Table 2

Reviewer commentary on care judged unsatisfactory overall

Overall care score 1Reviewer commentsComment type (Pos or Neg)/category
Admission phase score 1Poor history documentationNeg/B
Poor examination documentationNeg/B
Initial investigations requested CXR, ECG, bloods but no comment made re theseNeg/B
No ABGs and patient was tachypnoeic and hypoxicNeg/B
No O2 (not documented)Neg/B
Pitiful dose of frusemide (furosemide) (20 mg IV)Neg/C
Extremely poor managementNeg/C
Initial management phase score 1Medical team made no attempt to adequately treat the heart failureNeg/C
No comment on the CXRNeg/B
No ABGsNeg/B
CPAP started without ABGsNeg/B
Did record a resuscitation statusPos/B
Documentation very poor, for example, no reference to the fact that she was so unwell or whether they thought it likely that she would dieNeg/C
No discussion with the family or relativesNeg/C
Later managementSee previous
Overall care score 1All aspects of this case were very poor. History, examination, medical management, documentationNeg/C
If this lady was clearly dying and had multiple co-morbidities, they should have documented this, made the lady comfortable and called the family inNeg/C
  • ABGs, arterial blood gases; CPAP, continuous positive airway pressure; CXR, chest radiograph; ECG, electrocardiograph; GTN, glyceryl trinitrate; IV, intravenous; Neg, negative; Pos, positive.