Moral dilemma re death in a ward

[ben5575]

I'll try and keep this short:

• A friend of mine, who is a an experienced and qualified nurse, was in hospital last month for a week which included an operation.
• During their time there, they witnessed the decline and ultimate death of a woman in her early 40's through Hospital Acquired Pneumonia.
• It was clear to my friend that the clinical staff missed the deceased's obvious early stages of decline until it became too late.
• Whilst it could be argued that this is simply a matter of opinion, what is not in doubt was that when a doctor did finally notice the deceased's deterioration, they stated that the deceased needed medication.
• This medication was never prescribed.
• The deceased repeatedly asked for the medication to be prescribed whenever she came into contact with clincal staff, however the nurses said not to worry, the doctor would sort it.
• Unfortunately the deceased saw a different doctor each day and the prescribing of the medicine clearly fell through the handover gaps.
• In addition to this my friend who was themselves quite poorly repeatedly pointed out that the deceased had not received her medication and was clearly deteriorating rapidly.
• The patient then died leaving behind two children, the youngest being seven.

My friend is currently battling with their own health and is not in a position to become involved in reporting and arguing against a hospital (not least because they may have to go back in for further treatment).

So my dilemma.

Now that I know about this, should I report it? As I say if it was simply a matter of professional judgement then clearly I was not there nor am I qualified.

However 'presumably' the doctor made a note that the medicine needed to be prescribed and the clinical notes will show that it wasn't. As this is (again presumably) a matter of fact, this can be checked. If the death was 'routine' then perhaps this detail wouldn't have been picked up?

If these failings are systemic, then more people are likely to die. Or is it none of my business?

What should I do?

[Bill]

Tricky because you're going off hearsay rather than something you saw yourself, particularly if your friend doesn't want to get involved. I'd expect there to be an inquest so potentially worth flagging it to the coroner's office. Better to offer to support your friend so they can bring it up.

[Jamescrs]

You could and arguably should report it but my gut feeling is it won’t go anywhere as you effectively offer hearsay evidence without witnessing anything directly, but at least there would be a record.

[ADJimbo]

This is my professional sphere…

When a Patient deceases an attending Doctor (who will have seen the patient during their lifetime) will have attended to certify the death and start the MCCD (medical certificate cause of death) process of which, if the death was NOT expected, or the attending Doctor is NOT happy to sign for the death, they will refer the deceased to HM Coroner for further investigation. If the death was expected, the Doctor will then complete the MCCD and it will then go to the Medical Examiner for final signoff.

These are the new regulations which came into force in September 2024.

On a pragmatic note, and with the greatest of respect, you have not seen the medical notes and neither has your friend. It would be very, very uncommon for a patient not to be scribed for something for such a period of time. If this was ever to happen, then it would be picked-up on a top-to-top between the two Nursing leads at shift-handover and a resolution immediately put in place. It would have been picked up,on a daily ward-round as well…

I mean this with the greatest of respect, but without full knowledge of the patient and visibility over the HX and notes then it is impossible to know what’s gone on and above all, your view is speculative.

You are of course, free to contact HM Coroner and raise any concerns you have.

I hope this helps and gives some visibility over the processes that are in place.

[Badda]

The above is probably all the advice to need. However, this is not your dilemma, it’s your friends and I would urge them to raise this.

[Mojooo]

I'd raise it on behalf of your friend and act as the go between should they not be able to handle it direct.

[Mr Pointy]

If this has happened once It's probably happened before & may well happen again. How would you & your friend feel if another mother or father dies in the future?

[FMOB]

ADJimbo said:

This is my professional sphere…

When a Patient deceases an attending Doctor (who will have seen the patient during their lifetime) will have attended to certify the death and start the MCCD (medical certificate cause of death) process of which, if the death was NOT expected, or the attending Doctor is NOT happy to sign for the death, they will refer the deceased to HM Coroner for further investigation. If the death was expected, the Doctor will then complete the MCCD and it will then go to the Medical Examiner for final signoff.

These are the new regulations which came into force in September 2024.

On a pragmatic note, and with the greatest of respect, you have not seen the medical notes and neither has your friend. It would be very, very uncommon for a patient not to be scribed for something for such a period of time. If this was ever to happen, then it would be picked-up on a top-to-top between the two Nursing leads at shift-handover and a resolution immediately put in place. It would have been picked up,on a daily ward-round as well…

I mean this with the greatest of respect, but without full knowledge of the patient and visibility over the HX and notes then it is impossible to know what’s gone on and above all, your view is speculative.

You are of course, free to contact HM Coroner and raise any concerns you have.

I hope this helps and gives some visibility over the processes that are in place.

