When Dad was taken to Royal Blackburn hospital A&E unit with a blood rash under the skin of his arms and legs, it was suggested to the family that he was “suffering from neglect”
Using a snapshot of dad’s GP records, his “working diagnosis” was written to be: ?underlying malignancy – appears cachectic (read: muscle wastage/severe weight loss) this was without any test results being returned.
Royal Blackburn’s staff deemed dad to be suffering from serious weight loss, after comparing his weight on admission to his weight in GP records (this was in September 2014).
Dad’s last GP weight record was from 2005 and clearly documented as such, some 9 years earlier!
SIRS = if 2 or more of 4 criteria are met –
Dad’s presenting symptoms met two of the four criteria for SIRS – The SIRS/Sepsis care bundle was not used.
Sepsis = SIRS + new infection –
Dad presented with a new blood rash to his arms and legs (read: infection).
The SIRS/Sepsis care bundle was not used.
Severe sepsis = sepsis + organ dysf –
Abnormal LFTs (Liver function tests) – Dad’s admission form stated “deranged LFTs”
The SIRS/Sepsis care bundle was not used.
In our March 2015 face to face meeting (recorded), Royal Blackburn’s senior matron, Nicola Robinson claimed, “MAU have only a limited time to assess patients, I’ll look into why the SIRS/Sepsis care bundle was not looked at and also feed it back to the department”
This was placed on the A4 action plan for information to be given to the family – over a year later, we are still waiting!
Blood sugar/glucose – Diabetes?
Paramedics recorded a blood sugar level of 19.6 before taking dad to Royal Blackburn hospital.
Senior matron Nicola Robinson claims (on record) that this will have been retested (as it’s standard practice) and justifies it as being retested after dad had a fall whilst on ward C1.
Dad was admitted and tested by paramedics on 8th September 2014.
Dad was tested for the first time by Royal Blackburn staff after his fall in the early hours, on the 21st September 2014, scoring a blood sugar level of 10, after not eating for over 8 hours.
According to Royal Blackburn’s senior matron Nicola Robinson, “I will look into this and come back to you” (read: A4 action plan – March 2015 face to face meeting)
At our follow up meeting in August 2015, Nicola Robinson said this, “I write the diabetic criteria for Royal Blackburn and I can categorically say that your dad did not have diabetes!”
What about your promised investigation into why dad was not retested?
What about all the diabetic symptoms dad had?
What about the complete lack of treatment dad received for any of these symptoms?
How can Nicola Robinson be fit to make this assumption when Royal Blackburn hospital staff had failed to retest dad?
Who ordered that the standard practice of retesting blood sugars should not be done? (Ward consultant, on ward rounds, talking to ward sister?)
Not a word from Nicola Robinson, senior matron at Royal Blackburn hospital!
It gets worse…
On the 12th and 15th September, while dad was in hospital, the dietician requested “enteral feeding bloods” to be done. They were never done.
Enteral feeding is via a tube into the stomach, as dad was said to be terminally cachexic (muscle wastage) and his MUST score recorded as 5 (showing he needed enteral feeding) this is very disturbing.
What follows is beyond belief.
Dad had most of the symptoms of type 1 diabetes (as listed by diabetes UK).
Dad had a blockage in his pancreas (the insulin producing organ).
Dad never had his high (recorded) blood sugar levels retested in Royal Blackburn hospital (as is standard practice).
Two senior clinical staff (Dr Oliver Nicholson, radiologist at Royal Blackburn and Dr Robin Moseley of Addenbrookes hospital) had both suggested “Chronic pancreatitis”
In April 2016, Kevin McGee (Chairman of East Lancashire Health Trust – ELHT) wrote to our MP Graham Jones. On the subject of dad’s dietician requesting enteral feeding bloods to be done (while dad was in Royal Blackburn hospital) and why they failed to do them.
“On the 12th and 15th September 2014 the dietician requested enteral feeding bloods to be done to help aid nutritional monitoring. Magnesium and Phosphate were not checked, which would have given additional information, although this was not essential to his (dad’s) dietetic treatment.”
I’ve underlined “Magnesium and phosphate were not checked” as this is very significant.
Phosphate has well documented effects on magnesium absorption in the body.
Magnesium is essential for the effectiveness of insulin.
Without magnesium, the pancreas cannot secrete enough insulin, or the insulin it secretes won’t be efficient enough to control blood sugar levels, causing diabetes (as well as vascular problems).
To put it simply, if magnesium and phosphate levels were checked via enteral feeding bloods as requested by RBH’s dieticians, then diabetes (whether temporary or permanent) would have been picked up, recorded and acted upon.
Despite being asked directly by the family, Royal Blackburn and East Lancs Health Trust have offered no explanation as to why standard practice was not followed and the blood tests were not done.
More revelations from Kevin McGee (chairman) of East Lancs Health Trust, when the family asked, “What did Royal Blackburn do to manage dad’s blood glucose and why did Royal Blackburn not pass blood glucose information to dad’s GP?”;
“Ambulance recorded 19.6mmols on attendance to Royal Blackburn hospital’s emergency dept. (8th September 2014)
This should have led to further testing of glucose levels. [It did not]
The glucose level was 10mmols after (dad’s) fall (21st September 2014).
