Reviewer commentary on care judged unsatisfactory overall
| Overall care score 1 | Reviewer comments | Comment type (Pos or Neg)/category |
|---|---|---|
| Admission phase score 1 | Poor history documentation | Neg/B |
| Poor examination documentation | Neg/B | |
| Initial investigations requested CXR, ECG, bloods but no comment made re these | Neg/B | |
| No ABGs and patient was tachypnoeic and hypoxic | Neg/B | |
| No O2 (not documented) | Neg/B | |
| No GTN | Neg/B | |
| Pitiful dose of frusemide (furosemide) (20 mg IV) | Neg/C | |
| Extremely poor management | Neg/C | |
| Initial management phase score 1 | Medical team made no attempt to adequately treat the heart failure | Neg/C |
| No comment on the CXR | Neg/B | |
| No ABGs | Neg/B | |
| CPAP started without ABGs | Neg/B | |
| Did record a resuscitation status | Pos/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 die | Neg/C | |
| No discussion with the family or relatives | Neg/C | |
| Later management | See previous | |
| Overall care score 1 | All aspects of this case were very poor. History, examination, medical management, documentation | Neg/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 in | Neg/C |
ABGs, arterial blood gases; CPAP, continuous positive airway pressure; CXR, chest radiograph; ECG, electrocardiograph; GTN, glyceryl trinitrate; IV, intravenous; Neg, negative; Pos, positive.