S H E R I F F 'S D E T E R M I N A T I O N
UNDER THE FATAL ACCIDENTS AND
SUDDEN DEATHS INQUIRY (
INTO THE DEATH OF
MRS MOIRA PULLAR
Held at AIRDRIE on: 14 - 16 November 2005
SHERIFF'S DETERMINATION
AIRDRIE:
NOTE:
At the Inquiry, which was held on 14, 15
and
Mrs
Pullar's family, I was informed, had been unsuccessful in their attempt to
obtain Legal Aid and therefore had no legal representation. One of Mrs Pullar's daughters, Miss
Laura Pullar, asked questions on behalf of the family and at the end of the
proceedings made a very full and thorough submission on the matters which the
family wished me to consider in this Determination.
In
an Inquiry of this complexity where there are two very large volumes of
hospital records to be considered and where it was at one time suggested that a
number of separate matters involving different personnel might have contributed
to Mrs Pullar's death, it is unfortunate that the family could have been
disadvantaged by not being able to be legally represented.
Miss
Green however ensured that the case was fully presented to the Court and Miss
Pullar's questioning of the witnesses was of such a high standard that I hope
that Mrs Pullar's other relatives are satisfied that any point which they
wished made was brought to the attention of the Inquiry. I am very grateful to Miss Green and Mr
Crerar for their professional approach to this case and for the thorough and
careful way in which the evidence was presented and dealt with and I am
particularly grateful to Miss Laura Pullar for the excellent way in which she
put forward the points which the family wished explored and, in particular, for
the moderate way in which this was done.
It
must have been an exceptionally difficult and emotional task for her to
undertake at short notice, as I understand that it was only a short time before
the Inquiry date that it was known that their lawyers had withdrawn from acting
due to lack of Legal Aid.
It
was clear from the evidence that Mrs Pullar, whose date of birth was
The
cause of death was established by Dr Tobias Hatter, a lecturer in Forensic
Pathology at the
Dr
Hatter explained to me that the phrase "presumed insulin excess" arose from the
fact that he
had been advised that it was accepted that Mrs Pullar had in error received ten times the intended dose of insulin. However by the time he undertook the post
mortem there would be no trace of insulin in the system and therefore he could
not personally speak to its existence.
He was however clear that if it was established (as the later evidence
clearly did) that Mrs Pullar had been given ten times the intended dose, that
this would lead to a cardio respiratory arrest and that hypoxic and hypoglycaemic brain damage
would follow.
The
purpose of the Inquiry was to ascertain, if possible, the circumstances under
which this accidental overdose was given, whether there were any failures in
the system of working which caused this and what, if any, reasonable
precautions might have resulted in Mrs Pullar's death being avoided. It also allowed any other fact relevant to
the circumstances of the death to be explored.
Mrs
Pullar stayed originally at
It
is recognised that what may well be a normal dose of insulin for an otherwise
healthy person will have fatal consequences if given to somebody with major
renal problems and, in particular, somebody whose condition requires
haemodialysis.
At
the home her condition deteriorated during the first week of January 2004 and,
as a result, Dr Tricia Moylan, a Consultant in Geriatric medicine, made a
domiciliary visit to Carrickstone on the evening of 08 January and decided to
admit Mrs Pullar to
In
her letter to the receiving doctor, Dr Moylan recorded that "there has been a
marked deterioration in her condition in the past week with fluctuating
conscious level. She has had two
episodes of hypoglycaemia but fluctuation in conscious level has occurred
without a drop in the blood glucose."
The
letter records that Mrs Pullar had a complex previous medical history including
end stage renal failure, (for which she was due to receive her next stint of
haemodialysis on 09 January) diabetic nephropathy, diabetic retinopathy,
hypertension and recurrent falls.
Dr
Moylan concluded that it appeared likely that Mrs Pullar would require
long-term hospital care and felt that there was a need for a CT scan to check
for a subdural haemorrhage in view of the history of falls and fluctuating
conscious level. The consultant
concluded with enclosing the drug cardex for Mrs Pullar and indicating that if
a bed could be found for Mrs Pullar in Wards 20, 21 or 22, she personally would
continue her care.
Of
particular note in the drug cardex to which consultant drew attention was
the fact that she had reduced the insulin for Mrs Pullar from twelve units per day to eight units (given in
morning and evening doses of four units each).
I
am entirely satisfied as the results of the evidence, which I heard from
various doctors and, in particular, from Dr Myles Fisher, a Consultant in
Diabetes from Glasgow Royal Infirmary, that this dosage was appropriate and that
had it continued to be used, this tragedy would not have occurred.
On
her arrival at hospital Mrs Pullar was seen by Dr Rebecca Muirhead, a Senior
House Officer, and thereafter by Dr Sarah Drury, who was at that time a Junior
House Officer in the Emergency Receiving Unit.