This glucose level should have been uploaded to ICE (Pathology database – which GP has access to) and did not happen.
Again, this result should have led to further investigations and monitoring around the higher than normal blood glucose levels.
Regretfully, the information was not relayed to (dad’s) GP on discharge from hospital.”
So which Royal Blackburn ward consultant (Dr Mansoor?) decided that blood glucose levels did not need testing again while on ward C1, as is best practice?
Why were the blood glucose test results not uploaded to Royal Blackburn’s ICE pathology database? (Used by GP and pathologist at post-mortem)
Why did Royal Blackburn’s senior matron, Nicola Robinson, claim (at our August 2015 face to face meeting – on record) that “your dad’s glucose was retested and within normal limits” when East Lancs Health Trust chairman Kevin McGee now concedes that dad’s blood glucose levels were showing “higher than normal levels”?
The fundamental questions we asked have never been answered by Royal Blackburn’s senior staff or East Lancs Health Trust chairman Kevin McGee;
“Why did Royal Blackburn not pass blood glucose results on to dad’s GP?”
“What did Royal Blackburn do to manage dad’s blood glucose levels?”
Put these revelations altogether and it raises very serious questions for East Lancs Health Trust and Royal Blackburn senior staff to answer.
It is very strange that while having a “working diagnosis” of “possible pancreatic cancer” standard practice blood glucose testing was not done, of the two that were done, none were recorded on to the ICE database (which would have been accessed by dad’s GP to treat his symptoms and Dr Richard Prescott – the self proclaimed “independent” pathologist that despite diagnosing dad with cancer and sitting on Royal Blackburn’s HPB MDT, failed to inform the coroner’s office – when carrying out dad’s post-mortem).
Over a year and a half and still no explanations from Royal Blackburn senior staff or the Chairman of East Lancashire Health Trust, Kevin McGee, into why best practice was not done and whom was responsible for these failings.
Enteral feeding bloods would have revealed diabetes – these were not done despite clinical staff requesting them on the ward.
Retesting of blood glucose levels would have revealed diabetes – these were not done on the ward despite being NICE guidelines and best practice.
Dad’s blood glucose result, taken after a fall in the middle of the night, was not uploaded to Royal Blackburn’s ICE (pathology database) as is standard practice.
None of dad’s blood glucose results were passed on to his GP. (Exactly the same as the results from dad’s cytology biopsy which returned “no evidence of malignancy”)
This all pails into insignificance, when the family had to witness dad having severe symptoms of diabetes and not having them treated from 8th September to 21st October 2014 when he passed away, according to his clinical need (GMC good medical practice, Hippocratic oath, NICE guidelines and East Lancs Health Trust policy).
Dad’s fall while in Royal Blackburn hospital (ward C1):
We have continued to ask why Royal Blackburn’s on call ward doctor, falsified ward records to claim that dad’s fall “was witnessed”.
The on call doctor even added an explanation of what happened despite not being present, as stated by nurses present at the time and Royal Blackburn’s senior matron, Nicola Robinson, in our face to face meeting in March 2015 (on record).
Kevin McGee (Chairman of East Lancs Health Trust) wrote to our MP Graham Jones, with a completely different question and gave an answer to that.
Kevin McGee wrote, “When did (dad) fall? Did he have a falls risk assessment pre and post fall?”
What we actually asked was,
“Why was dad’s standing and lying blood pressure not taken after his fall?
Why was the family never told?
Why did the on call doctor record that the fall was witnessed by them and then proceed to give an explanation of what happened when they were not present at the time?”
Of course, Kevin McGee’s written response fails to answer any of the family’s questions.
Best practice and NICE guidelines have a falls checklist.
It includes various things to be recorded in the event of a patient suffering a fall.
Nurses recorded that dad’s fall was NOT witnessed.
FY1 on call doctor arrived on the ward later to check on another patient and was asked by nurses to check on dad.
The FY1 doctor recorded that dad’s fall WAS witnessed by them. It even explained how it happened and what they had witnessed, completely false and misleading!
Nurses recorded that the family needed to be told of dad’s fall, this was never done.
We didn’t find out about dad’s fall in hospital until months after his death when we finally received some of his medical notes from the hospital.
Dad’s standing and lying blood pressure was to be taken and recorded, this was never done.
Royal Blackburn’s senior matron, Nicola Robinson (at our March 2015 face to face meeting) agreed (on record) that the fall couldn’t have been witnessed and promised to investigate what had been reported by the FY1 doctor at the time (via our A4 action plan).
Nicola Robinson, senior Royal Blackburn staff and East Lancs Health Trust chairman have as yet, failed to answer or address why standard practice was not followed and why dad’s written records were falsified by the FY1 doctor on call.
Royal Blackburn hospital senior staff have not followed best practice and NICE guidelines. Why not?