"A&E admittance at Royal Liverpool Hospital with Severe Asthma"

About: The Royal Liverpool University Hospital / Accident and emergency

(as a relative),

My wife attended her GP clinic in the morning. She is asthmatic and had a chest infection. The GP prescribed antibiotics, steroids and because her oxygen and peak flow were low asked her to go back in the afternoon as a precaution.

By the time she went back her condition was so bad the GP called an ambulance to take her to hospital. She was put on a nebuliser and oxygen, but nevertheless nearly lost consciousness and did not remember the GP calling me (her husband) to say he was sending her into hospital.

She was blue lighted to A&E, arriving at 18. 14. I arrived about 10 minutes later, and found her lying unattended in the triage area, with no oxygen. I went straight over to a nurse and asked why, given her condition at the GP surgery and considering that the guidelines for treating severe asthma are clearly laid out in https: //www. brit-thoracic. org. uk/document-library/clinical-information/asthma/btssign-asthma-guideline-2014/.

The nurse said that the ambulance team had reported that her SATs had recovered, I asked her what they were, but she didn't know and my wife had not been seen before she was left on the bed in A&E. The nurse said she would be over in a moment to assess her. I measured my wife's respiratory rate and had it at around 25 breathes per minute (high, given she was in a resting state), and her respiratory effort was poor, with very obvious tracheal tugging.

The nurse came over about 15 minutes after I had approached her to take the SATs. She recorded her O2 at 96% but I could see on the machine that it was 93% and at one point had gone to 89% and she did not take her respiratory rate. She then went to leave, but I asked her why my wife was not being given either oxygen or Nebuliser and she said it was because her SATs were fine. I argued this point and insisted that I wanted her seen by a doctor immediately and reminded the nurse again that she had been referred by her GP and had nearly lost consciousness through the effort to breathe. The nurse told us at that point that some blood would also be taken as well.

A doctor arrived after about 10 minutes, listened to her chest, took her respiratory rate and immediately gave her a nebuliser. We were wheeled down to x-ray at around 19. 00. My wife was still connected to the Oxygen Tank on the trolley, even though the nebuliser had finished, so I told her to stay connected to it, because she had described the feeling of being able to breathe as 'bliss' - as anyone with asthma will know, it is a terrifying experience to struggle for breath, and I could see she was still struggling.

We were second in the queue for x-ray. The first in the queue was wheeled off and 2 more patients were wheeled into the queue. One of these patients was then wheeled into x-ray before my wife and the porter for the 2nd time came and queried why we were still waiting. He said he would check, I assume because it was unusual and or a one in one out based on queue position system. He came back and confirmed that we would be next in.

X-ray was completed at around 20: 00, but bloods had still not been taken at this point. The bay we had been occupying in the triage 'minors' had been taken so a cubicle was found in 'majors' - we were taken by the porter.

We waited in the cubicle for an hour without seeing anybody. At this point, I went to the nurses desk in majors and pointed out that it was an hour since x-ray, 3 hours nearly since being brought in and that no bloods had been taken. The nurse on the desk was very pointed in reporting that it was actually only 2. 45 hours since we had been brought in and that they were very busy. I asked why the blood had not been taken. It was an oversight (I could tell and the doctor confirmed as much later on), but the nurse was not transparent with this fact. I asked when the blood would be taken, and was told it would be done as soon as there was someone available to do it. I assume either something had gone amiss, or the fact that I had asked what was going on had some sort of effect, because not long after approaching the desk, a nurse arrived took some SATS and blood and escalated us. The time on the record said 20. 55 and the O2 level was 93% (thoracic society guidelines say it should be maintained at 94% - 98% with the use of oxygen if required). The doctor arrived some time later and based on the O2 and based on her PEF from the GP / Ambulance crew (this is an assumption, since nobody in the hospital had taken her PEF) was around 160 immediately put her on a nebuliser.

I had a strong conversation with the Doctor who said they did not understand why my wife had not been put on a nebuliser earlier in the evening, I explained that it had been at my request for her to see a doctor who had checked her respiratory rate and her chest via stethoscope. The doctor said that he SATs had been recorded at 99%. I challenged the idea that the SATs had been 99% given the conversation I had with the GP and what I had seen on the meters. I pointed out that my daughter has asthma, I have asthma and my wife has asthma, so we are well used to the facts and figures.

At some point, can't remember when, the nurse we were under the care of in majors had said that she could not prescribe nebuliser or oxygen because they are drugs and only doctors can prescribe them (not much use when the waiting time for a doctor is 4 hours - which is what I was quoted and an asthmatic can lose consciousness when fighting for breathe in 3 minutes and die in about 8 if O2 is low enough). Once the nebuliser had finished, no oxygen was provided. Curiously, because I don't really remember them getting measured and there isn't a time on the record, there are 2 O2 levels somewhere between 20. 55 and 00: 30 O2 of 99% and 100% was measured. I don't actually remember it being measured, but am surprised given that even oxygen assisted later in the evening it varied between 93% and 98%. The doctor came back again having had a look at the x-ray and confirmed shadowing and prescribed antibiotics and also confirmed that my wife would be admitted. Because of lack of beds, we were eventually placed in ESAU (surgery post-op, I think) which was used as overspill at the weekends. Whilst admitting my wife onto the ward, the nurse noted that her 02 was low, as was her respiratory rate and could see she was having trouble breathing and put her straight onto oxygen. Generally speaking once on ESAU the situation was calmer. The only incident was when I noticed the records in my wife's notes only started at 20. 55, but she had arrived at A&E at 18. 14. I was told that they use separate records. Also, when my wife was reading through her notes, the same nurse asked her if she was "having a nice read".

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Responses

Response from Royal Liverpool and Broadgreen University Hospitals NHS Trust

Thank you for your detailed comment in relation to your wife's care and treatment with us. We are sorry that you and your wife didn't have a good experience with us. We have shared your comment with senior staff within the emergency department.

We would like to hear from you so we can investigate this properly and learn from the issues you have raised. In order to do that, we need some details from you - such as name/date treated etc. Could you please contact us? You can call our PALS team on 0151 706 4903/2265 or email PALS&complaints@rlbuht.nhs.uk

Thank you.