Dr
Muirhead arranged for various investigations to be carried out and in
particular for a blood sample to be taken for analysis. The result was received after Dr
Muirhead went off duty and showed a blood glucose level
of 3.1, which indicated that Mrs Pullar was hypoglycaemic.
Dr
Drury completed the drug cardex for the hospital and, in particular, continued
the insulin prescription which Dr Moylan had authorised earlier. Accordingly, it was intended that Mrs
Pullar would receive four units twice a day.
Because
dosages of insulin require to be regularly monitored and, if necessary, altered
depending on the patient's condition and, in particular, blood glucose level,
it is accepted practice as established by the evidence to create a separate
diabetic chart. This provides a record of the type of
insulin used, the dosage and time given and results of all blood glucose
tests. It enables any adjustments in
dosages (which can be required when the patient has an erratic blood glucose
level) to be noted.
In
Mrs Pullar's case this document is page 437 of Volume 2 of the Hospital Medical
Records (production 1). In addition
there is a principal
drug cardex which records that insulin is one of the drugs
prescribed for Mrs Pullar. This
document is page 86 of the same volume.
The
purpose of the drug cardex is to provide written authorisation for the prescribing and
administration of drugs and it should be supported by the signature of a
doctor. Dr Drury did sign the
prescription for the insulin for Mrs Pullar on page 86 and under the heading
"dose" she wrote "4u."
At
some point between her writing this on the evening of
In
writing "4u" Dr Drury was indicating that she wished each dose to be four
units. The drug cardex,
(at page 86) does not have any means of specifying the unit of
measurement used for whatever is being prescribed. This is understandable as drugs are
measured in different units including miligrams, mililitres etc.
The
same situation does not apply to the diabetic chart where the only item which
is being recorded, is insulin for which there is standard unit of
measurement.
On
the diabetic chart as it existed in January 2004 there is a column headed
"units" in which for each entry a figure can be entered showing the number of
units administered.
Since
this tragedy the form has been redesigned so that the word "units" is
preprinted opposite
each entry so that it is not necessary to write the word or any
abbreviation of it.
When
Dr Drury wrote the cardex (page 86) she also wrote up the first entry in the
diabetic chart (page 437) and again used the abbreviation (4u). That entry is totally clear and, in
particular, the letter "u" is totally clear. Under no circumstances could it be
mistaken for the figure "o."
Mrs
Pullar was also seen by Dr Nick Kennedy, the receiving consultant and was
admitted to ward 14 at
The
diabetic chart (page 437) and the drug cardex (page 86) were thereafter
available for the staff in ward 14.
During
the night a number of blood glucose tests were carried out and Mrs Pullar's
blood glucose level increased. This
may well have been due to the infusion of dextrose, which the doctors had
prescribed. By the time a reading was
taken before breakfast on 09 January it had reached 4.3 which is within an acceptable range.
Thereafter
blood glucose readings were meant to be taken at least four times per day, ie., before each meal
and in the evening although it appears that in Mrs Pullar's case additional
readings were taken during the night if she required milk or any sustenance. It is normal practice when caring for a
patient such as Mrs Pullar to undertake a check of the blood/glucose level
before any food or drink is given. It is
thereby possible to see what would be appropriate and is required to maintain
the blood glucose balance at an acceptable level.
Mrs
Pullar's family visited her on 09 January and found her to be happy and
alert. The nursing records support this
assessment. It was not possible to
arrange for Mrs Pullar to have a CT scan on the Friday and the unit does not
operate at the weekend. As the post
mortem showed that there was no evidence of a subdural haemorrhage or any
problem which would have been revealed by a CT scan, this factor has no
relevance to the circumstances of Mrs Pullar's death.
In
accordance with Dr Drury's instruction, as contained on the diabetic chart,
arrangements were made to give Mrs Pullar a dose of insulin on the morning of
09 January prior to breakfast. This
and the next three doses on the evening of 09 January and morning and evening
of 10 January were given by Nurse Fiona Thomson, who in each case recorded that
this had been done on the diabetic chart.
I
am satisfied that on each occasion she gave Mrs Pullar four units. I have reached this conclusion based on
the evidence of Dr Fisher that had Mrs Pullar received ten times that dose on
either the Friday or the Saturday there would at that time have been clear
evidence in her condition. She would
have become hypoglycaemic, have lapsed into a coma and have died if this
situation had not been reversed. There
is no evidence that Mrs Pullar had any major hypoglycaemic incident on Friday
or Saturday and in the circumstances it is clear that she was given the correct
dose on all four occasions on Friday and Saturday.
The
practice in Ward 14 (and it is one which I was informed is in accordance with
proper and appropriate nursing practice) is for two nurses to check the drug
and the entry on the authorising sheet, (be it the drug cardex or the diabetic
chart) and having checked that the drug is in order and the correct dose has
been drawn to allow one of the nurses to administer it. Nurse Thomson was clear that on the four
occasions in which she had done this she had had another nurse with her and, in
particular, she believed that on the evening of Saturday 10 January that other
nurse had been Staff Nurse Catherine Walker. Catherine Walker had no recollection of
this.
