap at one point. Decided that he was only fit for ward based care. Improved for a short time but then died. Overall care seems satisfactory but there is an SI report concerning pressure sores. Serious Injury Report

Poor care of pressure sores involving both heels. Conclusion of SI Report

Poor documentation. Protocol not followed by nursing staff when problem was first outlined.

Please rate the care received by the patient during this phase. Score 4 Please rate the quality of the patient record in enabling a good quality of care to be provided. Score 5 Assessment of problems in healthcare In this section, the reviewer is asked to comment on whether one or more specific types of problem(s) were identified and, if so, to indicate whether any led to harm. Were there any problems with the care of the patient? (Please tick) Yes

66

If you did identify problems, please identify which problem type(s) from the selection below and indicate whether it led to any harm. Please tick all that relate to the case. Problem types 3. Problem related to treatment and management plan (including prevention of pressure ulcers, falls, VTE) Yes Did the problem lead to harm? Yes Avoidability of death judgement score We are interested in your view on the avoidability of death in this case. Please choose from the following scale. 6 Score 6 Definitely not avoidable Please explain your reasons for your judgement of the level of avoidability of death in this case, including anything particular that you have identified. It was felt that management of his skin fell below acceptable standards. In particular he developed pressure sores of both heels. Investigation concluded that set protocols for skin management were not carried out. This condition had no effect on his principle conditions or survival but may have led to discomfort from his heels.


Item Data


Reviewer DWY

Study Number 307

Storage Box 292

Age at death 75


67

Sex M



Time of Admission 13,53





Did Patient have Dementia Yes

Structured case note review data collection Phase of care: Phase of care: Overall assessment Please record your explicit judgements about the quality of care the patient received overall and whether it was in accordance with current good practice (for example, your professional standards). If there is any other information that you think is important or relevant that you wish to comment on then please do so. Admitted after a collapse at home. Very little history. Was known to have GI bleeding, melaenia in particular, also cirrhosis and a gastric ulcer. Continue to have haematemesis whilst IP. 2nd CXR result ‘suggestion of possible infection in L base’ Chest was judge clear on numerous occasions. On 7th day was said to sound chesty. Patient Episode Report should have GI bleeding as first cause of death. Please rate the care received by the patient during this phase. Score 5 Please rate the quality of the patient record in enabling a good quality of care to be provided. Score 4 Assessment of problems in healthcare In this section, the reviewer is asked to comment on whether one or more specific types of problem(s) were identified and, if so, to indicate whether any led to harm. Were there any problems with the care of the patient? Yes If you did identify problems, please identify which problem type(s) from the selection below and indicate whether it led to any harm. Please tick all that relate to the case. Problem types

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3. Problem related to other factors Yes Did the problem lead to harm? No Avoidability of death judgement score We are interested in your view on the avoidability of death in this case. Please choose from the following scale. Score 6 Score 6 Definitely not avoidable Please explain your reasons for your judgement of the level of avoidability of death in this case, including anything particular that you have identified. Little evidence of pneumonia until Day 7. If pneumonia then only an incidental part of his condition which was repeated GI bleeds GI Bleeding and haematemesis should have been main diagnoses Reason for signalling concern


Item Data


Reviewer DWY

Study Number 311

Storage Box 68

Age at death 96


Sex F




69





Did patient have Dementia

Structured case note review data collection Phases of care Please record your explicit judgements about the quality of care the patient received and whether it was in accordance with current good practice (for example, your professional standards or your professional perspective). If there is any other information that you think is important or relevant that you wish to comment on then please do so. Day 4 fell backwards. Assessed for falls and a prevention plan in place. Laceration of scalp occurred. Day 5 went into heart failure, bilat creps, peripheral oedema, JVP not seen. 500 mls fluid overnight. Term Heart Failure not used, given frusemide. Please rate the care received by the patient during this phase. Score 4 Phase of care: Overall assessment Please record your explicit judgements about the quality of care the patient received overall and whether it was in accordance with current good practice (for example, your professional standards). If there is any other information that you think is important or relevant that you wish to comment on then please do so. Admitted with features of CAP see CXR. Dehydrated, hypotension given fluid challenge of 500 mls, went into heart failure. Acute retention developed and confusion. Seems to have deteriorated from day 5 Poor cardiac output and then death. Though said to be on frusemide I could not see it on the treatment chart. No mention in progress notes. Please rate the care received by the patient during this phase. Score 4 Please rate the quality of the patient record in enabling a good quality of care to be provided. Score 4 Assessment of problems in healthcare In this section, the reviewer is asked to comment on whether one or more specific types of problem(s) were identified and, if so, to indicate whether any led to harm.