I think the above whilst factual is rather missing the point, the friend is an experienced nurse and saw the issues first hand, something in the process failed seemingly more than once and a patient died.

This may have been inevitable, facilitated by the failure or caused by it. One hopes this was a one off...

I think there is a moral and professional obligation to raise the issue but as a non-medical person I wouldn't know where to start.

[ben5575]

Ach it's a hard one.

My friend clearly feels incredibly guilty about not doing more at the time. Part of that was down to her being there in a patient capacity rather than a nurse, but also because she was herself battling to get her IV prescription renewed on a 24hr basis with the ever revolving clinical staff and was fearful that she was at risk as well. In her words, 'I watched them kill her'.

I don't think she would raise it herself (mainly because of the above), but I do think that if it was investigated (because something had happened) and she was approached about what she saw, it would help her dealing with it.

I obviously appreciate that if it were simply a case of some random person (me) reporting a he said/she said incident then clearly I wouldn't be so exercised about it. I simply wouldn't get involved.

However presumably the noting of the medication being required and the timings of it being prescribed (or not) is a matter of clinical record and something that can be simply checked.

If it was, then no problem. If it wasn't then the processes helpfully explained about are failing. And that speaks a systemic failure which potentially puts more patients at risk.

[FMOB]

Maybe report it to PALS in the first instance so at least the observation gets recorded and linked to the patient.

[Caddyshack]

My wife had brain surgery for a bleed in the last 10 days. Once she was out of ICU she was on a brain ward, She noticed one nurse kept getting confused with meds so my wife (in a very drugged condition) paid very particular attention to the meds this nurse gave her and then called the manager, they checked through and despite my wife reminding this nurse several times it seems she had been giving her meds with the opposite desired effect and were incorrect.

The manager took it very seriously.

Things like this can kill people.

[bishop finger]

It is what it is. Everyone dies. In 100 years from today everyone on earth will be dead

[Caddyshack]

bishop finger said:

It is what it is. Everyone dies. In 100 years from today everyone on earth will be dead

According to an actuary “the person who will live to be 200 years old has already been born”

[paulguitar]

bishop finger said:

It is what it is. Everyone dies. In 100 years from today everyone on earth will be dead

Oh, it doesn't matter then, cool.

[gangzoom]

Caddyshack said:

bishop finger said:

It is what it is. Everyone dies. In 100 years from today everyone on earth will be dead

According to an actuary “the person who will live to be 200 years old has already been born”

Annual mortality rates isn't linear, once you get to 90+ you are in double-digit mortality figures. There is finite limit to human physiology, we were never really meant to live beyond 50ish. Unless anti ageing gene manipulation actually demonstrates real results, no one is going to live to 200.

[Scarletpimpofnel]

ADJimbo said:

This is my professional sphere…

When a Patient deceases an attending Doctor (who will have seen the patient during their lifetime) will have attended to certify the death and start the MCCD (medical certificate cause of death) process of which, if the death was NOT expected, or the attending Doctor is NOT happy to sign for the death, they will refer the deceased to HM Coroner for further investigation. If the death was expected, the Doctor will then complete the MCCD and it will then go to the Medical Examiner for final signoff.

These are the new regulations which came into force in September 2024.

On a pragmatic note, and with the greatest of respect, you have not seen the medical notes and neither has your friend. It would be very, very uncommon for a patient not to be scribed for something for such a period of time. If this was ever to happen, then it would be picked-up on a top-to-top between the two Nursing leads at shift-handover and a resolution immediately put in place. It would have been picked up,on a daily ward-round as well…

I mean this with the greatest of respect, but without full knowledge of the patient and visibility over the HX and notes then it is impossible to know what’s gone on and above all, your view is speculative.

You are of course, free to contact HM Coroner and raise any concerns you have.

I hope this helps and gives some visibility over the processes that are in place.

With the greatest of respect I think you are seeing the NHS and it's processes through rose tinted glasses. I could have written an almost identical post to the OP and I doubt very much the NHS ever freely admits they "killed Mrs Muggins through confusion and incompetence". I wonder how many Drs that know they have cocked up refer a death to the coroner?

[Rockatansky]

Maybe I'm over simplifying things here, but I think it boils down to your own personal decision making / peace of mind barometer.

I always feel that one needs to be able to look at oneself in the mirror at the end of each day and be at peace with one's actions. Those could be mundane or life changing, you could be a psychopath with no feelings or the most sensitive soul, makes no odds.

If you're happy to do nothing and move on, that's OK.

If you feel it's someone's responsibility to say something, that's OK.

Only you can look at yourself and give the answer.

