Based at the University Hospitals of Leicester, we serve the educational needs of healthcare practitioners in Acute & Emergency Medicine across the East Midlands, UK
Updated: 23rd Apr 2018
A: Sources reviewed – notes, x-rays, staff statements etc
B: Comments – my chronology of events, analysis and documentation of any actions taken. Opinion on whether mistakes were made.
C: Text for response letter – 'Dear Mr Bloggs I was sorry to hear that you were upset by your treatment in the ED on…'
By having B and C this means that there is a clear medical analysis and documentation for future reference, but also makes it clear which parts need to be copied and pasted into the letter to the patient.
(a) Say sorry – either for events, if justified, or if not for the person having been made to feel that way
(b) Address all the issues listed (otherwise it’ll go to round 2)
(c) The 1st commonest mistake (IMHO): use plain language and avoid medical terms; if useful to use the medical term then translate it into plain language – scrutinise every medical term and abbreviation
(d) Refer to the person as “Mrs Bloggs”, “your mother” etc. – not “the patient” and limit the use of he/she during the text
(e) Avoid those awful doctor phrases…
Not consistent with…
Not convinced that…
The medical doctors…
Frailty, safeguarding, etc.
The patient denied that…
(f) Stop and think from the patient’s/relative’s point of view, e.g.
Waiting always feels like forever when you’re a patient
Our environment looks chaotic, intimidating, and abrupt
Staff tolerate noise levels, smells, shouting patients and can tune out a bit but it’s quite a shock to a lot of people
We think we’re giving information consistently but slight changes of phrase mean lots of different things to the patient
We’re not good at updating what the pt is currently waiting for
They think their circumstances are unique – therefore – “top” top tip is…
(g) The 2nd commonest mistake (IMHO): don’t write the patient part as “here is my opinion” – that is for the 1st part (for the trust). This makes us sound arrogant. The patient part is a sympathetic acknowledgement that they have been upset enough to write, with an explanation of events. Every nuance will matter (and hurt) when the patient receives this.
h) Inspire confidence by painting a bigger picture and showing that we are trained to see many such cases regularly – e.g. saying things like…
”What we normally do in this situation is…”
“In these cases 80% of people will xxx but in your case…”
“Normally the labs are very good in doing tests promptly, but…”
“The doctor you saw is one of our best doctors, but it seems that this time…”
“We will make sure that we learn some lessons from this so that it won’t happen again.”
(j) do not rely on others to proof read (eg mistakes like he/she, getting a date wrong) – do it yourself!
(a) Personal feedback
(b) System problem you can fix (go ahead)
(c) System problem the right person needs to fix
(d) Learning from the event – individual / group / nursing team lead or matrons / department
(e) Feeding into clinical governance process
(f) Any “heads ups”? eg Comms team, other specialities, leads of CBU or higher, inquest team, etc.
(a) personal feedback only if there is a learning point – if so you vs Educational Supervisor, not if there isn’t (just upsets people); ensure they understand the complaints process and that it’s fairly routine (non-threatening)
(b) statements only if they’re going to clarify or add something (people find writing a statement very threatening)
(c) Always let ED Supervisor / Line Manager know – people can be quite badly affected by a complaint and may need some pastoral support
Complaint rec’d 28th Jan 2011 re: xxxxxxx
Complaint no. G226228, S0289416
ED records 29 Aug 2010
EDU records 30 Aug 2010
Images on Impax
Mr Wxxxx presented 3 days after a fall in which he had injured his back, with a collapse episode. His thoracic and lumbar X-Rays were shown to Dr xxxx, ED consultant, by the SHO. Neither doctor saw the fractures of T10 and L4.
He was placed on EDU overnight, and said to have had a comfortable night (recorded in notes) and this was relayed to the wife. She disputes this. He was transferred to GGH and left to sit on a chair on CDU. She says that no documentation travelled with him.
Statement from Sr Paula Blanchard.
Dear Mr and Mrs Wxxxx,
I am very sorry to hear that we missed two fractures of the spine when Mr Wxxxx attended the Emergency Department last August. I have gone through the notes and looked at the x-rays and both of the fractures are called a “compression” fracture. This type of fracture can be tricky to diagnose because the vertebra bone is squashed rather than broken, as such. In particular as people get older the changes of wear and tear and arthritis can make subtle fractures difficult to spot. I therefore can understand why the two doctors who saw Mr Wxxxx did not see the fractures.
We have a safety net system whereby if the radiologist’s report shows a fracture and we have sent someone home, we are alerted to this and take action. Unfortunately this system only works for discharged patients. For a patient who is admitted into the main hospital, we would rely on the ward doctors checking the radiologist’s report, for picking up a missed injury. This is possibly what happened at the Glenfield Hospital.
For this kind of fracture there is no specific treatment, only pain relief and rest, therefore I am sure Mr Wxxxx came to no further harm, but I do apologise that it took a while for the injury to come to light.
Regarding the issues around the uncomfortable night in our EDU unit, the transfer to a chair rather than a bed at the Glenfield CDU, and the lack of documentation from our end, I have asked our EDU senior sister to look into this.
She would like to reassure you that the ambulance crew responsible for transporting patients across site would not leave the department without holding the patient notes.