70

Were there any problems with the care of the patient? (Please tick) Yes (please continue below) If you did identify problems, please identify which problem type(s) from the selection below and indicate whether it led to any harm. Please tick all that relate to the case. Problem types 1. Problem in assessment, investigation or diagnosis (including assessment of pressure ulcer risk, venous thromboembolism (VTE) risk, history of falls) Yes Did the problem lead to harm? Yes 2. Problem with medication / IV fluids / electrolytes / oxygen (other than anaesthetic) Yes Did the problem lead to harm? Yes 3. Problem related to treatment and management plan (including prevention of pressure ulcers, falls, VTE) Yes Did the problemlead to harm? Yes 6. Problem in clinical monitoring (including failure to plan, to undertake, or to recognise and respond to changes) Yes Did the problem lead to harm? Yes Avoidability of death judgement score We are interested in your view on the avoidability of death in this case. Please choose from the following scale. Score 4 Score 4 Possibly avoidable but not very likely (less than 50:50) Please explain your reasons for your judgement of the level of avoidability of death in this case, including anything particular that you have identified. Patient admitted with a pneumonia, confirmed by CXR. Given iv fluids because of dehydration and possible hypotension. She then went into heart failure. Though it was suggested she should have frusemide, this was not written on treatment chart or referred to in the clinical notes, nor was the diagnosis of heart failure written down. The development of heart failure must have led to some SOB and if not treated certainly contribute to his death. The fall was unfortunate and resulted in a minor injury but would not have contributed to her death.

Study number 312

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Structured case note review data collection Material in bold reflects the data collected from the notes Note all findings, except preventability of death are scored from the following scale Very poor 1 2 3 4 5 Excellent Please circle only one score Please enter the following.

Item Data


Reviewer DWY

Study Number 312

Storage Box 68

Age at death 64


Sex F









Structured case note review data collection Phases of care: Admission and initial management (approximately the first 24 hours) Please record your explicit judgements about the quality of care the patient received and whether it was in accordance with current good practice (for example, your professional standards or your professional perspective). If there is any other information that you think is important or relevant that you wish to comment on then please do so. Heart failure given as diagnosis at the Post Take assessment, but little evidence on examination by admitting doctor, chest wheeze, no creps, JVP normal , oedema of legs but has cellulitis, orthopnea not mentioned. CXR did not confirm heart failure Note HR not given in admitting record. Please rate the care received by the patient during this phase. Score 4 Phase of care: Overall assessment

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Please record your explicit judgements about the quality of care the patient received overall and whether it was in accordance with current good practice (for example, your professional standards). If there is any other information that you think is important or relevant that you wish to comment on then please do so. Progression of both infection and heat failure seems likely these combined to cause her death. Perhaps more vigour treatment of CCF might have helped was given. Was given iv frusemide without effect. Please rate the care received by the patient during this phase. Score 5 Please rate the quality of the patient record in enabling a good quality of care to be provided. Score 5 Assessment of problems in healthcare In this section, the reviewer is asked to comment on whether one or more specific types of problem(s) were identified and, if so, to indicate whether any led to harm. Were there any problems with the care of the patient? Yes If you did identify problems, please identify which problem type(s) from the selection below and indicate whether it led to any harm. Please tick all that relate to the case. Problem types 1. Problem in assessment, investigation or diagnosis (including assessment of pressure ulcer risk, venous thromboembolism (VTE) risk, history of falls) Yes Did the problem lead to harm? Yes Avoidability of death judgement score We are interested in your view on the avoidability of death in this case. Please choose from the following scale. Score 6 Score 6 Definitely not avoidable Please explain your reasons for your judgement of the level of avoidability of death in this case, including anything particular that you have identified. Some doubt over the presents of heart failure. Little evidence for it at initial assessment. No improvement with i.v. frusemide and heart failure not amongst the coded diagnoses. The diagnosis of heart failure in a patient who did not have it and was not treated for it would make no difference to course of disease.

