Wednesday, 25 November 2015

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Patient sent home from Carlisle hospital died days later

A patient died after a ruptured aneurysm – just days after being sent home from hospital with only paracetamol.

Jeremy Rushmer photo
Jeremy Rushmer

The person was taken to Carlisle’s Cumberland Infirmary with shooting pains in the chest and difficulty in breathing.

Staff on duty in the accident and emergency department carried out routine tests and, after finding nothing conclusive, decided they were suffering from an infection.

The patient was discharged with paracetamol and ibuprofen.

Details of the death have prompted a call from city MP John Stevenson for an investigation, particularly examining staffing levels in the hospital’s A&E department on the day in question and whether they could be a factor..

While the hospital would not comment on an individual case, executives have insisted that it has robust systems in place to follow up on every death to ensure patient safety.

Details of the incident – categorised as a serious complaint – have been revealed in a document highlighting complaints against North Cumbria University Hospitals NHS Trust, which runs the infirmary.

The governing body of NHS Cumbria Clinical Commissioning Group (CCG), which is responsible for commissioning health services in the county, has looked at a quality report which includes details of the case.

It reveals that the trust’s patient safety panel reviewed six new serious complaints received in May, upholding three other serious complaints. It is one of these upheld complaints which relates to the death of the patient.

It states: “Patient admitted to A&E via ambulance with shooting pains in chest and difficulty in breathing.

“All appropriate tests conducted including ECG (clear), bloods (inconclusive). Diagnosis: ‘infection’. Patient discharged with paracetemol and ibuprofen.

“Patient continued with head and neck pains over the weekend. Patient died later.

“Death certificate indicates - pericardial tamponade (compression of the heart caused by fluid in the sac around it) - ruptured dissecting thoracic aneurysm.”

The report concludes that a mortality review was completed and results will be shared with the accident and emergency department. No further details of the patient have been released.

Mr Stevenson said: “Clearly this is a matter that needs to be properly investigated and there has to be some sort of understanding about what happened on that occasion.

“Procedures need to be looked at and whether the right level of staff were on duty at that time.”

He added: “At the end of the day, it’s the hospital’s responsibility to make sure there is the right level of staffing and the right competencies to ensure that patients are properly treated.”

Dr Jeremy Rushmer, medical director at North Cumbria University Hospitals NHS Trust, said they couldn’t comment on individual patients, but reassured the public that all deaths are reviewed continuously.

“Since January 2014, we have begun using a new standardised process to ensure every single death is reviewed, with findings shared amongst clinical teams on a regular basis so that any learning can be shared widely.

“This, along with many other improvements, is helping us to create a positive safety culture with our hospitals and ensure our mortality rates remain within expected range as they have been for many months now.”

The CCG report also raises concerns over the number of patient safety incidents reported by staff at the hospital trust in the month of July.

“Of concern is the number of incidents reported via the reporting system STEIS to date by the trust in July, with eight reported on July 3 alone,” it states.

These included delayed diagnosis, a drug incident, a communication issue, two pressure ulcers and one slip, trip or fall.

In addition there was a “transfusion incident” which may be escalated to a never event, depending on the outcome.

CCG bosses raised concerns both because incidents appear to be reported in a batch and the volume of incidents received in July.
It questioned whether this was as a result of a change in reporting culture or a quality issue.

However, the trust has explained that while incidents were uploaded “in batch” to the national reporting system, internal investigations had already begun much earlier.

Dr Rushmer said: “As part of continued improvements to patient safety, we’ve had a noticeable increase in the number of incidents now being openly reported by staff. This demonstrates the significant shift taking place to create a safe reporting culture so that appropriate learning can take place across our hospitals.”

He said that efforts were ongoing to remind staff to record incidents onto the STEIS database as soon as internal investigations are begun.

“Most importantly, however, we are pleased that our staff are continuing to actively report all incidents so that we can share learning and, as far as possible, prevent any such incidents happening again in future.”


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