Nurse
Thomson did not use the drug cardex (page 86) as her authority for finding the
appropriate dose, instead she used the insulin chart (page 437) on which Dr
Drury had clearly written "4u."
Nurse
Thomson using the same method of recording the figure purported to write
"4u." Examination of page 437 reveals
that of the four entries only that for the Saturday evening could under any
circumstance be described as clearly "4u."
Even then the "u" displays a distinct curve in respect of the two arms
pointing inwards. The other three
entries can best be described as leaving a minimal and barely visible gap
between the loops at the top of the two arms so that it could easily be read as
"o" thereby
making a subsequent person believe that the dosage given had been "40" and not
"4u.".
Nurse
Thomson was not on duty on Sunday 11 January and accordingly was not involved
in the administration of Mrs Pullar's insulin on that morning. There were twenty-four patients in Ward 14
that morning and the nursing staff consisted of three staff nurses, Kathleen
Walker, Lindsay Walker and Staff Nurse Banks. All were of equal grade but Staff Nurse
Lindsay Walker had only recently reached that level and Kathleen Walker was the
most experienced of the three and assumed responsibility for the ward. This is in accordance with normal
practice when there is more than one nurse of equal grade on duty.
There were also two auxiliary nurses
starting duty and both were present when the nightduty staff handed over at
around
Nurse
Kathleen Walker advised the other members of staff that a new system of work
allocation was being operated in the ward.
This had been in operation during the week preceding
Sunday 11 January but Nurse Lindsay Walker had not been on duty when it had
been operated and at least one member of the auxiliary nursing staff was
unfamiliar with it.
The
practice, until that week, had been for all the nurses to accept responsibility
for all the patients and for one auxiliary to undertake the blood sugar
readings for the whole ward. The new
trial system, which had been instigated by the ward sister, Karen Ewart,
involved dividing the nurses into teams, each team being responsible for
certain patients.
Sister
Ewart was on duty on 10 January until
When
she gave evidence Sister Ewart indicated that she expected the auxiliary member
of her team to be responsible for the taking of the blood sugars for the
patients involved with that team and not for all the patients in the ward. This contradicts the understanding of Nurse
Kathleen Walker who believed that one of the auxiliaries would undertake the
blood sugar test for the whole ward notwithstanding the new team
arrangement. Kathleen Walker believed
that the auxiliaries would undertake this task and that where there was more
than one auxiliary on duty (as was the usual position) the auxiliaries would
decide between themselves who would undertake all the tests at a particular
time.
The
two auxiliaries on duty that morning were Nancy Cassidy and Walter Bow. Nancy Cassidy could not recollect whether prior to
11 January it had been the policy for one auxiliary to do all the blood glucose
readings for the ward under the trial system. She was however clear that now there is a
policy whereby all blood glucose readings are done by one member of the
auxiliary staff.
On
11 January Nurse Kathleen Walker stated that the work of the ward should be
undertaken by three teams. Nurse
Lindsay Walker would work with Nancy Cassidy and Nurse Banks would work with
auxiliary nurse Bow and she would work on her own. Each team would have eight patients and
amongst the patients for whom Nurse Kathleen Walker was to be responsible was
Mrs Pullar.
Nurse
Lindsay Walker protested at this proposal.
She pointed out that as there were five nursing members of staff this
figure could not be divided into three teams.
She was unfamiliar with the new system having never been involved in it
earlier and she considered that the previous system whereby all five would be
responsible for the twenty-four patients should apply.
Nurse
Kathleen Walker indicated that the new trial system had been introduced and
would apply that day and that she would work without an auxiliary, each other
team having a staff nurse and an auxiliary responsible for eight patients.
According
to Nancy Cassidy (and Nurse Kathleen Walker was not in a position to contradict
this) Miss Cassidy offered to carry out the blood sugar readings for Kathleen
Walker's patients but Kathleen Walker indicated to her that she should keep to
her own teamwork. Kathleen Walker has
no recollection of this conversation but accepts that it could have
happened. I believe that it did occur
and that as a result auxiliary nurse Cassidy did not carry out the blood
glucose reading on Mrs Pullar before lunch and in fact no such reading was
undertaken.
This
was a fundamental and vital failure.
Had it been done, as was required, then I am satisfied from the evidence
which I heard and, in particular, from the evidence from Dr Fisher, that the
deterioration in Mrs Pullar's condition would have been apparent and remedial
steps could have been taken which might have saved her life.
Staff
Nurse Cassidy indicated that she recollected that Mrs Pullar had not had her
breakfast and she had to give it to her.
Because of her medical condition Mrs Pullar did require to be assisted
in relation to feeding and this is a task which would have been undertaken
either by the nursing staff responsible for Mrs Pullar or by any other member
of staff who was available.
