A Fife family has expressed feelings that the findings of a fatal accident inquiry into the death of a loved one did not go far enough.
“It was stated during the inquiry that by delaying commencement of antibiotics by more than one hour our mum’s chance of survival reduced significantly from 80% to 50%.
“The family feels that there needs to be a protocol put in place that states when junior doctors cannot gain intravenous access to administer fluids and antibiotics to a critically-ill patient they should seek immediate assistance from more experienced staff.”
In his findings, Sheriff McCulloch noted it had been “generally accepted” the quicker that antibiotics and fluids are administered, the better the outcome.ReasonableHowever, he described suggestions things would have moved quicker in A&E as an “inappropriate comparison,” as he found the decision to admit to ward seven reasonable at the time.
Sheriff McCulloch stated in his report that the level of care given was considered to be “appropriate,” but said the “overall picture was of delay” and that the delay may have had a bearing on the outcome.
“Our mum was highlighted as being in a critical state at 3pm on admission to ward seven,” Mrs Leonard added. “The hospital medical records recorded at this time say, ‘FEWS scale 8 urgent medical attention required.’
“It is then further recorded, ‘O2 given’ (oxygen) at 1700 hours, which was two hours after being highlighted by the ward doctor that it was required.
“Fluids and antibiotics were given at 1930 hours, which was four-and-a-half hours after being highlighted by the ward doctor that it was required.
“Sheriff McCulloch also stated, ‘Hindsight might suggest that it would have been better to treat her with greater urgency.’ This statement makes us believe that some recommendation should have been made.”
Mrs Mackie and Mrs Leonard added they wished to thank Dr Thomas Hartung who, on assessing their mum at 6.30pm that day, immediately realised the severity of the situation.
Sheriff McCulloch ruled there were “no reasonable precautions” whereby death might have been avoided, and that there were no defects in any system that contributed to her death.
While Anne Mackie and Linda Leonard said they agreed with Sheriff Grant McCulloch’s ruling that their mother Jessie Taylor’s death could not have been avoided, they said it was a “great disappointment” no recommendations were made to prevent delays in treatment at Victoria Hospital, Kirkcaldy.
Mrs Taylor (65) died from multiple organ failure caused by streptococcal sepsis and right lung pneumonia at Queen Margaret Hospital, Dunfermline, on September 20, 2009 the day after she had been admitted to Victoria Hospital complaining of flu-like symptoms.
The inquiry at Kirkcaldy Sheriff Court this year was held after Mrs Taylor’s family raised fears that the hysteria surrounding swine flu may have influenced her treatment and that something had gone wrong with her care.
She had walked into an out-of-hours surgery at 2.05pm on September 19, been alert and talking at 6pm, yet died the following morning.
The decision to admit her initially into ward seven, an infectious diseases ward, rather than A&E was also highlighted, as was a lengthy delay in giving her fluids, oxygen and antibiotics as medical staff experienced problems in gaining intravenous access.EffectivenessThe family also questioned the effectiveness of the Fife Early Warning System (FEWS), in which a patient’s vital signs are monitored and is then given a score to determine the best course of action.
A low overall score indicates the patient is deteriorating and monitored very closely. Should the score fall below a certain level, the hospital’s rescue system intervenes to help avoid the chance of the patient suffering cardiac arrest-the point at which a “crash call” would be made.
“It is extremely worrying to know that patients being admitted to Victoria Hospital with a FEWS score of eight may not actually receive adequate treatment for four and a half hours, thus reducing their chance of survival,” Mrs Mackie said.
While Anne Mackie and Linda Leonard said they agreed with Sheriff Grant McCulloch’s ruling that their mother Jessie Taylor’s death could not have been avoided, they said it was a “great disappointment” no recommendations were made to prevent delays in treatment at Victoria Hospital, Kirkcaldy.
Mrs Taylor (65) died from multiple organ failure caused by streptococcal sepsis and right lung pneumonia at Queen Margaret Hospital, Dunfermline, on September 20, 2009 the day after she had been admitted to Victoria Hospital complaining of flu-like symptoms.
The inquiry at Kirkcaldy Sheriff Court this year was held after Mrs Taylor’s family raised fears that the hysteria surrounding swine flu may have influenced her treatment and that something had gone wrong with her care.
She had walked into an out-of-hours surgery at 2.05pm on September 19, been alert and talking at 6pm, yet died the following morning.
The decision to admit her initially into ward seven, an infectious diseases ward, rather than A&E was also highlighted, as was a lengthy delay in giving her fluids, oxygen and antibiotics as medical staff experienced problems in gaining intravenous access.EffectivenessThe family also questioned the effectiveness of the Fife Early Warning System (FEWS), in which a patient’s vital signs are monitored and is then given a score to determine the best course of action.
A low overall score indicates the patient is deteriorating and monitored very closely. Should the score fall below a certain level, the hospital’s rescue system intervenes to help avoid the chance of the patient suffering cardiac arrest-the point at which a “crash call” would be made.
“It is extremely worrying to know that patients being admitted to Victoria Hospital with a FEWS score of eight may not actually receive adequate treatment for four and a half hours, thus reducing their chance of survival,” Mrs Mackie said.