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Item Data


Reviewer DWY

Study Number 317

Storage Box 4

Age at death 73


Sex F


Date of Admission Mar 2015







Structured case note review data collection Phases of care: admission and first 24 hrs Please record your explicit judgements about the quality of care the patient received and whether it was in accordance with current good practice (for example, your professional standards or your professional perspective). If there is any other information that you think is important or relevant that you wish to comment on then please do so. CXR showed L Consolidation, CURB65 was 5, Prescribed Tazocin then Co amoxiclav iv and Clartithromycin iv in A&E according to Trust antibiotic guide lines. Please rate the care received by the patient during this phase. Score 5 Phase of care: Overall assessment

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Please record your explicit judgements about the quality of care the patient received overall and whether it was in accordance with current good practice (for example, your professional standards). If there is any other information that you think is important or relevant that you wish to comment on then please do so. Admitted to ITU recently, whilst on chemothrapy. Lobar pneumonia, T1 RF, CURB65 was 5. In ward clarithromycin given orally should have continued with iv. Sepsis with shock developed Initial lactate was 8. Remained hypotensive and pancytopenic died after 5 days whilst still in ITU. Please rate the care received by the patient during this phase. Score 4 Please rate the quality of the patient record in enabling a good quality of care to be provided. Score 5 Assessment of problems in healthcare In this section, the reviewer is asked to comment on whether one or more specific types of problem(s) were identified and, if so, to indicate whether any led to harm. Were there any problems with the care of the patient? (Please tick) Yes (please continue below) If you did identify problems, please identify which problem type(s) from the selection below and indicate whether it led to any harm. Please tick all that relate to the case. Problem types 2. Problem with medication / IV fluids / electrolytes / oxygen (other than anaesthetic) Yes Did the problem lead to harm? No Avoidability of death judgement score We are interested in your view on the avoidability of death in this case. Please choose from the following scale. Score 6 Score 6 Definitely not avoidable Please explain your reasons for your judgement of the level of avoidability of death in this case, including anything particular that you have identified. Trust guidelines for antibiotics in community acquired pneumonia not followed. Clarithromycin was given orally rather than by i.v. though first does in A&E was i.v. It seems unlikely this would have an effect on the disease progression

75


Item Data


Reviewer DWY

Study Number 319

Storage Box 230

Age at death 99


Sex F









Case note review data collection Phases of care: Admission and initial management (approximately the first 24 hours) Please record your explicit judgements about the quality of care the patient received and whether it was in accordance with current good practice (for example, your professional standards or your professional perspective). If there is any other information that you think is important or relevant that you wish to comment on then please do so. Significant pneumonia RLL consolidation, CURB65 was 3. CXR shows consolidation. Antibiotic usage CURB65 score of 3, according to guidelines IV for both co amxiclav and clarithromycin. Clarithromycin given orally.