It
is unclear why Nurse Kathleen Walker was unaware that one of her patients, Mrs
Pullar, had not taken her breakfast and it is unclear whether she asked Nurse
Cassidy to do this or whether Nurse Cassidy noticed that the patient had not
had her food and spontaneously undertook the task of feeding her.
The
circumstances of Mrs Pullar's breakfast are not directly relevant to her death
but may possibly indicate that things were not as well organised within the
ward as they should have been.
Kathleen
Walker, as the nurse responsible for Mrs Pullar, knew that she required an
insulin injection before she ate at breakfast time and she therefore referred
to the diabetic chart.
She
would have observed that no attempt had been made to obtain medical
authorisation for the doses given on Saturday or Friday by Nurse Thomson. She advised me that
she did not look to the original entry by Dr Drury at the top of the page nor
did she have regard to the drug cardex in proceeding with the insulin
injection.
Tragically,
she misread the entry for Saturday morning (which is immediately above that
which she was about to enter for Sunday morning) and instead of giving 4 units
she gave 40 units.
She
did not have this dosage checked by another nurse as would have been proper and
appropriate practice as spoken to by Sister Ewart and by the nursing expert,
Mrs Gayle Richard, who gave impressive independent evidence at the end of the
Inquiry.
Nurse
Kathleen Walker did not have the drug prescribed by a doctor nor did she at any
point have a doctor check the dosage which she had given.
There
can be little doubt that had she asked a doctor to either authorise the insulin
dosage which she was giving or alternatively had asked the doctor to authorise
in retrospect the prescription then Mrs Pullar's life would probably have been
saved.
Any
doctor, knowing Mrs Pullar's condition, would have realised that while forty
units can be an acceptable dosage for
certain diabetic patients, it was potentially fatal for a patient with the
renal problems which Mrs Pullar had. No doctor had one
been asked to authorise the insulin dosage would have authorised forty units.
Even
if Staff Nurse Kathleen Walker had given the incorrect dosage a doctor could
have endeavoured to reverse the effects if made aware of the error.
Tragically,
no doctor ever saw what Kathleen Walker had written until Mrs Pullar's
condition was such that it was impossible to save her life, and as no other
nurse saw the entry which Kathleen Walker made until it was too late and she
did not check the dosage with any other nurse at the time Mrs Pullar received
ten times the appropriate dose of insulin before breakfast.
Nurse
Kathleen Walker remained the senior nurse in the ward for the remainder of the
day but Staff Nurse Banks finished her duty at the end of her shift in the
early afternoon. This meant that the
ward now had two nurses, Nurse Kathleen Walker and Nurse Lindsay Walker on duty.
Nurse
Kathleen Walker therefore decided that the nursing care should be undertaken by
two teams each to be responsible for twelve patients. She advised nurse Lindsay Walker that she
(Kathleen Walker) would take over the care of all of nurse Banks' patients and
retain four of the patients she had had care of in the morning and the
remaining patients (which included Mrs Pullar) would pass into the care of
nurse Lindsay Walker. Accordingly,
from the time that the nurses returned from their own lunch (around
There
was a dispute in the evidence between whether Mrs Pullar had had her lunch or
not. Kathleen Walker gave evidence that
she had given Mrs Pullar her soup and sweet but that she had not had her main
course.
Mrs
Pullar's daughter, in her evidence, stated that she had been told by one of the
other patients when she had arrived at visiting time that her mother was
"stubborn" because she would not eat her lunch. Nurse Lindsay Walker also stated that she
had been told by a patient that Mrs Pullar had not had any lunch.
There
was no direct evidence that Mrs Pullar did not have some lunch. The recollection of Mrs Natalie Martin (Mrs
Pullar's daughter) that a comment had been made about her mother's lunch could
be consistent with nurse Kathleen Walker's evidence
that Mrs Pullar did not have her main course. I am not prepared to make a finding that
nurse Kathleen Walker did not give Mrs Pullar lunch.
For
any diabetic patient it is essential to know what they have eaten and when so
that their blood glucose level can remain balanced. It is therefore inconceivable that an
attempt was not made to feed Mrs Pullar and I have therefore concluded that she
did have soup and sweet at lunchtime.
From
nurse Kathleen Walker's evidence it is apparent that
she saw no sign of any particular problem with Mrs Pullar at this time although
there had been evidence (which I shall refer later) that Mrs Pullar had been
clammy in the course of the morning.
The
significance of my acceptance that Nurse Kathleen Walker did provide lunch for
Mrs Pullar exposes a further flaw in the nursing procedure which existed. Had Kathleen Walker checked the diabetic
chart she would have found that no blood glucose reading had been taken
pre-lunch. As I have indicated, had
this been done, it would undoubtedly have shown that Mrs Pullar's level had
been affected by the wrong dosage given to her earlier by Kathleen Walker. Any nurse before feeding an insulin
dependent patient should have checked the blood sugar reading before commencing
feeding the patient. One of the main
reasons why these readings were ordered pre- each meal was to enable any
adjustment in the feeding or alternatively in the insulin dosage to be made as
soon as possible.
