Case 4 Falling asleep en-route

Mr Aziz is a 68-year-old man who has been brought to the Emergency Department by ambulance. He had been referred to the on-call medical team by his GP with a 48-hour history of cough and increased shortness of breath. The ambulance staff diverted to the Emergency Department en-route as he had deteriorated in the vehicle.

Dr Singh, a staff grade doctor, reviews Mr Aziz and finds him to be flushed and pyrexial (38.3 °C). He is barely responsive, grunting incomprehensibly to painful stimulus.

What other information do you want to know?

Observations show a blood pressure of 156/92 and a regular pulse of 96. The respiratory rate is 8 per minute and the pulse oximeter registers 86%. Mr Aziz’s medication list, which was brought in by the ambulance staff, includes salmeterol, tiotropium and theophylline. Dr Singh notes that oxygen is being administered via a non-rebreathe mask and questions carbon dioxide narcosis. He immediately reduces the oxygen flow to 2 litres per minute via nasal cannulae whilst undertaking an arterial blood gas analysis:

pH 7.15, pO2 8.1 kPa, pCO2 16.2 kPa

What course of action would you advocate at this point in time?

Dr Singh’s working diagnosis is one of an infective exacerbation of COPD complicated by CO2 retention. Following blood tests (including blood cultures), he prescribes intravenous antibiotics, prednisolone, nebulizers and oxygen at 2 litres per minute via mask or nasal cannulae according to patient preference. Over the next twenty minutes or so, Mr Aziz’s level of consciousness improves. He is transferred to the ward, via radiology.

The on-call medical team visits Mr Aziz on the ward several hours later for a routine review and finds him lying flat, unresponsive and making only occasional respiratory effort. Oxygen is being administered at 5 litres per minute via a facemask. The Consultant asks for an urgent blood gas to be carried out which shows: pH 7.08, pO2 7.0 kPa, pCO2 21.2 kPa

What would you do now?

The team use a bag and mask in order to improve Mr Aziz’s ventilation whilst awaiting assistance from the anaesthetist. During intubation, despite all appropriate precautions, he aspirates significant volumes of gastric content into his lungs. He is transferred to ITU but develops multi-organ failure over the next 48 hours. A decision is made not to offer renal replacement therapy and Mr Aziz dies four days after admission.

What are your thoughts about Mr Aziz’s overall management? How should the hospital review his care? What should his wife be told?

Expert opinion

Although Mr Aziz’s initial history was limited, there was a clear story of worsening shortness of breath and cough preceding an abrupt deterioration in the ambulance. Carbon dioxide narcosis was promptly recognized and efforts were made to treat it.

Whilst it may seem reasonable to simply reduce the inspired oxygen concentration in a closely monitored environment such as the Emergency Department, Dr Singh should have ensured that Mr Aziz was prescribed and given a known and fixed dose of oxygen via Venturi mask. Dr Singh should also have made efforts to obtain objective evidence of an improvement in Mr Aziz’s CO2 levels prior to transfer from the Emergency Department.

In addition, Dr Singh failed to handover the concern that Mr Aziz had become unwell as a direct result of giving high dose oxygen. It is not enough to make an entry in the notes or drug chart – Mr Aziz was very unwell on admission and this should have been conveyed verbally to the nursing and medical teams who took over Mr Aziz’s care from ED.

Mr Aziz’s care was reported to the hospital’s clinical risk management team via the incident reporting system. An investigation was launched. Simultaneously, the case was discussed at the acute medicine morbidity and mortality meeting, with input from a respiratory specialist. In the event, it appears that the hospital porter inadvertently administered 5 litres of oxygen per minute when switching the oxygen supply from piped to bottled in preparation for transfer. A second porter conveyed Mr Aziz from radiology to the ward and, having not met Mr Aziz before, was not aware of the precipitous fall in his level of consciousness. On the ward, the oxygen was switched over like for like. Nursing staff assumed, given that the diagnosis of CO2 retention had been made in the Emergency Department, that the appropriate oxygen therapy was being administered. No check was made against the prescription chart.

