'You don't write prescription when the patient is dead'

Chris Donegan • Published 29 Oct 2009 09:00 0 Comments

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Record keeping at the Erne Hospital at the time of Lucy Crawford's death was "deplorable and inexcuable," according to an expert medical witness.

Dr. Dewi Evans, a retired consultant paediatrician with 30 years experience, investigated the events that led to the fatal collapse of the 17-month-old baby girl in the hospital's paediatric ward almost 10 years ago.

His findings form the basis of charges against his fellow paediatrician, Dr. Jarleth O'Donohoe, who was responsible for Lucy's care and stands accused by the General Medical Council of serious professional misconduct.

Lucy, daughter of Neville and Mae Crawford, from Letterbreen, had been sick and as a result of losing fluid through vomiting became moderately dehydrated. She was admitted to the Erne for observation. She was killed when she was put on an intravenous drip to replace the fluids she had lost and was given too much of the wrong type of solution.

Nurse Bridget Swift, who put up the drip, said she did what Dr. O'Donohoe told her.

He never wrote it down.

Dr. Evans told a GMC Fitness to Practice Panel in Manchester: "The record keeping is dreadful. It is deplorable and inexcusable.

"It is drummed into us time and time again by the medical defence unions. The note keeping here is shocking. The medical record is poor.

"The fluid chart record is also incomplete and that is very worrying and very disturbing. Each patient who comes into hospital deserves a care plan," he stated.

He added that the nurse was responsible for ensuring that the instruction left by the medical officer (in this case Dr. O'Donohoe) was carried out to the letter.

And Dr. Evans added: "This was not a life or death emergency in my opinion at the time of admittance."

Dr. O' Donohoe has already admitted failing to monitor or check the fluid regime that contributed to the tragedy, but has disputed Nurse Swift's recollection that he verbally instructed her to give 100mls of .18 per cent saline solution every hour until the little girl passed urine.

She stood by her evidence when questioned by the panel via a video link - denying that the doctor had instructed her to give a single bolus of 100mls of .9 per cent saline solution to Lucy over an hour followed by 30mls per hour of .18 solution.

Dr. Evans added: "The trouble with verbal instruction is people can mishear them and you get yourself into difficulties, so you write it down or get the junior doctor to write it down. In an emergency you write it down yourself - this is why we are always advised to do that."

Dr. Evans said that the fluid given was the wrong type and should have been normal 0.9 saline solution to prevent the liquid being absorbed so readily into the brain cells.

Staff at the Erne failed to properly manage her fluid level and she died from the resulting swelling of her brain.

Dr Evans said: "I would have given her 200mls of normal saline. She had too much fluid and the wrong fluid. It was the double whammy of having fluid that was too dilute and too high that led to the subsequent events."

He said that if she had stayed at home for some reason she would have come into the hospital the following day with severe dehydration.

Dr. O'Donohoe's barrister, Alison Foster, suggested that the record written by Dr. O'Donohoe two days after Lucy's death of what he recollected prescribing would have been the correct treatment.

"You don't write up your prescription when the patient is dead," protested Dr. Evans.

He described the whole fluid management plan as "well below standard".

He stated: "This girl crashed on the watch of a fellow paediatrician."

He said there were warning signs from the readings taken by medical staff including one which was a "big red flag that if you are not careful your patient will develop shock".

He was also critical of Nurse Bridget Swift for not confronting Dr. O'Donohoe and saying: "You haven't completed this fluid chart, what do you want?"

He said it was a team effort and she should have been assertive enough to question the doctor.

System's disaster

The nurse in charge of the Children's Ward at the Erne Hospital the night baby Lucy Crawford died has admitted that the system of managing patient care at the time could "potentially lead to disaster".

Nurse Sally McManus was one of several nurses giving evidence against Dr. Jarleth O'Donohoe, the consultant paediatrician responsible for looking after the little girl the night she was given a fatal overdose of the wrong type of fluid.

The GMC(General Medical Council), whose job it is to protect the public by ensuring doctors maintain proper standards, is accusing Dr. O'Donohoe of serious professional misconduct in his treatment of Lucy.

Giving evidence via video link to its Fitness to Practice hearing in Manchester, Nurse McManus agreed that the system in place at the Erne Hospital could "potentially lead to disaster."

Accompanied by the Western Trust's head of litigation services and Mary McKenna, head of paediatrics, Nurse McManus told the hearing there was no protocol in place at that time to properly account for the way care was organised.

Dr. O'Donohoe's barrister, Alison Foster, asked nurse McManus: "That is potentially disastrous? This was a system that could potentially lead to disaster?"

Nurse McManus, who trained at London's renowned Great Ormonde Street Hospital, said: "Yes, I agree with you. That system has now changed."

Ms Foster submitted that when Dr. O'Donohoe arrived at the Erne three years prior to Lucy's death there was nothing in place and it was him who developed forms for recording patient notes. He was also responsible for educating staff on making notes and carried out a monthly check.

She said he also bought reference material after the Western Health and Social Care Trust refused to pay for it.

She argued that the reason for the disciplinary hearing was that Dr. O'Donohoe failed to make a note of the treatment he prescribed.

"This failure was but one in a system failure," she submitted.

"Chances are, we wouldn't be here if that note had been made," added Ms Foster.

This article appeared in Impartial Reporter 29 Oct 09

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