Instead,
it appears from her evidence, that nurse Kathleen
Walker proceeded to give Mrs Pullar soup and sweet for lunch without checking
the chart to see her blood glucose reading.
Earlier
in the morning, around
It
was suggested that this might have been the initial signs of Mrs Pullar's
condition changing because of the overdose and clearly if this was so then this
initial sign had not been followed up.
If indeed Mrs Pullar's condition had changed that morning by the time
she was being bathed
then a nurse of Kathleen Walker's experience should have reacted and
investigated the matter further.
I
am however not prepared to find that Mrs Pullar's condition at around
There
was no evidence that Mrs Pullar was sweating at the time that Kathleen Walker
saw her to give her lunch around
Nurse
Lindsay Walker, who had had no contact with Mrs Pullar during the morning but
had been present at the initial handover from the nightstaff and therefore knew
that her patient was diabetic and suffering from renal failure, did a general
walk round of her patients. This was
around
She
noted that the patient was lying in bed moaning. She did not touch her, test her or take her
temperature etc. but she did believe that she was not sweaty.
Because
of Mrs Pullar's condition she asked Nurse Kathleen Walker to look at the
patient but Kathleen Walker indicated that, in her opinion, there was not cause
for concern.
Lindsay
Walker disagreed and decided to contact the Junior House Officer. She however did not return to the patient
nor make any checks as to her condition thereafter. While she believed that she was quite
drowsy and her condition was such that she felt a doctor should be informed she
did not check the records (whereby she would have found that the blood glucose
reading pre-lunch had not taken place) nor did she carry out any physical
examination of Mrs Pullar or make any assessment other than a visual one.
Lindsay
Walker in her evidence indicated that it had failed to "click" with her that
Mrs Pullar was a diabetic. Even if
she had forgotten that this patient was a diabetic (the fact she knew from the
handover in the morning) it is difficult to understand why she failed to
provide any nursing care for Mrs Pullar prior to the arrival of the
doctor.
Lindsay
Walker indicated that she had telephoned for a junior house doctor between 2.00
and
Dr
Andrew Fyfe, who was a junior house doctor at the time, gave evidence that he
had responded to the call within five minutes. It is clear from all the evidence however
that he did not arrive at the ward until at least
It
is regrettable that during that time gap Nurse Lindsay Walker did not return to
Mrs Pullar and monitor her condition and perhaps carry out further
assessments. Had she been aware that Mrs Pullar's
condition was deteriorating she could have made an emergency call for a doctor
and remedial steps could have been instituted earlier.
It
is impossible to say at what point Mrs Pullar's condition
deteriorated to the extent that nothing further could have been done but it was
clear from Dr Fisher's evidence and from that of the other medical witnesses
that an insulin overdose can be reversed and the affects compensated for
provided the situation is found early enough.
Around
3.00 pm visiting started in the ward and two of Mrs Pullar's daughters
arrived. When they arrived at their
mother's bed she did not appear to be orientated and was pale, cold and
unresponsive. They were told by other
patients that their mother had been sweating and grinding her teeth but there
was no nursing evidence that this had taken place.
Mrs
Martin went out to speak to the nurses indicating that they were worried but
she was informed that Mrs Pullar had been checked around
There
was a dispute between the nurses and Mrs Pullar's daughters as to exactly what
had happened and what the nursing response was. Both daughters were clear that Mrs Martin
had gone out, had spent some time apparently at the nursing station and had
returned with the information that Mrs Pullar had been poor all day and that it
was only thereafter when Miss Moira Pullar had gone out and told the nurses
that there was no pulse that there had been any reaction.
Both
Nurse Walkers were clear that Mrs Martin was in the process of describing her
concerns about her mother when her sister had emerged from the ward indicating
that there was no pulse and that they had reacted thereafter.
In
the confusion of a crisis it is always possible for recollections to become
confused. Clearly Mrs Pullar's
daughters were very upset and that upset grew greater when they realised that
their mother's condition was such that it could not be reversed. It may be that Mrs Martin did not indicate
to the nurses as forcibly as she did in her evidence how great her concern was
at her mother's condition but I am satisfied from what she told me and from the
evidence I heard from Miss Pullar that they were both sufficiently concerned by
the time that Mrs Martin left to speak to the nurses that the nurses should
have reacted and gone to see Mrs Pullar then rather than await until Miss
Pullar emerged from the ward indicating that she could find no pulse. I preferred the evidence of Mrs Martin and
Miss Pullar that Mrs Martin returned to the ward before Miss Pullar went out
and indicated there was no pulse as opposed to the evidence of the nurses that
Mrs Martin had not moved from the nursing station before her sister stated that
there was no pulse and the nurses reacted.
