Hospital staff failed to notice patient had died
STAFF failed to notice that a patient had died according to a report listing a catalogue of problems identified by auditors who studied the quality of care given at Leicestershire and Rutland’s hospitals.
The failure was one of 19 bullet points listed under the category “End of Life – characteristics of poor/very poor care” in the auditors’ recently-published report.
The report was the result of the most recent Learning Lessons to Improve Care Clinical Quality Audit. The document was released by Leicestershire’s three clinical commissioning groups (CCGs), which commission health services, the University Hospitals of Leicester NHS Trust (UHL), which runs Leicestershire’s hospitals, and Leicestershire Partnership NHS Trust (LPT), which runs mental health services.
The report is a comprehensive look at the quality of care across the NHS locally, and follows the publication of a similar audit carried out in 2014.
Auditors looked into deaths of patients under the care of UHL, at LPT’s community hospitals, and deaths in the community within 30 days of being discharged from UHL, between from June 20 and July 21, 2017.
There are no more details about the patient who died and was not noticed, including no information about how long it was until someone realised they were dead.
Other examples of poor or very poor care included patients being resuscitated against their wishes because paperwork saying they did not want to be revived had not been prepared or signed off, and patients dying in hospital rather than at home or in a hospice as they had wanted.
Compilers of the report used patient records and spoke with loved ones of people who died either in local hospitals or in the community within the 30 days.
During the period covered by the audit, 319 people died. The figure excludes babies, children and deaths on mental health wards. Case records from 181 patients were reviewed, with 177 cases being given an overall care rating.
The report also damningly revealed that 143 patients – the vast majority of those looked at – were admitted to hospital unnecessarily.
The previous audit report, published in 2014, was prompted by UHL having a high Sum- mary Hospital-Level Mortality Indicator – a figure which flags up a higher-than-expected number of deaths. It acts as an early warning system highlighting a need for further investigation.
Issues highlighted then, including confusion about “do not attempt resuscitation” (DNACPR) orders, and patients being admitted to hospital when other types of care such as end-of-life, palliative or continuing care would have been more suitable, have been raised in the latest report as still needing improvement.
In response to the recurring themes, UHL medical director Andrew Furlong said: “We will use this latest report as a driver to increase the scale and pace of change across local health organisations.”
Speaking about the latest report at a meeting of all three CCGs, chief nurse and quality lead for West Leicestershire CCG Caroline Trevithick said: “Having these patients’ stories really brings it home to people to enable them to focus on what needs to be done.
“The audit does demonstrate evidence of us moving forward, but it does also demonstrate there are some fundamental problems. We have an action plan in place and a lot of what is included in that action plan is already in place.”
In total, 177 cases were given a rating.Three quarters of the patients reviewed were over 71 years of age.
Two thirds of the deaths occurred in hospital, the other third was at home or a care home. Ten of the patients died in a hospice.
The vast majority of patients were emergency admissions.
The number of deaths on a Monday in the community was double than on any other day of the week. The report states this is because of shortfalls in weekend admissions processes.
Good or excellent ratings were given in 91 of the cases.
Twenty-nine of the patients received poor or very poor care, 57 cases were rated adequate.
The report is split into sections: overall care, pre admission care, initial management and admission, ongoing care, procedure care, perioperative care, readmission care, discharge care, end of life care.
In 39 of the cases, reviewers found evidence of families struggling to cope with the care of their relative with lack of support from social services and other agencies listed as reasons.
This was largely put down to the absence of advanced care plans – plans devised by GPs and patients to prevent hospital admissions – and a lack of community services.
Dr Chris Trzcinski said: “Nearly 50 per cent of these patients could have been at home, people who went to hos- pital didn’t need to go to hospital. They could have been more comfortable at home and there is also a significant cost.
“The reason people ended up in hospital is because there aren’t trusted community services in place so that they can stay at home.”
There were 14 cases where patients experienced delays of more than four hours in A&E, 11 of the patients were over 80 with five of them being in their 90s.
But it was noted this was an area of significant improvement. Prompt attention and respecting patients’ wishes were examples of excellent or good care (114 cases).
In one case study, a son told auditors he was very unhappy with his mother’s end-of-life care after she was told her prognosis at 3am on a noisy busy ward.
Examples of good or excellent care were also given.
In 10 cases, poor or very poor care was noted, with examples including patients’ wishes not being respected and no record of end of discharge discussions with the family. Delays resulted in some patients who had expressed a wish to die at home, dying on the ward.
Good/excellent examples of care during the discharge process were smooth planning of discharge, support being arranged post discharge and patients being in their ferred place of death.
Talking to patients and their families about end-of-life care was largely positive but there were occasions where relatives had said there was a lack of or late discussion.
In five cases end of life care was rated as very poor. In two of the cases, resuscitation was attempted when DNACPR orders had been considered but not discussed with the patient or family. On one occasion a patient who wanted but did not have a DNACPR order arrested twice, the order was not in place the first time and was not arranged and signed off before the second arrest.
A 13-page action plan has been drawn up with recommendations on how improvements can be made. They include reviewing admission avoidance schemes for end-oflife patients, improving advanced care plans and improving communication between GP practices after discharge and palliative care teams. The frailty task force has pre- been asked to review admission avoidance schemes to prevent people being taken into hospital when they don’t need to be.
The action plan also outlines proposals to improve advance care planning so that patients can remain in their preferred place of death rather than being admitted to hospital. Changes in this area should be made by March 2019 and will involve all local hospitals, the frailty task force and East Midlands Ambulance Service.
Efforts will be made to prevent dehydration and to better manage urine infections in elderly patients.
Clinical issues outlined in the action plan include fluid management, diabetic monitoring, Warfarin management, weight management, examining the provision of community services before the discharge of patients with pressure sores, or at risk of developing infections.
Access to primary care assessment at weekends and early in the working day, and reducing late night hospital admissions have also been listed as a focus.
Ambulance staff better supported. will be
Professor Mayur Lakhani, GP and chairman of the LLR Clinical Taskforce said: “I appreciate the numbers and statistics within the report represent a loved one and death and dying is often a subject difficult to talk about.
“I am particularly grateful to the relatives who shared with us their experiences of care and talked about prognosis and care plans being a key feature of the care and decisions they made about their loved ones care.
“As a practising GP I welcome the fact this report recognises improvements in care, but am concerned that some patients and their loved one have received poor care.
“We are determined to tackle the root cause of this through our robust action plan, so that we deliver sustained improvements. “
Andrew Furlong, medical director at the University Hospitals of Leicester NHS Trust said: “I would like to echo Dr Lakhani’s comments and reiterate my thanks for the families involved in this report.
“There are some recurring themes from 2014 in respect of the care of frail older people. And, just as we did in 2014, this is part of our ongoing process of improvement to ensure our patients are getting the best care.”