Monday, 14 January 2008

Being ill

I saw a lady at her home who'd taken to her bed and stopped eating. Her GP asked a Community Psychiatric Nurse (CPN) to see her at home because she was depressed. On reading the referral she seemed to have significant infirmity so the nurse and I went to see her together, with her family, to sleuth out what was going on and what we could do to help.

The patient was not well. She'd lost a massive amount of weight. Lying in bed, breathless and gasping, with open leg ulcers and a cough, she looked profoundly unwell. Her mouth was dry and had oral candidiasis (thrush) in it. She was clinically anaemic. She had focal signs in her chest suggesting a left lower lobe infection. Her lungs were over expanded, pushing her liver down. Her abdomen was tender. She was clinically dehydrated.

She was too breathless to talk with me in anything other than two words at a time. She said she was thirsty but was too tired to sit up to drink and had to be helped up.

Her mood wasn't great but, really, it was the last thing her family or the CPN and I were worried about. Her GP had seen her the day before (and then initiated the referral) and had her district nurses visiting daily to dress the leg ulcers and had arranged a mattress to reduce pressure areas.

The CPN and I spoke with the family about depression and how we would treat that where ever the patient was (at home or on a medical ward) but that her physical health was causing us concern and this needed addressing, rather than just treatment or admission under our care.

We left and I 'phoned her GP and explained what we'd found (that she was physically ill and not needing urgent psychiatric input at present, but I'd happily follow her up where ever), the GP arranged admission that afternoon. 3 days later she died on the medical ward.


Disillusioned said...

How very sad.

Mousie said...

A GP who couldn't recognise a critically ill patient right under his nose? Surely not!

Elaine said...

this is desperately sad.

marcella said...

Just perhaps she wanted to die at home surrounded by her loved ones and a sympathetic psychiatrist or two rather than on the medical admissions unit surrounded by tubes and other people's ill health? Not excusing the GP or anyone else if her physical health wasn't being attended to at all, but perhaps there was nothing else they could do so they thought they'd give psychiatry a try.

The Shrink said...

Marcella, I'm all for that if that's been thought through and that's the choice made.

Here, unfortunately, her physical health hadn't been looked at 'til I saw her.

She'd been presumed to simply be depressed. I believe the outcome from such a presumption was suboptimal.

Elaine said...

Dear shrink "the outcome of such a presumption was suboptimal."

A mastery of understatement.

Anonymous said...

Babies have Health Visitors who routinely screen them for baby things. They're also meant to screen elderly but I don't think they have time for that (not sure if UK even have Health Visitors anymore?)
Anyhooos... I'd guess the GP didn't even see the old dear - possibly went on a verbal request/opinion of family? And why go himself if he can get another team to do it who has a medically qualified member?

toolate said...

So, what was on the death certificate of this poor woman?

Fulminating malabsorption?
Fulminating neglect?
Loss of appitite in Chronic depressive?
Political victim?
A consequence of indifference?

Will there be an enquiry?
Is the outcome of any enquiry predictable?
If so, in what way?

Milk & Two Sugars said...

Much badness.

The Shrink said...

CRP was almost 300, neutrophilia was 27, the Consultant Physician found the same chest signs that I did.

Tainted Halo, realistically a Health Visitor couldn't organise the care needed and would involve the GP. To the GPs credit, she did visit the patient the day before I did.

Too Late, I spoke with the Consultant Physician, the cause of death has been documented as respiratory infection. No enquiry is planned.

M&2S, agreed. Much badness.

Anonymous said...

No, I agree that HV would only refer back to the GP anyhow. What I was implying (in an obviously vague way) was elderly screening was meant to be the remit of HV, but they seem to have run out of resources too (well, to be honest, I don't think it ever got off the ground properly), and if this lady had been screened regularly some things might have been picked up. But then, it's the old argument; how much resource do you 'waste' screening healthy people instead of spending it on treating the ones already diagnosed?

Anonymous said...

What can I say?

A ltter to the PCT and GMC maybe.

We are not talking peterhainoversight we are talking manslaughter.


Dr John Crippen

Anonymous said...

Just re-read it his morning. It still sounds gross - and I make no excuses. But it may be over simplistic.

There is a problem. And that problem is a resource problem. A problem caused by our target dominated NHS. I don't know if it applies in this case, but it certainly applies in many others

All GPs have a large number of frail elderly patients, usually female, who live alone and are struggling. The subprime minister has deemed these people to be in need of social care, not of "medical" care.