It
is impossible to tell from the evidence which was led before me whether that
couple of minutes (the sisters estimated it at two or three) would have made
any difference. I was not given any
evidence as to how long the supply of oxygen to Mrs Pullar's brain had been
compromised and at what point it might have been possible to resuscitate
her. It is accordingly speculation as
to whether the failure of the nurses to respond to Mrs Martin is a relevant
factor.
Once
the emergency services had been sent for (Dr Fyfe coincidentally arrived on the
ward) everything possible was done for Mrs Pullar. She was ultimately moved to ward one where
she was nursed with care and where she received every
possible medical assistance available.
Unfortunately her condition was such that it was impossible to reverse
the coma into which she had slipped and at
Miss
Laura Pullar, in her final address to me, asked me to record that Mrs Pullar's
family were grateful for the care and support which their mother received in
ward one and that they accepted that no blame or criticism could or should be
made in relation to their mother's treatment there nor for the efforts made by
the nurses and doctors within ward fourteen once the crash team had been sent
for and the emergency procedure put into effect.
In
her final speech Miss Green invited me to make a determination that Mrs Pullar
had died on
Miss Laura Pullar and Mr Crerar, on behalf of the Hospital, indicated that they were in agreement.
Miss
Green invited me to consider and rule on certain matters and to include
particular points in my determination.
She
pointed out that it was clear from the notes that Kathleen Walker had been
involved in the drawing up of 4 units of insulin for Mrs Pullar on the Saturday
night and she suggested that it was therefore odd that she should have chosen
to give 40 units on the Sunday morning.
Kathleen Walker had no recollection of being involved in the insulin
dose check on the Saturday night and given that she was on the Sunday morning
involved in running a busy ward I do not consider that it would be fair to
criticise her for her failure to recollect a particular dosage which she had
checked (but not given as this was done by Nurse Thomson) on the previous
evening.
Where
I consider that Miss Green is correct in her criticism of Kathleen Walker (and
Miss Laura Pullar supported this) is in her failure to have the dose of insulin
which she was giving to Mrs Pullar on the Sunday morning checked by another nurse. It was accepted and normal practice for two
nurses to check the dose and Kathleen Walker failed to do this. She also failed to have the prescription
for the insulin signed by a doctor. I
was informed that because of the need to give insulin at a particular time (ie
before a meal) it is sometimes not possible to have a doctor present in time
but it was accepted that proper normal procedure would involve the nurse at the
earliest possible opportunity thereafter having the entry checked and
countersigned by a doctor and this, Kathleen Walker did not do. Sister Ewart was clear that the correct
and authorised practice had not been followed.
It is apparent from the records that this had not been done on any occasion in the ward in relation to Mrs Pullar. Neither on the Friday nor on the Saturday had any attempt been made to show the record to a doctor or to have a medical countersignature. Mr Crerar argued that this did not necessarily indicate a failure in the system applying in the ward but I do not agree. I consider that Miss Laura Pullar and Miss Green are justified in inviting me to note this as a failure in the system operating within ward fourteen at that time.
I
believe that it can fairly be stated that had the system been properly
operated, that the nature of Nurse Thomson's handwriting would have been
clarified by the doctor countersigning and that, had a doctor prescribed the
insulin on the Sunday morning, he or she would clearly have indicated 4 units
thereby avoiding the mistake.
Furthermore,
had the 40 units been given in error the doctor would have
realised this and instituted remedial measures forthwith.
I
have therefore concluded that there was a failure in the system for recording
and prescribing insulin within ward fourteen and that this must be recorded as
a defect in a
system of working which contributed to Mrs Pullar's death.
The
cause of Kathleen Walker's mistake was the handwriting of Nurse Thomson. It is fundamental that figures in relation
to drugs are written clearly and cannot be readily misinterpreted. It is exceptionally easy to understand how
Kathleen Walker made the error which she did.
The vast majority of people seeing the entry to which she referred
immediately above the one which she was about to enter
would have read that as 40 and not 4u.
It is therefore appropriate that Nurse Thomson's involvement is recorded
as a factor in Mrs Pullar's death.
Had she written the figures clearly for Saturday morning (and her
entries for other times are little better) then this tragedy would not have
happened.
Kathleen
Walker however cannot escape total responsibility in this connection. If she had looked to the top of the page
where Dr Drury's entry was she would have seen 4u written clearly. Had she chosen to refer to the
prescription chart she would also have seen the entry clearly as 4u. She did neither and thereby lost an
opportunity to give the correct dose to Mrs Pullar.
As
I have indicated, for some reason and by somebody whose identity was not
revealed, the entry on the prescription chart was subsequently altered. As Kathleen Walker was clear that she had
not referred to the prescription chart in making her decision it is not
relevant to Mrs Pullar's death and it must therefore remain as another mystery.