It seems that a catalogue of errors befell Mr Aziz as he passed through the healthcare system – high-dose oxygen therapy in the ambulance; recognition of the problem in the Emergency Department but an inadequate response; a simple error on the part of portering staff; inadequate supervision of oxygen therapy by nursing staff in the emergency department or on the ward; and, the absence of a face-to-face medical or nursing handover.

The attempts to revive Mr Aziz on the ward and subsequently in the intensive care unit were appropriate. The threshold for intubation and ventilation is often set rather higher than it ought to be for patients with a history of COPD. In this case, it is likely that the iatrogenic component to Mr Aziz’s clinical state prompted action. There was potentially a place for noninvasive ventilation in the emergency department after Mr Aziz’s conscious level had begun to improve but whist he was acidotic and retaining CO2. The absence of a second blood gas estimation meant that this treatment was not given appropriate consideration.

The hospital should be open and honest with Mr Aziz’s family.

Legal comment

The fact that a doctor acts in a suboptimal manner does not necessarily mean that the doctor has been negligent in his/her actions or omissions. The actions in this case have been within the bounds of acceptable practice but nevertheless the patient has suffered an adverse outcome.

Whilst each doctor owes a duty of care to his patient, the overarching legal liability rests with the Trust as it has vicarious liability for the actions of its employees. Hence in this scenario, although the actions of an individual employee may not necessarily have been negligent, the culmination of the patient’s interaction with the healthcare system has resulted in his death. In these cases rather than investigating each element that may have contributed to the patient’s death, the legal representative for the patient’s estate is likely to allege ‘res ipsa loquitur’, that is to say, the thing speaks for itself. The solicitor would invite the court to an inference of negligence because the death of the patient is such that there can be no other explanation. It may be impossible to know what in fact transpired and in this scenario the Trust would have to produce evidence to rebut the presumption of negligence by offering a plausible, nonnegligent explanation.

The legal representatives acting for the Trust would seek to argue that proper care was exercised but that regrettably the adverse outcome was extremely rare or impossible to explain in the light of current knowledge. In any event, the claimant has to still surmount the burden of proof which even where breach of duty is clear, the cause of the injury cannot be proved on the balance of probability. Moreover, the court would need to decide what would the outcome have been for this patient had care been optimal.

In relation to the aspiration at the time of intubation, one needs to consider whether this represents unnecessary harm or unavoidable risk. Doctors have a duty at all times to act in the best interests of their patients. All clinical interventions carry a degree of risk and the assessment that is undertaken by doctors on an ongoing basis is whether the benefit of the intervention is greater than the unavoidable risk of performing the procedure.

Where the care of the patient passes between different NHS organizations they are all represented by the NHS Litigation Authority. In this example the NHSLA would represent both the ambulance Trust and the acute NHS Trust. Liability would then be apportioned between the co-NHS defendants. Most often, where the NHS is admitting liability, dispute between the two NHS co-defendants is not encouraged as this may lead to wasted costs.

The action of one public authority may interrupt the chain of causation such that the impact of an NHS organization’s care early on in the patient care pathway is superseded by the actions of a subsequent legal entity. This may provide the first NHS organization with a causation defence.

Where there has been an adverse incident which is properly investigated in accordance with the Trust’s incident reporting policy, then in accordance with the NHS ‘Being Open’ policy it is most common for the report and action plan to be shared with the patient or the patient’s family. The Trust needs to think about the most sensitive way of informing and maintaining communication with the patient’s wife, not only providing her with a paper copy of the report but also facilitating a meeting and discussion of the contents of the report since it contains clinical vocabulary and concepts which may be unfamiliar to a lay person. It may be equally important to the patient’s family that there is evidence of organizational learning and that any action plan has been completed prior to a closure of a Serious Incident Requiring Investigation (SIRI) process.

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