Hospital medical admissions and MAUs are now geared to point scoring and protcols. To "completed events". Elderly patients with multiple medical problems never have "completed events." One problem leads on to another.

Mrs Boggins has osteroporotic fractures, a bit of CCF, a bit of COPD, a bit of faecal incontinence, a bit of urinary incontinence and a lot of loneliness (daughter lives 60 miles away and rarely visits).

One day, Mrs Boggins' neighbour asks you to call as she has had a fall. "She should be in hospital, doctor". She has indeed had a fall. Nothing broken, but she has been on the floor for two hours. So you sent her in. You phone the MAU and some pisspot F1 gives you the third degree about WHY you need to send her in. "This sounds like a social admission". Bloody right. But you can't say that. So you pick one her problems, say the CCF. Always a good one. Anyone can see her ankles are swollen. She is kept in A/E for three hours and 59 minutes and then moved to a pretend ward. The F1 changes her furosemide to bumetanide and sends her home with a note saying "GP to check E & U in two weeks. Please refer to the falls team."

The "Falls Team" is a collection of HCPs who duly see Mrs B and say "Is she depressed? Suggested psychiatric assessment." Mrs B is not psychiatrically ill, she is lonely. Four weeks later she gets to the Psychogeriatric clinic. The locum consultant does not speak much English, and puts her on mirtazepine. Two nights later she falls out of bed. The call centre call an ambulance. The wise and learned paramedics put her back in bed and leave a summary saying "patient declined admission - GP please assess."

Actually, she did not decline admission. She was not really given the choice. The neighbour says the paramedics told her there was no point in going into hospital. Mind you, these days they are right.

Mrs B. has now stopped eating. She does not drink much either. She gets dehydrated. So you send her in again. This time she is kept for 36 hours, rehydrated, and sent home with a note saying "GP to check E & U in two weeks". No follow up.

And so it goes on. And on. And on. And on. She needs care, and she is not getting it.

Finally, in extremis, you decide to see if you can wangle a psychiatric admission. Where I work you can't refer directly to a psychiatrist, you have to refer to the CMHT, a load of well meaning amateurs. Fortunately on this occasion, a doctor gets involved. I have never seen a psychiatrist with a stethoscope but fortunately this one has one, and he spots the obvious multiple medical problems and sends her in.

This time, she dies.

It might have been last time, or next time, but it happens to be this time.

I think I might just write this up in more detail


Dr John Crippen

Garth Marenghi said...

A sad case for sure.

However I am completely unimpressed with the people who are always keen to jump on this kind of story and use it as a defence of empowering people with much less training and knowledge than GPs.

This kind of empowerment, for example letting nurses practice medicine in an unsupervised fashion after just a four week clinical skills course, will only lead to many more cases like this.

This kind of case is awful and cannot be condoned, but it can't be used in that way, there is no logic in such arguments.

Kirsten said...

Why didn't the family call the GP in before this? GPs don't routinely call round all the patients on their list to see how everyone's doing. They rely on patients and families and other professionals involving them when necessary. And people have the right to refuse to have their GP called and they have the right not to call the GP themselves.

The Shrink said...

Pendleton Rules :

The GP did a lot well :
The GP normally is a good GP. She visited this patient on the day her family asked her to, she arranged referral to our service that day, I saw the patient the next day then spoke with the GP that afternoon who arranged admisison for that same afternoon. The GP'd sorted out district nursing care.

What could be done differently :
1) Physical morbidity could have been more promptly addressed but in truth, as Dr Crippen says, I really don't think that would have changed the outcome over the onger term. I believe better symptomatic relief in effectively what was palliative care could have been delivered if the physical morbidity was being optomised.
2) The GP didn't follow our local "depression" protocol. She should have tried managing the patient in Primary Care, using an SSRI, switching, doing all that NICE CG23 states. But as one who encourages common sense and dislikes protocols, I can't knock the GP for being sensible and referring to us directly.

As Dr Crippen more articulately and explicitly stated, the crux was that this sort of patient often doesn't fit in any one service, social and health services both fail to deliver unmet need, then they die.

Garth, agreed, this isn't evidence that more staff but less medics is a good thing. Quite the converse. GPs arguably are the best folk to orchestrate care.

Kirsten, they had, the GP had sorted out district nurses, then at family's request had visited again (then initiated the referral to my corner).