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Please rate the care received by the patient during this phase. Score 4 Phase of care: Overall assessment Please record your explicit judgements about the quality of care the patient received overall and whether it was in accordance with current good practice (for example, your professional standards). If there is any other information that you think is important or relevant that you wish to comment on then please do so. Dementia recent deterioration. CURB65 Score 3. DM on sliding scale insulin. Some initial improvement but on Day 11 CXR report fluid overload, basel crackles noted no peripheral oedema. Over transfusion. Frusemide given 1st iv then orally. Fluid over load settled. Flagging this up as there seems to be problems with over transfusion. No effect on outcome of patient. CCF or LVF not mentioned in coded diagnoses. Please rate the care received by the patient during this phase. Score 4 Please rate the quality of the patient record in enabling a good quality of care to be provided. Score 4 Assessment of problems in healthcare In this section, the reviewer is asked to comment on whether one or more specific types of problem(s) were identified and, if so, to indicate whether any led to harm. Were there any problems with the care of the patient? Yes If you did identify problems, please identify which problem type(s) from the selection below and indicate whether it led to any harm. Please tick all that relate to the case. Problem types 2. Problem with medication / IV fluids / electrolytes / oxygen (other than anaesthetic) Yes Did the problem lead to harm? Probably 3. Problem related to treatment and management plan (including prevention of pressure ulcers, falls, VTE) Yes Did the problemlead to harm? Yes

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Avoidability of death judgement score We are interested in your view on the avoidability of death in this case. Please choose from the following scale. Score 6 Score 6 Definitely not avoidable Please explain your reasons for your judgement of the level of avoidability of death in this case, including anything particular that you have identified. The patient went in mild LVF due to i.v. fluids on day 11. This settled with fruseimde. Patient died on day 25. It is unlikely the LVF had any impact on the course of her disease. In addition clarithromycin given orally rather than iv. Unlikely this had any effect on her outcome. CCF not mentioned in list of diagnoses.


Item Data


Reviewer DWY

Study Number 322

Storage Box 230

Age at death 74


Sex M



Time of Admission Not available

Specialty Team at Death Haematology



78



Structured case note review data collection Phases of care: Admission and initial management (approximately the first 24 hours) Please record your explicit judgements about the quality of care the patient received and whether it. in accordance with current good practice (for example, your professional standards or your professional perspective). If there is any other information that you think is important or relevant that you wish to comment on then please do so. Under care of haematologist for AML on regular transfusion. 2/03/16 present to haematologist complaining of weight loss and not feeling well, non-productive cough. Examination suggested LRTI, this was confirmed by CXR. Plan was to transfuse 2 units on 2nd and 1 on 3rd. To start oral co-amoxicillin and clarithromycin for 7days. Temp 37.2 Hb 67, WCC 8.5 plats 22 CRP 112. The aim was to avoid admission because admission would not alter treatment. Next entry 14/03/16 at 12.55 reflecting admission, not coping at home, weight loss and dehydration. ? still on antibiotics. Iv antibiotics started. Prednisolone and Palliative team contacted. Question had he been admitted would this have made any difference? Please rate the care received by the patient during this phase. Score 3 Phase of care: Overall assessment Please record your explicit judgements about the quality of care the patient received overall and whether it was in accordance with current good practice (for example, your professional standards). If there is any other information that you think is important or relevant that you wish to comment on then please do so. After admission, 2 weeks after presentation with pneumonia, all care given Please rate the care received by the patient during this phase. Score 5 Please rate the quality of the patient record in enabling a good quality of care to be provided. Score 5 Assessment of problems in healthcare In this section, the reviewer is asked to comment on whether one or more specific types of problem(s) were identified and, if so, to indicate whether any led to harm.

79

Were there any problems with the care of the patient? (Please tick) Yes If you did identify problems, please identify which problem type(s) from the selection below and indicate whether it led to any harm. Please tick all that relate to the case. Problem types 3. Problem related to treatment and management plan (including prevention of pressure ulcers, falls, VTE) Yes Did the problemlead to harm? Yes 6. Problem in clinical monitoring (including failure to plan, to undertake, or to recognise and respond to changes) Yes Did the problem lead to harm? Yes Avoidability of death judgement score We are interested in your view on the avoidability of death in this case. Please choose from the following scale. 5 Score 5 Slight evidence of avoidability Please explain your reasons for your judgement of the level of avoidability of death in this case, including anything particular that you have identified. Patient with progressive Acute Myeloid Leukaemia, transfusion dependent. This normally means whole gamet of treatment tried but now patient resistant to everything. Kept going by repeated blood transfusions. The question is should the patient have been admitted on the 2/03/2015? The reason given for not admitting are correct in the short term but forgets longer term considerations of what to do if the patient is not improving. This turned out to be the case. He was admitted 2 weeks later still with a pneumonia. Antibiotics of coamoxicilin and clarithromycin were change to Tazocin something which should have been done 10 days earlier. Condition improved initially, he felt better. But no overall change and died on day 13 of admission. Whilst admission may not have changed final event, patient would have been more comfortable.

