Case report:

“NITU patient 4 days post extubation for empyema washout, increasing oxygen requirement for last 2 days with deteriorating GCS, being treated for chest infection. Acute further deterioration post CT head scan with desaturation to 80% on 100% O2 - intubated. Family updated. Paper notes had been in disarray with only notes from most recent 2 days clipped in folder, rest loose and out of order. On sorting notes the following morning, found documentation of decision not for intubation in event of further deterioration from 6 days previous, due to poor prognosis from underlying muscle weakness. This had been discussed with the family. This had not been documented on the ICU admission or ICU handover sheet and verbal handover between juniors the day prior was that the patient was for respiratory and cardiac escalation.”

Commentary:

This story highlights the absolute and inviolable need for careful and professional maintenance of patients’ clinical notes. The clinician’s responsibility is enshrined in the GMC’s Good Medical Practice [1] but organisations also have a responsibility to ensure the healthcare record is preserved in good order. As highlighted in this story, escalation decisions in particular need to be clearly documented in a standardised way that is easily accessible.  In this story, the failure to discover an apparent advance decision is a serious matter. It led to a patient being subjected to a treatment which had previously been decided against. Depending on the nature of this decision, failure to adhere to it could be viewed as unlawful or negligent and so could have had significant professional and legal ramifications for the individuals and organisation.

Reference:

[1] Good Medical Practice. GMC, 2013