1. Clinical Governance Acute Care Unit 18/05/2009

2. Mrs. SB Admitted 02/04/09

3. 56, admitted at 07.23 from Nursing Home Diarrhoea, drowsiness, fever Dense left hemiplegia and dysarthria following haemorrhagic stroke in 1995 Function: –Immobile –Transfers with hoist –Needs help with washing and dressing –Feeds herself –Communicates – no mention of cognitive problems –Long-term urinary catheter ? continent of faeces DVT left leg 2006 Type 2 diabetes and Hypertension Chronic renal impairment and anaemia Recurrent UTIs (Allergic to Penicillin)

4. Diagnosis Sepsis – likely source: –catheter-associated UTI IV fluids IV sliding scale insulin IV ciprofloxacin and IV gentamicin given (one dose each at 12.45 on 02/04) Catheter changed

5. Progress Continued to have profuse, offensive diarrhoea CSU and stool specimen sent Remained pyrexial ~ 38 Antibiotics changed to oral, but not given: “5. = patient nil by mouth” Obs. at 18.00 on 03/04: HR 113, BP 140/75, urine output 20 ml/hour

6. Cardiac Arrest 20.20 on 03/04 Became unresponsive mid-conversation EMD, briefly VT then asystole Death confirmed at 20.45

7. Microbiology Urine – Pseudomonas and Enterococcus Stool – Campylobacter Coroner and Health Protection Agency notified

8. Critique Delay of > 5 hours in giving first doses of antibiotics Only 1 dose of antibiotics received by patient Discussion in notes about changing back to IV – no action taken

9. Mr. MG Admitted 04/04/09

10. 57, admitted at 06.22, from own home Increasingly painful, swollen legs Fluid leaking from skin 2 courses of antibiotics in past 3 months Dressings changed by Practice Nurse once / week Type 2 diabetes and ischaemic heart disease (MI in 2000) History of heart failure and AF (now in sinus rhythm) Obesity

11. Medication Nifedipine10 mgtds Frusemide80 mg o.d. Frusemide40 mg lunchtime Digoxin250 μg o.d. Carvedilol3.125 mgo.d. Metformin1 gb.d. Rosiglitazone4 mgb.d.

12. On Examination Apyrexial HR 105 BP 117/87 Sat. 97% on air BM 11 GCS 15/15 Heart sounds:NAD Chest:NAD Abdomen:NAD Legs: –Oedema to knees –Erythematous calves –Areas of broken skin –2 ulcers on left calf (not deep) –Pedal pulses not palpable

13. Investigations ECG – Sinus rhythm, rate 112, bifascicular block, poor R-wave progression CXR – Cardiomegaly, upper lobe venous distension Hb12.1 WBC8.7 Neut.6.55 Plt.254 MCV84.2 INR1.6 Na126 K5.5 Urea13.9(6.7) Creat.145(105) Bil.37 Alb.29 CRP8.6

14. Management Analgesia IV Tazocin – first dose given 2 p.m. IV fluids - had total of 1 litre Digoxin stopped, frusemide dose reduced Surgical opinion: –Pulses present on Doppler –?DVT Echocardiogram / renal tract ultrasound

15. Cardiac Arrest 17.00 on 04/04/09 VF then asystole Death confirmed 17.20 Referred to coroner

16. Cause of death 1.a.Left ventricular failure 1.b.Ischaemic heart disease 2.Hypertension, diabetes, congestive cardiac failure

17. Critique Diuretics were not given IV fluids were given Delay in giving first dose of antibiotics (? relevant) Appropriateness of Tazocin (or any antibiotic) Not prescribed prophylactic Clexane

18. Mr. RR Admitted 18/04/09

19. 59, admitted at 07.05 from home Lives with wife Breathlessness and haemoptysis Known to oncologists at Stoke Mandeville: –Ca bladder diagnosed 18 months ago –Resected and ileal conduit fashioned –Adjuvant chemotherapy – 6 months –3 weeks ago – cerebellar metastases –Completed 5 # DXT 4 days ago –On dexamethasone 8 mg o.d. DVT left leg November ’08 – treated with Tinzaparin (stopped 3 weeks ago)

20. On Examination Apyrexial HR155 BP125/88 RR24 Sat.92% on 15L BM 25.4 GCS 15/15 Heart sounds:NAD Chest:NAD Abdomen: distended, lower laparotomy scar, iliostomy ECG – 136, sinus tachycardia

22. Bloods Hb13.6 WBC10.1 Plt.127 INR1.1 D-dimer>1000 Na134 pH 7.237 K4.9pO 2 10.9 U13.0pCO 2 2.23 Cr.156HCO 3 6.9 Bil28BE -19.5 Alb28Sat. 93.7% CRP283.8

23. Treatment IV fluids (received 3 litres in 12 hours) IV sliding scale insulin CT-PA requested – arranged for that evening Observations at 17.45: –T =37.8 –HR 137 –BP105/77 –RR32 –Sat.89% on 15L

24. Course Blood pressure continued to drop, despite fluid resuscitation Discussed with ITU – not for intubation Reteplase 10 units IV given – no improvement Cardiac arrest ~ 18.15 Death confirmed 18.27

25. Critique No antibiotics given despite evident sepsis Not given Tinzaparin despite suspicion of PE

26. Discussion Common Theme: Should any of these patients have been subjected to a resuscitation attempt?