Study number 324

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Structured case note review data collection Material in bold reflects the data collected from the notes Note all findings, except preventability of death are scored from the following scale Very poor 1 2 3 4 5 Excellent Please circle only one score.

Item Data


Reviewer DWY

Study Number 324

Storage Box 202

Age at death 87


Sex


Date of Admission 17/062015







Structured case note review data collection Phases of care: Admission and initial management (approximately the first 24 hours) Please record your explicit judgements about the quality of care the patient received and whether it was in accordance with current good practice (for example, your professional standards or your professional perspective). If there is any other information that you think is important or relevant that you wish to comment on then please do so. Admitted with feature of pneumonia. Given iv fluids, after less than a day had developed pulmonary oedema. Please rate the care received by the patient during this phase. Score 4 Phase of care: Overall assessment Please record your explicit judgements about the quality of care the patient received overall and whether it was in accordance with current good practice (for example, your professional standards). If there is any other information that you think is important or

81

relevant that you wish to comment on then please do so. Admitted with pneumonia Day 2 Went into heart failure after iv fluids. Pulmonary oedema confirmed by CXR. Uncontrolled AF might be an additional feature causing onset of HF. Treated with digoxin and frusemide for a week. Patient Episode Report issues. Heart failure not mentioned or significant hyponatraemia (Na 114) not mentioned Please rate the care received by the patient during this phase. Score 4 Please rate the quality of the patient record in enabling a good quality of care to be provided. Score 4 Assessment of problems in healthcare In this section, the reviewer is asked to comment on whether one or more specific types of problem(s) were identified and, if so, to indicate whether any led to harm. Were there any problems with the care of the patient? (Please tick) Yes (please continue below) If you did identify problems, please identify which problem type(s) from the selection below and indicate whether it led to any harm. Please tick all that relate to the case. Problem types 1. Problem in assessment, investigation or diagnosis (including assessment of pressure ulcer risk, venous thromboembolism (VTE) risk, history of falls) Yes Did the problem lead to harm? Yes 2. Problem with medication / IV fluids / electrolytes / oxygen (other than anaesthetic) Yes Did the problem lead to harm Yes Avoidability of death judgement score We are interested in your view on the avoidability of death in this case. Please choose from the following scale. Score 6 Score 6 Definitely not avoidable Please explain your reasons for your judgement of the level of avoidability of death in this case, including anything particular that you have identified.

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Admitted with pneumonia, thought to be dehydrated given i.v. fluids. Then patient went into LVF with pulmonary oedema. Two other contributing conditions: the patient initially had uncontrolled AF though pulse was only 92 on assessment in MRU. An increased troponin was found raising the possibility of a myocardial infarction. None the less the iv fluids were almost certainly the main issue. However the patient lived for another 18 days. Therefore impact of this seems minimal


Item Data


Reviewer DWY

Study Number 325

Storage Box 202

Age at death 72


Sex F









Structured case note review data collection Phases of care: Admission and initial management (approximately the first 24 hours) Please record your explicit judgements about the quality of care the patient received and whether it was in accordance with current good practice (for example, your professional

