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Safety Story

Unexpected outcome from a procedure - patient safety story

Published on: 16/11/2022

On 21st May 2013, I was sent on relief to a 31 bedded surgical ward. The ward was very short-staffed and it was a busy theatre day as well. I was working with a Nurse Manager, a Pre-Reg nurse, an agency and an attendant.  The student and I took handover on 3 six bay rooms and 2 side rooms while the manager organised the rest of the ward.

I allocated the student to look after the patients who needed breakfast while I quickly ran around checking the observation sheets. I checked that the patients for theatre were ready and then turned my attention to my post-op patients.

Mary was on Day 1 post abdominal surgery. She was on intravenous fluids, patient-controlled analgesia and oxygen. She said she was comfortable at rest but did have shoulder pain on coughing. I encouraged her to use the PCA and after checking her vitals I moved along to see the other post-ops. The Consultant reviewed Mary while I was attending to another patient. Mary informed me that he reassured her that her shoulder pain was to be expected, he encouraged her to mobilise and advised her that she could commence sips. 

She mobilised to the bathroom with assistance for a wash and on return to her bedside sat in an armchair. Her Early Warning Score was 3 at that time but I was not alarmed as she had mobilised and was on 2L oxygen.  

Late morning, she had routine bloods taken and after physiotherapy, she returned to bed for a rest. When I checked on Mary she looked uncomfortable and she felt she may have overdone it. I checked her pulse noting she had a slight tachycardia so I encouraged her to use more analgesia.

Just after lunch, the Physiotherapist informed me that Mary was light-headed so she didn’t take her out for a walk. She had used a lot of analgesia and had pin point pupils. We got her back to bed as she felt unwell. At this point, she was hypotensive and had a tachycardia.  I contacted the surgical team, did an ECG and increased her fluids.

I continued to keep her under observation while I managed two other patients who had returned from theatre as well as giving 2pm medications.  About an hour later, the student called me to say Mary was nauseated. When I went to give her an anti-emetic, I noticed she was very clammy. She said she was dying and asked me to get her husband in. I reassured her that it was probably the analgesia that was making her feel poorly and that she’d be fine.

The Intern arrived after 4 pm. He reviewed Mary and said the Registrar was on the way. It was about 5 pm when the Registrar and consultant came to the ward. I went to get her blood results while they reviewed her. I was alarmed to see that her urea and creatinine were extremely raised. Mary told the Consultant that her shoulder pain had gotten steadily worse throughout the day. He asked for an urgent x-ray and increased her intravenous fluids.

The Nurse Manager arrived and questioned why I had not documented more frequent observations in the Early Warning Score sheet. This was done in front of the consultant and patient who looked even more apprehensive. I was told to write up my notes and another nurse would take over from me. I completed my nursing notes on all the patients and left the ward after 6.30 pm.

I returned to work in my own ward the next day and was called into the manager’s office. She said that Mary had died at 11 pm that evening and that there was criticism of my records and the care I had given. My manager was sympathetic but advised me to jot down what happened as the risk manager wanted to interview me.

I was devastated for Mary and her husband who had joked with me that afternoon about Mary liking her morphine. I remembered telling her she’d be fine when she said she felt something bad was going to happen. I also remembered the nurse manager telling the consultant that I hadn’t recorded the observations enough and was distraught that perhaps I was somehow to blame. It was so unfair as I hadn’t stopped running all day and stayed back after my shift had finished because it was the right thing to do and I couldn’t just walk away when it was so busy.

Later that day I met the risk manager who asked if I was ok. I burst into tears when she tried to be nice to me - it was as if she had opened the floodgates – a patient I had cared for died, I couldn’t cope with someone being nice to me!

She asked me why I was so hard on myself and I told her about the conversation I had overheard and how I had left the ward that evening totally deflated but this was nothing now that the patient had died. She explained that she would carry out a review of Mary’s care but not to worry. How could I not worry? A patient died and I was being asked to account for my actions.

I was so angry, I had never had any training on the Early Warning Score but I was a bloody good nurse and I may not have recorded every single thing I did with Mary that day, but I did the best I could when the ward was short staffed, and the manager never came near me.

The risk manager was soothing but I knew someone would be held to account and it would be me. She offered me support but I just wanted to get away from her, she asked if I wanted Employee Assistance and I felt my world was falling apart.

We arranged to meet the next day to finalise my statement. I phoned my partner and he told me that I shouldn’t have given a statement without getting advice. I didn’t sleep that night with worry. The next day when I was on duty the consultant was on my ward and he approached me. He asked me what had gone wrong the day I looked after Mary and why hadn’t I called his team sooner. He was told that not completing the Early Warning Score sheet was a fitness-to-practice issue but this was something he wouldn’t share with Mary’s husband who wanted answers.

I felt sick; I didn’t know who to turn to. I contacted my friend and she tried to reassure me but I couldn’t even listen to her. I felt I was going to be physically sick and couldn’t concentrate on anything. Eventually, my manager told me to go home but to let the risk manager know as we were to meet up in the afternoon. I called her and she said she’d come to see me. When she arrived she didn’t say a word she just hugged me and I felt my heart burst. I vividly remember that moment thinking I had never felt so crushed before – this is what devastated sadness feels like.

The risk manager took me to her office. I told her about the conversation with the consultant. She could see I was destroyed and kept telling me that it wasn’t my fault, that I was good at my job and my line manager totally trusted me.  It didn’t help, Mary had died on my watch!

I gave my statement and was told to keep my chin up. She gave me her number and told me to call her anytime. She couldn’t see that meeting her would be painful and so I kept it all inside and returned to work on my ward half the person I had been.

I had been planning my wedding but I felt my light had gone out and felt it was wrong to be planning my wedding in the aftermath of this awful event. Some weeks later, I met the Intern who had reviewed Mary and he asked me how come I hadn’t noticed the patient had deteriorated. I couldn’t even answer him – I knew then I had to move to another hospital. That evening as I was leaving the ward the manager called me aside saying she was worried about me. I had lost weight and was drawn – Did she think I was made of stone?

The next day the risk manager came to the ward and I felt sick with worry. She took me for coffee and asked me to tell my story again as if it was for the first time. She jotted down some notes. She read out the statement I had given her 5 weeks earlier and then read out the notes she had just written. I was shocked at just how different they were. My statement was an account of my care and observations and the notes she wrote were ones of self-doubt and self-criticism.

She reminded me that Mary’s death was subject to a Coroner’s Case and we didn’t know the cause of death and I was doing a disservice to every other patient in my care. She asked me what exactly I was taking the blame for. Did I order the bloods? Did I neglect to call the doctor? Did I falsely reassure Mary, knowing her fate was to die?

She made me promise to phone the Employee Assistance Programme and I did.

The risk manager phoned me when the Coroner’s Case was scheduled as I was called to give a statement and she came with me. It brought it all back, that sick feeling in my stomach that I’d have to meet Mary’s husband again and see the anger in his eyes.

I answered the questions asked of me by the Coroner, he was very formal but his questions were very clear and there were no catches. He noted that my care was exemplary.   Mary had sustained a perforation during surgery. She needed antibiotics and surgery to save her life.

That was over 3 years ago, a time in my life I will never forget. I did get married but it was a very different person who walked up the aisle. I did leave my job and went to work for an agency while I sorted my life out.

I am strong now, and I care for my patients zealously, perhaps too intensely at times. I can never let go of the feeling that Mary might be alive if I had done more.

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