"Error in transfer of notes"

My aunt was admitted from her care home; due to her medication notes from the care home not being properly transferred she went from being chatty, sitting up, able to answer questions, awake etc to being “virtually comatose”, sleeping for the whole day & night. It was hard to rouse her on visiting and when we could, she was asleep again within 2 minutes. As this dramatic change in behaviour was not noted in her notes, when she was transferred from the assessment unit to a ward, the medical staff did not know that the sleepiness was not normal and it went without being investigated.

As my aunt was asleep constantly, she was not taking in food nor was she drinking. In fact, we worked out that she went at least 48 hours from when she was sitting up in bed, talking to her partner who gave her lunch until our request for her to be given fluids via IV to be carried out. In fact, the nursing staff told us, on the ward, that they were awaiting an on call doctor (it was Sunday) to come down to write up my aunt for IV fluids. It was only when we discovered, another 16 hours later, that the on call doctor refused to write up the fluids as “they didn’t like to change a patient’s treatment”, that we called for fluids to be given. It wasn’t a treatment change, it was a bag of fluids to keep my aunt hydrated. This finally happened another 14 hrs further on. Having spoken to my aunt’s consultant they agreed to give fluids sub-cuteaneously but later the decision was made to insert a catheter & give a bag of fluids over 24 hours. Just to underline it was now nearly 96 hours since we could we could identify that my aunt had last had a proper meal (lunch) and drinks. 

My aunt had been admitted due to a suspected DVT which was ultimately diagnosed; severe dehydration can cause DVTs and a whole host of other serious issues, including death.

The situation for my aunt only improved because we “happened” be leaving the ward to head back home (not local) when the registrar arrived. She looked through all the notes, listened to our concerns, examined my aunt and spoke to her partner on speaker phone to get further information. It was at this point that the error was spotted that a sedative which my aunt took as required when at the care home had been written up to be given every 4 hrs. It was no wonder that my aunt had been “virtually unconscious” for days on end. The registrar stopped the sedative immediately; just 7 hrs later my aunt was awake, sitting up, responding to both her partner and the tv! I have little doubt that if we hadn’t continued to raise concerns and had seen the registrar by chance who took a thorough review as to what had happened since admittance and spotted the serious error, we would have lost my aunt within another few days. There were many errors and points for concern but the most serious was that one medication being written up incorrectly which should never have happened and should have been identified sooner. I am still considering a formal complaint, as I have to wonder how many other patients who cannot speak for themselves are admitted and deteriorate without obvious cause and without it being noted, who do not have family and friends to fight their corner. Based on our experience there may be patients who die unnecessarily either as an in-patient or soon after discharge. It is extremely worrying. Final note; the consultant was prepared to discharge my aunt in the condition to which she had deteriorated if her scan for the DVT had proved negative. Shocking.