83

standards or your professional perspective). If there is any other information that you think is important or relevant that you wish to comment on then please do so. RAT form no diagnosis or problem list given AF not on Patient Episode Report Please rate the care received by the patient during this phase. Score 5 Please rate the quality of the patient record in enabling a good quality of care to be provided. Score 4 Assessment of problems in healthcare In this section, the reviewer is asked to comment on whether one or more specific types of problem(s) were identified and, if so, to indicate whether any led to harm. Were there any problems with the care of the patient? (Please tick) Yes If you did identify problems, please identify which problem type(s) from the selection below and indicate whether it led to any harm. Please tick all that relate to the case. Problem types 8. Problem of any other type not fitting the categories above Yes Did the problem lead to harm? No Avoidability of death judgement score We are interested in your view on the avoidability of death in this case. Please choose from the following scale. Score 6 Score 6 Definitely not avoidable Please explain your reasons for your judgement of the level of avoidability of death in this case, including anything particular that you have identified. Not producing a diagnostic or problem list at the end of an admission note may seem a trivial error. However it does reveal a lack of expertise in writing clinical notes especially first contact notes and secondly suggest a lack of reflection and consideration of the diagnostic possibility given the findings. These factors point to a poorly trained and supervised doctor. Given the number of other medical attendants who reviewed the patient the omission did not cause any harm.

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In addition significant diagnosis missing from Patient Episode Report, which is the coding diagnoses produced by coding office.


Item Data


Reviewer DWY

Study Number 327

Storage Box 202

Age at death 70


Sex F









Structured case note review data collection Phases of care: Please record your explicit judgements about the quality of care the patient received and whether it was in accordance with current good practice (for example, your professional standards or your professional perspective). If there is any other information that you think is important or relevant that you wish to comment on then please do so. A&E notes no diagnostic or problem list, Treatment sheet missing

85

No strong evidence for pneumonia. The diagnosis was always presumptive. Sputum white, WCC raised, pleural effusion could all be due to Ca Treated for both pneumonia and heart failure. Heart failures seem to have been the main issue. Please rate the care received by the patient during this phase. Score 4 Assessment of problems in healthcare In this section, the reviewer is asked to comment on whether one or more specific types of problem(s) were identified and, if so, to indicate whether any led to harm. Were there any problems with the care of the patient? (Please tick) Yes (please continue below) If you did identify problems, please identify which problem type(s) from the selection below and indicate whether it led to any harm. Please tick all that relate to the case. Problem types 8. Problem of any other type not fitting the categories above Yes Did the problem lead to harm? No Avoidability of death judgement score We are interested in your view on the avoidability of death in this case. Please choose from the following scale. Score 6 Score 6 Definitely not avoidable Please explain your reasons for your judgement of the level of avoidability of death in this case, including anything particular that you have identified. A&E notes incomplete. Admitting officer did not put a diagnostic or problem list at the end of his admission findings. This is not good practice and could result in an inappropriate management plan. In addition the EMCP form in the MRU was not dated nor had the time on it. Whilst this will not lead to poor care it does show an inconsistent attitude to Trust policies which might result in issues at another time

Study number 338 Structured case note review data collection

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Material in bold reflects the data collected from the notes Note all findings, except preventability of death are scored from the following scale Very poor 1 2 3 4 5 Excellent Please circle only one score. Please enter the following.

Item Data


Reviewer DWY

Study Number 338

Storage Box 68

Age at death 68

Date of Death

Sex M


Date of Admission Dec 2015







Structured case note review data collection Phases of care: Admission and initial management (approximately the first 24 hours) Please record your explicit judgements about the quality of care the patient received and whether it was in accordance with current good practice (for example, your professional standards or your professional perspective). If there is any other information that you think is important or relevant that you wish to comment on then please do so. A&E SHO no diagnosis or problem list after examination Please rate the care received by the patient during this phase. Score 5 Phase of care: Overall assessment Please record your explicit judgements about the quality of care the patient received overall and whether it was in accordance with current good practice (for example, your professional standards). If there is any other information that you think is important or relevant that you wish to comment on then please do so.