On receiving your concerns she requested a copy of your notes and found that the EDU notes had indeed been transferred, and were correctly placed with the main hospital notes. Therefore we cannot understand what the problem was.
Unfortunately the bed situation at the Glenfield hospital is so tight that we have to place patients on a chair quite often, until a bed comes up. Clearly with Mr Wxxxx being in pain from his back, this was not satisfactory. Our senior sister apologises that we did not insist on a bed, although we do find that waiting for a bed space (as opposed to a chair) can cause a delay of up to eight hours, for the transfer, and perhaps the staff were trying to avoid that.
She feels that the EDU staff should have discussed the situation with you and given you the chance to decide your preference and is very sorry this did not happen.
We both hope that Mr Wxxxx is now recovering and apologise for the problems you have kindly taken the trouble to write to us about.
Dear Mrs Cxxxx,
I am writing to apologise for the care you received at Leicester Royal Infirmary Emergency Department. I have read through your concerns and fully understand why have made this complaint and I am sorry that you felt you were not adequately looked after.
In your letter you mention the following things:
A fractured sternum was not diagnosed. As a result you did not get enough painkillers and had to seek additional help from your GP.
You felt that the staff did not appreciate how serious the incident was that you were involved in.
You told the staff that you could hear a clicking sensation in your chest, and thought this was serious.
Whenever an error occurs it is vitally important to learn from any mistakes so that similar events do not happen in the future. To this end I have looked at all your notes and discussed what happened to all the staff involved. Below is what I have found out.
You arrived at Leicester Royal Infirmary at 16:25 on the 6th of June 2010 after being involved a serious crash as a front-seat passenger. Upon arrival you were assessed by nursing staff and were found to have the pain at the following sites:
Lower Back (Lumbar area)
Central chest pain
You were seen by CONSULTANT NAME who examined you and made an initial diagnosis of a sprained ankle, a lower back sprain and a bruise to your chest. People, such as yourself, often present with multiple injuries and so what usually happens is that we admit patients to the short stay ward for a short period of observation. We do this so we can re-examine them later on so we do not miss any important injuries and to make sure they are comfortable before discharge. This system exists because we understand that no matter how experienced the doctor, injuries become more apparent over time and so can be missed on first assessment.
The doctor that saw you wanted this to happen but unfortunately it did not. If you had been admitted to the ward and subsequently seen by an additional Consultant on the ward round I am confident that your chest injury would have been picked up and you would have been treated appropriately.
This follow up process is usually prescribed on specific documentation called a "Trauma Pathway". I could find no such pathway in your notes.
The current system for recording patient information is being changed to a computerised system to ensure that such events do not happen again. I also communicated these events to the staff that looked after you. We have re-emphasised the importance of effective communication and the correct use of patient pathways and paperwork to the junior staff in teaching sessions. Your case is being used (in an anonymised format) to highlight the need to expedite the introduction of a computerised paperless system currently in the Emergency Department to ensure such important documents are completed correctly and not misplaced.
I am glad that you were treated effectively by your General Practitioner and that you are recovering well.
Once again I apologise for the distress you have suffered.
Dear Mrs Cxxxxx,
I am writing to apologise for the care you received at Leicester Royal Infirmary Emergency Department and that we missed the fracture of your sternum. This is indeed a significant injury and causes a lot of pain for a matter of months.
I have read through your concerns, read the medical records and have a written statement from the consultant who was the doctor who saw you. In your letter you mention the following things that upset you:
A fractured sternum was not diagnosed. As a result you did not get enough pain killers and had to see your GP to get the diagnosis.
You felt that the staff did not appreciate how serious the incident was that you were involved in.
You told the staff that you could hear a clicking sensation in your chest, and this was not listened to.
There was a delay in getting painkilling medication.
There is no mention in your notes of the deaths of people involved in the crash unfortunately. It is not clear whether the paramedics made this clear to staff. This must have been an extremely distressing event for you.
In these sorts of situations we are well aware that with the distress, and with several injuries, it is not always easy to make an accurate diagnosis on each of the injuries at that stage, and for that reason we often use the ward you describe, as a period of rest and painkillers, with a plan for a senior doctor review in a few hours’ time. I think that had the consultant known about the deaths of the other car occupants, he would have arranged to review you later on, and the fracture of the sternum may have been more obvious up at this stage.
You are right that it took too long for you to get painkillers. You arrived at 16.25 hours, were seen by the consultant at 17.15 and were prescribed them at 17.30. The national guidelines are to have painkillers within 20 minutes of arrival. We often do “audits” of this to monitor our patient care. We are sorry for the delay on this occasion.
In my opinion it is very uncommon for this consultant to make an error. There is no record in his notes of you experiencing clicking that you describe, but he has documented examining your chest and that it was painful to compress it back and front. A sternum fracture can be hard to pick up because most seatbelt injuries (without a fracture) appear this way too. The consultant would like to apologise for missing the fracture. Had we picked up the fracture you would still have been discharged home, but with the knowledge that you would probably need strong painkillers for several weeks and find it hard to drive or lift things.
Once again I apologise for the delay in getting painkillers and the fact we missed the fracture.