It
cannot however be emphasised sufficiently that for any person to deliberately
tamper with medical or nursing records is exceptionally grave. While in this case it was not relevant were such a practice ever to occur again it could
result in the perversion of justice. I
would hope that the Hospital Authorities will make it crystal clear to all
their staff the consequences of tampering with records and will endeavour to
ensure that this never occurs again.
Miss
Green suggested that the use of the letter "u" to denote units had perhaps
caused confusion. The diabetic chart
used in the hospital has subsequently been altered so that the word "units" is
already preprinted before each entry, accordingly, there would be no need in
the future to write the letter "u". She suggested that in fact there had been
no need to write the letter at all by either Dr Drury or by any of the nurses
as the column was headed with the word "units."
I
am not prepared to make any criticism of Dr Drury or of the nurses for using
the letter "u." I consider that the
new design is an improvement because the word "units" is specifically
preprinted for each entry and that this will, hopefully, avoid the necessity of
anybody writing the word or shorthanding it to "u." In January 2004 it is perfectly
understandable for a doctor or a nurse to use the letter "u" to indicate units
and I do not feel that Dr Drury can be faulted for doing this even if the
column had a heading on it. In any
event for the reasons which I have given the entry on the prescription chart
(Page 86) would still require to have "u" or "units" written.
While
I accept that the new form is an improvement I am not prepared to say that the
form which existed in January 2004 was defective or inadequate. The basic mistake, which led to this
tragedy, was the poor handwriting of Nurse Thomson and the failure of Kathleen
Walker to have the dosage checked by another nurse and countersigned by a
doctor.
No
handwriting would change no matter which form was being used and the error by
Kathleen Walker in failing to have her dosage checked and countersigned would
have arisen whichever form was in place.
Miss
Green continued with her submissions by suggesting that I made a finding under
subsection (d) that there had been no adequate working routine in place on ward
fourteen on
Miss
Laura Pullar supported this contention supplementing it by suggesting that
there was poor communication between the nurses and the doctors which had
resulted in no check being made of the diabetic chart by a doctor after Dr
Drury's initial entry.
She
also pointed out that there did not appear to be an efficient system whereby
the junior house doctor could be sent for.
Lindsay Walker contended that she had sent for the junior house doctor
to check Mrs Pullar between 2.00 and 2.30 pm and it was accepted that Dr Fyfe
had not arrived till at least 3.20 pm but indicated that he had only received
the message five minutes before.
Dealing
with the latter point first I was unclear from the evidence which I heard how
urgent Lindsay Walker had regarded the call for the junior house officer when
she made it. If it was indeed urgent
it is difficult to understand why Dr Fyfe was not summoned speedily but it is
equally difficult to understand why Lindsay Walker did not go back to the
patient to check her condition and to monitor it. If the call was not to be an urgent one it
is perhaps understandable why Dr Fyfe did not receive the message as quickly as
he could have. Without evidence as to
how the call system operated in Monklands, I cannot include any finding in this
connection in my determination.
I
do however consider that there is substance in the point made by Miss Green and
by Miss Pullar that there does appear to have been some confusion within the
ward as to who was to be in charge and how duties were to be delegated.
It
is apparent from the evidence given by Sister Ewart that the person who should
have been in charge was Kathleen Walker.
She was the most experienced nurse on duty and it was correct that she
should accept responsibility for the ward.
Where however criticism may be made is that she was endeavouring to
impose the system which had been initiated earlier in the week on members of
staff to whom no explanation had been given and who were unaware of the
change. It is apparent that neither Nurse Lindsay Walker or Nurse Cassidy were aware of
the affects of the new regime whereby patients were nursed by teams as opposed
to any nurse available. While Nurse
Cassidy had been part of one of two teams on the 10th Nurse Lindsay
Walker had no experience of this new system and neither had any experience
using three teams particularly when one of the teams was lacking an auxiliary nurse.
I
believe that criticism can and should be made of a system which is introduced
without all the members of staff fully understanding it and where it is
possible for there to be a misconception as to who is to undertake particular
tasks.
It
was clear from the evidence that there was a basic misunderstanding as to who
should undertake the blood sugar readings for the ward. Kathleen Walker appeared to consider that
this was being dealt with by the auxiliary whereas Nurse Cassidy indicated that
she had specifically asked and had been told that each team would do its
own.
Something
as fundamental as the taking of an essential reading for which nutrition and
insulin levels would depend should not have been left as a source of confusion.
Sister
Ewart, in her evidence, indicated that the system which she had intended should
exist would involve each team's auxiliary being responsible for the blood
sugars of that team's patients alone.
Kathleen Walker appeared to consider that the former system whereby one
auxiliary undertook this task for the ward still prevailed.
Miss
Green suggested that there should in fact be formal meetings and discussions
with the staff before any changes implemented but I agree with Mr Crerar's view
that this would be impracticable. I
do however consider that it is important where fundamental changes in practice
are being tried by senior management that all those involved are aware of
exactly what the new system is and what changes it involves in their work
pattern.