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Fail patient dying really. Though COPD in past no evidence of pneumonia now no CXR changes. Creps R base heard once on Day 2. Main problem was clotting disturbance with haematemesis. Get feel of very frail patient fading away, urea 1.1. Please rate the care received by the patient during this phase. Please rate the quality of the patient record in enabling a good quality of care to be provided. Score 4 Assessment of problems in healthcare In this section, the reviewer is asked to comment on whether one or more specific types of problem(s) were identified and, if so, to indicate whether any led to harm. Were there any problems with the care of the patient? Yes (please continue below) If you did identify problems, please identify which problem type(s) from the selection below and indicate whether it led to any harm. Please tick all that relate to the case. Problem types 8. Problem of any other type not fitting the categories above Yes Did the problem lead to harm? No Avoidability of death judgement score We are interested in your view on the avoidability of death in this case. Please choose from the following scale. Score 6 Score 6 Definitely not avoidable Please explain your reasons for your judgement of the level of avoidability of death in this case, including anything particular that you have identified. Poor record keeping in A&E Department see note on 325.

Study Number 340 Structured case note review data collection Material in bold reflects the data collected from the notes

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Note all findings, except preventability of death are scored from the following scale Very poor 1 2 3 4 5 Excellent Please circle only one score. Please enter the following.

Item Data


Reviewer DWY

Study Number 340

Storage Box 68

Age at death 93


Sex M









Structured case note review data collection Phases of care: Admission and initial management (approximately the first 24 hours) Please record your explicit judgements about the quality of care the patient received and whether it was in accordance with current good practice (for example, your professional standards or your professional perspective). If there is any other information that you think is important or relevant that you wish to comment on then please do so. Admitted because of increasing SOB, pyrexia CXR chronic changes no focal consolidation, possible R consolidation later. Initial improvement then deterioration. CURB65 of 3 means iv Co-amoxiclavand Clarithomycin from Trust guidelines. Only Co amoxiclav given iv. Please rate the care received by the patient during this phase. Score 5 Phase of care: Overall assessment

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Please record your explicit judgements about the quality of care the patient received overall and whether it was in accordance with current good practice (for example, your professional standards). If there is any other information that you think is important or relevant that you wish to comment on then please do so. See above Please rate the care received by the patient during this phase. Score 5 Please rate the quality of the patient record in enabling a good quality of care to be provided. Score 5 Assessment of problems in healthcare In this section, the reviewer is asked to comment on whether one or more specific types of problem(s) were identified and, if so, to indicate whether any led to harm. Were there any problems with the care of the patient? (Please tick) Yes If you did identify problems, please identify which problem type(s) from the selection below and indicate whether it led to any harm. Please tick all that relate to the case. Problem types 2. Problem with medication / IV fluids / electrolytes / oxygen (other than anaesthetic) Yes Did the problem lead to harm? No 3. Problem related to treatment and management plan (including prevention of pressure ulcers, falls, VTE) Yes Did the problemlead to harm? No Avoidability of death judgement score We are interested in your view on the avoidability of death in this case. Please choose from the following scale. Score 6 Score 6 Definitely not avoidable Please explain your reasons for your judgement of the level of avoidability of death in this case, including anything particular that you have identified. Though the patient was given oral clarithromycin rather than i.v. I do not think this would make any difference in this patient.

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Item Data


Reviewer DWY

Study Number 343

Storage Box 68

Age at death 69


Sex F









Structured case note review data collection Phases of care: Admission and initial management (approximately the first 24 hours) Please record your explicit judgements about the quality of care the patient received and whether it was in accordance with current good practice (for example, your professional standards or your professional perspective). If there is any other information that you think is important or relevant that you wish to comment on then please do so. Subject of a Serious Incident Report. Due to no action over a NEWS score of 7, then 11. NEWS scores due to BP becoming un-recordable and subsequent collapse of patient. Day 2 and day 3 clinical progress notes missing.

