Case 30 Keep an open mind

Mr Watkins is a 61-year-old man who brings himself up to the Emergency Department because he is unwell with vomiting and abdominal pain. The triage nurse finds him to be clammy, vomiting and in obvious distress. His blood pressure is 196/103, his heart rate 50 beats per minute, his temperature 34.4 °C and his respiratory rate 28 breaths per minute. Oxygen saturations are 98% on room air. The nurse asks the medical FY2, Dr Singleton to see Mr Watkins. Dr Singleton undertakes a prompt assessment, inserts an intravenous line and administers a litre of normal saline along with 8 mg morphine (titrated to pain) and 10 mg of metoclopramide. Dr Singleton thinks Mr Watkins probably has an acute gastroenteritis but also wonders about pancreatitis. He sends off blood for electrolytes, haematology, amylase and liver function tests before arranging chest and plain abdominal X-rays.

Half an hour later Mr Watkins is much more settled and his son arrives to see him. Shortly afterwards Dr Singleton hears the son shouting, ‘come quickly, Dad can’t breathe’.

What possibilities should cross Dr Singleton’s mind?

When Dr Singleton enters the cubicle, he finds Mr Watkins deeply cyanosed with oxygen saturations of 50%. He is making ineffectual respiratory efforts and Dr Singleton suggests to the attending nurse that airway obstruction seems likely. However, on careful examination he cannot identify any obstruction. Dr Singleton administers 400 mg of naloxone in case this is respiratory arrest caused by the morphine he gave earlier. He inserts an endotracheal tube (without any difficulty or resistance from the patient) and manually bags Mr Watkins whose saturations rapidly improve. Throughout all of this Mr Watkins’s blood pressure and pulse have been maintained.

Gradually Mr Watkins begins to breathe spontaneously and he is extubated. A CT pulmonary angiogram is arranged urgently in case this was respiratory arrest caused by a pulmonary embolism, but no clot is seen on the scan. The radiologist also scans Mr Watkins’s neck and comments that there is no evidence of any obstructing lesion around the airway. Over the next 24 hours Mr Watkins recovers fully from both his presenting complaint and from his respiratory arrest. Dr Singleton is perturbed by the turn of events, which he is struggling to explain, but rationalizes that maybe this was all caused by an unusual reaction to the intravenous morphine he had administered. He discusses it with his Consultant but no further action is taken.

Should Dr Singleton have considered any other course of action?

Five weeks later another case arises in the Emergency Department where a patient becomes inexplicably hypoglycaemic and the consultant on duty writes in the notes ‘it is difficult to explain the sequence of events’. He discusses the case with risk management and with his colleagues who all chip in with their recent experiences in the Emergency Department. It becomes clear that there have been ten unusual clinical events in the preceding three months and a very rapid internal investigation is triggered that day. It soon becomes apparent that deliberate harm cannot be ruled out and when on-call rotas are examined one individual stands out as having been present for all 10 cases. The police are involved and a nurse is arrested when arriving at work on the following Monday morning.

The nurse is subsequently charged and found guilty of 2 counts of murder and 16 counts of grievous bodily harm. Forensic tests show that the nurse had variously and inappropriately administered vecuronium, midazolam and insulin to patients in the emergency department. Mr Watkins was almost certainly administered vecuronium and suffered ‘dry drowning’. He subsequently recalled the nurse injecting something into the intravenous line in his arm and then almost immediately being unable to breathe. He remained conscious but unable to communicate throughout the emergency activity that then ensued. Fortunately he survived and suffered no long-term physical harm.

Expert opinion

As Sherlock Holmes says in The Sign of Four, ‘when you have eliminated the impossible, whatever remains, however improbable, must be the truth’. In a healthcare context it is all too easy to rationalize the seemingly inexplicable and one probably will feel that it is always more likely that a genuine medical complication is presenting in an unusual way than that a colleague may be deliberately setting out to cause harm. However, even though deliberate harm of this nature is fortunately rare, unexplained complications do arise much more frequently from drug dispensing or administration errors and you should always be prepared to consider that somewhere along the line an error might have occurred. Be particularly vigilant when hypoglycaemia arises in a patient who has previously been stable and who is not receiving insulin or hypoglycaemic agents.

Whenever you propose a diagnosis or explanation ensure the facts fit the mechanism you propose. Be logical and analytical – it is why you spent years learning basic anatomy, physiology, biochemistry, pharmacology and pathology.

Legal comment

When senior clinical staff are presented with sufficient evidence for reasonable grounds to suspect that deliberate harm has occurred, contact should be made with the local police Criminal Investigation Department (CID). The Trust will have established relationships with the local police both through both the Trust legal team and Trust security department. There will often be a hospital police liaison officer and there is an overarching memorandum of understanding between the NHS and the police. If a decision is taken out of hours, then the duty executive would be the person from the Trust to contact the police. Conviction for a criminal offence requires proof beyond reasonable doubt that the person charged has carried out an unlawful act (actus reus) and in doing so had the necessary state of mind (mens rea).

In addition under PACE (Police and Criminal Evidence) codes of practice, all citizens have a duty to help police officers to prevent crime and to discover offenders. This is a civic rather than a legal duty. When first notified, the police will advise on the preservation of evidence. Any subsequent clinical risk investigation must not interfere with the initial police enquiry by either contaminating evidence or interfering with potential witnesses before a criminal prosecution. Consent will be required from all patients to whose care the police suspect the healthcare professional contributed.

Organizational learning for the Trust only takes place after the police investigation and prosecution. In the meantime, the Trust’s Human Resources Department would advise on suspension under the Trust’s Conduct/Disciplinary Action Procedure. The paramount duty is to protect other patients from harm whilst investigations are on-going. The Trust’s clinical risk teams are available to discuss concerns on an anonymous basis. An initial telephone call to raise the possibility that an individual may be causing deliberate harm to patients would be rapidly escalated. An initial meeting would be set up quickly to decide the best course of action for the Trust, including making contact with the appropriate external agencies.

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