Mr
Crerar, on behalf of the Hospital and the staff, accepted that some
responsibility for Mrs Pullar's death had to remain with Kathleen Walker. She had failed to follow the accepted
practice and protocol of having insulin
checked and she had failed (as had Nurse Thomson) to follow the practice which
Sister Ewart indicated should have been in effect whereby insulin was
prescribed by a doctor and a doctor's signature was necessary.
Mr
Crerar however argued that I should not make a finding in relation to Nurse
Thomson's handwriting. He argued that
it was not sufficiently relevant in that had Nurse Kathleen Walker carried out
the appropriate checks and in particular if she had looked back to the entry by
Dr Drury or had looked at the prescription chart (page 86) she would have seen
the correct dosage. I do not accept
this. There is a responsibility on
all those involved in writing up medication and test findings to ensure that
their figures are sufficiently clear that they are not capable of
misinterpretation. It is a
fundamental element of medical and nursing care that records are kept so that
others can refer to them and obtain correct information thereby. Nurse Thomson's figures were so poorly written
that most people would have misinterpreted them and Kathleen Walker did.
Mr
Crerar also argued that I should not criticise Nurse Lindsay Walker. He correctly pointed out that she had
taken the trouble to visit Mrs Pullar when she had taken over her care and that
she had been sufficiently concerned that she had spoken to Kathleen Walker who
had firstly overall responsibility for the ward and had also been nursing Mrs
Pullar during the morning.
Lindsay
Walker had furthermore sent for a doctor despite the view of Kathleen Walker
that this was not necessary. Mr
Crerar therefore argued that it would be unreasonable to criticise Lindsay
Walker's actions.
I
accept that Lindsay Walker did take the trouble to see Mrs Pullar and was sufficiently
concerned to raise the matter with Kathleen Walker and also to send for the
doctor. What however I cannot find an
adequate explanation for is her failure to return to Mrs Pullar and examine her
thoroughly. The nursing expert, Mrs
Gayle Richards, criticised her for failing to take steps to assess the
patient. She did not return to see if
Mrs Pullar's condition had altered, she did not touch her to see if there were signs of clamminess
and she did not carry out any check to see if her level of consciousness had
altered. I believe that the evidence established
that Nurse Lindsay Walker should have, if she was so concerned, returned to see
the patient and maintained observations on her. She failed in this although she appreciated
that the doctor had not responded to her call and by that failure she allowed
time which might have proved valuable to lapse.
It
is impossible to tell at what point Mrs Pullar's condition deteriorated to the
extent that the hospital staff were unable to reverse her decline. Clearly this was the position by the time
the crash team arrived in the ward but both Dr Fisher and Dr Nick Kennedy, the
consultant involved in the emergency receiving unit, were clear in their
evidence that it is possible to reverse an overdose of insulin if the matter is
dealt with timeously.
I have reached the conclusion that Nurse Lindsay Walker's failure to properly assess Mrs Pullar after she became concerned about her may have delayed time when emergency medical steps could have been taken. It is however impossible to state that Mrs Pullar's death would have been avoided had Lindsay Walker returned to the ward during the gap before visiting hour when she was awaiting the junior house officer. It is therefore appropriate to include this finding under subsection (e) - any other facts relevant to the circumstances of the death as opposed to subsection (c) which requires me to make a finding that a reasonable precaution was not followed whereby the death "might have been avoided."
I accordingly find and determine that Mrs Moira Pullar (date
of birth 20.07.41) who
had been a patient in Carrickstone House Care
Home, Cumbernauld and whose home address was 19 Abbotsford Court,
Cumbernauld died in ward One of
Monklands District General Hospital, Airdrie, at 0015 hours on 17 January 2004
and that the cause of death was bronchial pneumonia due to hypoxic and
hypoglycaemic brain damage due to cardiac respiratory arrest due to an insulin excess. A contributory factor was Mrs Pullar's
diabetes mellitus and diabetic nephropathy.
In terms of
Section 6(1)(c) a reasonable precaution whereby the death might
have been avoided would have been if Nurse Kathleen Walker had checked the
dosage of insulin which she gave Mrs Pullar on the morning of Sunday 11 January
with another nurse in accordance with normal protocol and if the prescription
had been authorised or checked by a doctor.
In terms of Section 6(1)(d) there
was a defect in the system of nursing whereby insulin doses were given without
a doctor's prescription or supervision.
There was also a defect in the system of nursing on 11 January whereby
there was a lack of clarity as to who was to be responsible for the taking of blood
sugar levels for patients requiring these readings whereby no reading was taken
for Mrs Pullar pre-lunch. These two
defects in the system of working contributed to the factors which led to her
death.
In terms of Section 6(1)(e) the facts which are relevant to the
circumstances of Mrs Pullar's death include the confusion within the nursing
staff of Ward 14 on