[Caddyshack]

gangzoom said:

Caddyshack said:

bishop finger said:

It is what it is. Everyone dies. In 100 years from today everyone on earth will be dead

According to an actuary “the person who will live to be 200 years old has already been born”

Annual mortality rates isn't linear, once you get to 90+ you are in double-digit mortality figures. There is finite limit to human physiology, we were never really meant to live beyond 50ish. Unless anti ageing gene manipulation actually demonstrates real results, no one is going to live to 200.

The actuary that told me has made many millions in the insurance world, he owns several companies that are high street names.

It’s obvious that annual mortality rates isn’t linear.

It, apparently, wouldn’t take much genetic manipulation to get 100% increase in life expectancy, could someone who is a child now expect to see real results in gene manipulation over the next 70 years?, it’s not too unbelievable based on what we have seen from the last 100 years of medical and scientific discoveries.

[ADJimbo]

Scarletpimpofnel said:

ADJimbo said:

This is my professional sphere…

When a Patient deceases an attending Doctor (who will have seen the patient during their lifetime) will have attended to certify the death and start the MCCD (medical certificate cause of death) process of which, if the death was NOT expected, or the attending Doctor is NOT happy to sign for the death, they will refer the deceased to HM Coroner for further investigation. If the death was expected, the Doctor will then complete the MCCD and it will then go to the Medical Examiner for final signoff.

These are the new regulations which came into force in September 2024.

On a pragmatic note, and with the greatest of respect, you have not seen the medical notes and neither has your friend. It would be very, very uncommon for a patient not to be scribed for something for such a period of time. If this was ever to happen, then it would be picked-up on a top-to-top between the two Nursing leads at shift-handover and a resolution immediately put in place. It would have been picked up,on a daily ward-round as well…

I mean this with the greatest of respect, but without full knowledge of the patient and visibility over the HX and notes then it is impossible to know what’s gone on and above all, your view is speculative.

You are of course, free to contact HM Coroner and raise any concerns you have.

I hope this helps and gives some visibility over the processes that are in place.

With the greatest of respect I think you are seeing the NHS and it's processes through rose tinted glasses. I could have written an almost identical post to the OP and I doubt very much the NHS ever freely admits they "killed Mrs Muggins through confusion and incompetence". I wonder how many Drs that know they have cocked up refer a death to the coroner?

You’re obviously aware of the processes and legalities surrounding the certification of death, the issuing of the MCCD and where appropriate, the issuing of the Cremation4 and/or the role of the Medical Examiner and/or Medical Referee? Have you read the Shipman Inquiry and the strict rules which were implemented off the back of this inquiry?

For a Doctor to issue a MCCD it has to be countersigned by another Doctor (“examiner”) who is unconnected with the patient and the issuing Doctor, but will have sight of the HX / notes and if required, can examine the deceased patient. If there was any sign of a procedural failing it would be escalated to HM Coroner as an examiner would not put their professional registration at risk to cover-up for another Doctor.

It would be the examiner that refers and not the issuing Doctor.

Put simply, and off the back of the Shipman Inquiry, the days of the same single Doctor being able to act as Judge, Jury and Executioner by covering up their own or colleague failings went out in the mid-2000’s.

It’s not a rose-tinted view at all - it’s a working knowledge of how the system works and how stringent it is compared with the days of yesteryear.

As I continue to reiterate, if the OP or his friend remain unhappy then this can be raised with HM Coroner or via the appropriate NHS Trust.

[mkjess123]

My wife has been quite ill for a number of years and she has been admitted to hospitals on various occasions. On one particular 9 day period in hospital, I can only describe her treatment as shocking. On each occasion that I left, I had a genuine and real fear for her safety. I could list the many examples, but they are best described as the nurses really not giving a toss!

Medication was deliberately changed by nurses from doctors instructions, and medication was incorrectly given to the wrong patients on an almost daily basis.

I understand you friends position, having myself been in a relatable position, although in a different profession. However, I strongly believe that there are times in life where you have to stand up and be counted, and this is one of those. If your friend is willing, they should bring this to somebodies attention.

I'm aware that there are members on here who are in the medical profession and at the risk of offending them, there is absolutely no way that a Hospital Trust will investigate this in a fair and thorough manner. It will be watered down and unlikely to go anywhere. Look at the way that the NHS dealt with the Lucy Letby matters.

Yes, they could go the Coroner route, but this is so very long and slow that it's unlikely to see the light of day.

Personally if I were in your position, I would spend some time with your friend and clarify the points / issues etc, and then if they are willing, put pen to paper with a brief explanation of events. I would then contact one of the legal firms advertised at every hospital and pass it to them. They can easily locate the next of kin, and IF mistakes have been made that resulted in the death of a mother of young children, they could bring at least some degree of account to the matter.

I'm no fan of these legal firms, but this is one occasion where their involvement would be of help.