Afifa Qaisar · Prevention of Future Deaths report

On 26th June 2013 I commenced an investigation into the death of Afifa Qaisar dob 4th April 1975. The investigation concluded on the 6th March 2014 and the conclusion was that the deceased died from Natural Causes, the medical cause of death being 1a Viral Encephalopathy

CIRCUMSTANCES OF THE DEATH On the 23rd June 2013 she was admitted to Tameside General Hospital with collapse and confusion. The initial diagnosis was meningitis, with sepsis. She was admitted to the hospital but died at 20.30 hours the same day.

1. During the course of the event it became apparent that the time of delivery/administration of various drugs was of the utmost importance. The nursing staff had completed the records to say that the drugs had been ‘given’. The Ward manager accepted that this simply meant that the drip had been ‘put up’ and did not confirm that the drug had actually been delivered into the vein of the patient. The husband of the patient contended that the ‘bag’ remained full and that he did not see any evidence that its contents were in fact administered to the patient.

2. During resuscitation the staff wished to use a “Gum –elastic Bougie Airway” but when they looked they found it was not available on the ‘crash trolley’.

3. It transpired that this patient was NEVER notified to the RMO on duty as should be the case.

4. I heard evidence that she required platelets to be transfused but there was a considerable delay in these being made available “because “they are not kept on site”, and in any event there is no ‘agitator’ on site for their preparation.

5. When the husband of the deceased drew to the attention of the staff that the saline infusion appeared not to be ‘running’ so he was told by the nurse to “hold her arm straight” to enable it to do so. He and I, and the Ward manager, felt that this was entirely inappropriate.

6. Despite the fact that this patient was receiving (apparently) i.v. fluids, at no time was a fluid balance chart commenced nor was the patient catheterised. The Ward manager agreed that both of these failings were unacceptable.

7. It was acknowledged early in the patient’s passage through the hospital that she would need platelets and Hb support, yet it took over four and a half hours for anything to be done about this.