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Please rate the care received by the patient during this phase Score 3 Phase of care: Overall assessment Please record your explicit judgements about the quality of care the patient received overall and whether it was in accordance with current good practice (for example, your professional standards). If there is any other information that you think is important or relevant that you wish to comment on then please do so. Admitted after fall, alcohol abuse. Progress notes for 27/28th missing which are day 1, day 2. On day 3 collapse, cardiac arrest. BP un-recordable. Patient made a partial recovery from collapse, no account of arrest Overall patient in a poor state. No explanation for collapse given possibilities include MI, pulmonary embolism, arrhythmia. Initial evidence for pneumonia thin, first CXR report lung fields clear. Repeat CXR showed pneumonia in L lung. On this basis diagnose made and Teicoplanin started. Please rate the care received by the patient during this phase. Score 4 Please rate the quality of the patient record in enabling a good quality of care to be provided. Score 3 Assessment of problems in healthcare In this section, the reviewer is asked to comment on whether one or more specific types of problem(s) were identified and, if so, to indicate whether any led to harm. Were there any problems with the care of the patient? Yes (please continue below) If you did identify problems, please identify which problem type(s) from the selection below and indicate whether it led to any harm. Please tick all that relate to the case. Problem types 6. Problem in clinical monitoring (including failure to plan, to undertake, or to recognise and respond to changes) Yes Did the problem lead to harm? Probably Avoidability of death judgement score

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We are interested in your view on the avoidability of death in this case. Please choose from the following scale. Score 4 Score 4 Possibly avoidable but not very likely (less than 50:50) Please explain your reasons for your judgement of the level of avoidability of death in this case, including anything particular that you have identified. Sequence of events admission, then deterioration (NEWS), then arrest/collapse, then partial recovery, then death. All events occurred with 2 days. Cardiovascular state unstable and presumably a cardiac incidence lead to death, given the rapidity of this occurring. Lack of information on nature of collapse is a problem. If first CXR was clear any pneumonia would have been just starting and hence not likely to seriously be affecting the patient. Better monitoring of the patient might have identified possible issues which might have delayed death.

Study number 344 Structured case note review data collection Material in bold reflects the data collected from the notes

Note all findings, except preventability of death are scored from the following scale Very poor 1 2 3 4 5 Excellent Please circle only one score. Please enter the following.

Item Data


Reviewer DWY

Study Number 244

Storage Box 4

Age at death 86


Sex M

Social deprivation indicator (first 3/4

93

alphanumeric items of postcode):


Time of Admission Not recorded






Structured case note review data collection Phases of care: Admission and initial management (approximately the first 24 hours) Please record your explicit judgements about the quality of care the patient received and whether it was in accordance with current good practice (for example, your professional standards or your professional perspective). If there is any other information that you think is important or relevant that you wish to comment on then please do so. Few days SOB increased, cough, temp, HAP diagnoses because in nursing home. 13/09/15 4.30 patient admitted to ward from MRU. Patient refused examination and them observations. 22.30 NEWs went from 3 to 7 O2 started, i.v. fluids in progress. NEWS rose mainly to drop in O2 saturation recovered shortly. Nurse called Dr on call who did not come. Site manager reviewed patient. Said stable according to vital signs NEWS 2. 14/09/15 00.15 patient found to have died. Concerns of nursing staff should have been addressed Patient’s conditions was unstable. Please rate the care received by the patient during this phase. Score 3 Please rate the quality of the patient record in enabling a good quality of care to be provided. Score 5 Assessment of problems in healthcare In this section, the reviewer is asked to comment on whether one or more specific types of problem(s) were identified and, if so, to indicate whether any led to harm. Were there any problems with the care of the patient? Yes If you did identify problems, please identify which problem type(s) from the selection below and indicate whether it led to any harm. Please tick all that relate to the case.

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Problem types 1. Problem in assessment, investigation or diagnosis (including assessment of pressure ulcer risk, venous thromboembolism (VTE) risk, history of falls) Yes Did the problem lead to harm? Probably Avoidability of death judgement score We are interested in your view on the avoidability of death in this case. Please choose from the following scale. Score 4 Score 4 Possibly avoidable but not very likely (less than 50:50) Please explain your reasons for your judgement of the level of avoidability of death in this case, including anything particular that you have identified. Patient’s condition deteriorating for months, admitted from a Nursing Home with a chest infection and died shortly after admission. The important point is that the ward staff requested a doctor to see the patient not so much because of a change in the patient’s condition but because he was a new patient to the ward and had not been seen by any medical staff after the transfer. The doctor refused to come. However the doctor’s action or non-action does raise a doubt though given the rapidity of the death it is unlikely he/she could have done anything.

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