Posted by: Witch Doctor | July 16, 2012

Two tragic avoidable deaths


Dr No is on to the case of a young man, Kane Gorny, who suffered from the uncommon condition “diabetes insipidus” and died in a surgical ward after dialing 999 to call the police because he could not get staff to understand he needed more fluid. The police arrived but were sent home and the patient sedated rather than treated appropriately.

Simple basic nursing observations were not done.

Here’s another case :


This girl was seriously ill with septicaemia as a result of a severe, acute kidney infection.

Once more, simple basic nursing observations were not done.

“But he added that the case “classically exemplified” a failure in the NHS where taking the pulse and temperature of a patient had become a “Cinderella task”.

“A very similar picture frequently emerges of observations that are not done or their importance goes unrecognised,” he said.

“Nurses have to tick boxes on a whole host of things and the priority given to observations has fallen by the wayside and are carried out by care assistants and auxiliaries and not registered nurses.”

It appears also that directions were not followed regarding the prescription of antibiotics.

“The inquest also heard that an on-duty doctor had recommended twice that Laura be given antibiotics – but these were never prescribed to the stricken trainee beautician. However, it was decided that these antibiotics would not have saved her life.”

The Witch doctor begs to differ with the above statement.

Unless the patient suffers from an extremely rare bacterial infection that is resistant to all antibiotics, then it is a fact that the right antibiotic or combination of antibiotics given in a timely manner, in the right dose, and by the right method not only saves lives but it is likely that a previously healthy patient will return to a completely normal life.

However, this is not all just about basic nursing observations not being done and prescribed antibiotics not being given.

A proper consultant delivered service would have ensured that this teenager was optimally treated, and assuming she was not already moribund on arrival at the hospital, (unlikely because she and her mother had been texting each other) she would probably have survived.

Sometime The Witch Doctor might explain how a consultant delivered service works because nobody seems to know or care any more.

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    “Mistakes Chronicled on Medicare Patients: One of every seven Medicare beneficiaries who is hospitalized is harmed as a result of problems with the medical care there, according to a new study from the Office of Inspector General for the Department of Health and Human Services.”
    New York Times. Duff Wilson. 15 November, 2010

    Click to access oei-06-09-00090.pdf

    “Adverse events in hospitals: national incidence among Medicare beneficiaries.”
    Daniel R. Levinson, Inspector General. November 2010. OEI-06-09-00090
    US Department of Health and Human Services. Office of Inspector General.

    “An estimated 13.5 percent of hospitalized Medicare beneficiaries experienced adverse events during their hospital stays. Of the nearly 1 million Medicare beneficiaries discharged from hospitals in October 2008, about 1 in 7 experienced an adverse event that met at least 1 of our criteria (13.5 percent).“

  2. Dear WD,

    Two very tragic cases indeed. One issue not discussed is continuity of care; endless handovers are no substitute for regular review by the admitting team. Laura was admitted as an “acute abdomen” for which an investigative procedure was done for appendicitis. In part this is modern medicines excessive faith in high tech solutions, and all too common. The real investigations should have been at the bedside with hand on belly and eye on the obs chart. An MSU or even dipstick urine would have given the diagnosis, and in a lass this age a urine

    should have been taken for a pregnancy test in case of ectopic.

    • Sorry hit post button by accident. A senior surgeon had reviewed the patient and recommended antibiotics. Why did he not prescribe himself or wait while the houseman did. This is a failure of the entire surgical team; poor continuity due to the shift system; and a failure to understand the importance of basic history and examination. This is also true of the case at St Georges. This is what medical education has brought us to. I am saddened but not surprised. I have seen too much of this to be surprised anymore.

  3. I wonder if antibiotics were indeed prescribed but not given. I had an experience with a relative of mine who was unconscious and seriously ill from presumed septicaemia. They were not allowed to carry the prescribed antibiotic on the ward because of the “antibiotic policy,” although it could be obtained on request from pharmacy. However, the “protocol” from obtaining it from pharmacy seemed to be too cumbersome for the staff to follow and so the antibiotic prescribed at 4.00pm in the afternoon had still not been given by the following morning. No alternative antibiotic had been given either.

    I think these “mishaps” are very common nowadays and would go as far as to say that in some circumstances patients need a medically qualified “minder” as they stumble through the maze of pathways and protocols that has become modern medicine. I have been such a “minder” on several occasions when members of my family have been in hospital and even as a consultant (and not a shrinking violet), in the same hospital have found the role difficult. What chance do others have?

    Medicine needs to get back to basics and consultants need to take overall responsibility for the patients in their care as well as being highly visible. Only the consultants have the authority to sort this out.

    • All true. I have had to tactfully interfere with a couple of friends and neigbours much as you have done. Was it ever thus? I think not, but maybe I have false memories, or perhaps still in blissful ignorance of errors made decades ago.

      I can recall a number of patients that I wish I had managed differently; would it have made a difference? My learning curve was someone elses death or disability, a difficult burden to live with.

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