Next management steps

D has been in the ED for 8 and a half hours. His NEWS2 is now 8. He has had 10mg midazolam (buccal) about 6 and a half hours ago, and some IV fluids (started 4 hours ago). He has not been examined nor had any other treatment. He has passed urine and his sister has asked for some clean sheets so she can change his bed. She was told to pop out whilst the ED staff changed him. Despite being very weak, D becomes very distressed whilst being changed. 

Carers such as Ds sister can not only be an important source of information, but can also help to reassure a person and help them to feel safe. For more about how healthcare professionals and carers can work together, take a look at this.

Escalation of care

NEWS2 guidance tells us that a total score of 7 or more should trigger an emergency response, including critical care review. Of course, as with all things in medicine, we put things into clinical context. D had no advanced care plan to suggest that he should not be considered for critical care. Decisions regarding escalation of care and resuscitation should not be made solely on a diagnosis of learning disability or autism (more here). Most people with a learning disability have an excellent quality of life. Its important to remember the impact of illness, also, on how a person presents to you in the ED we often see people on their worst day. We cant know how unwell they are unless we know what they are like when they are well. And we cant know what someone is like when they are well unless we try to find out usually by speaking to family or carers. 

What happened next

D was admitted to the assessment unit under the care of the medical team, 8 and a half hours after arriving in ED, and shortly after receiving a dose of lorazepam. His NEWS2 score had not been relayed to the HST on call for medicine (nor his family). He was seen by a nurse on arrival to the unit and was awaiting medical review when he arrested, 1 hour and 49 minutes later. ROSC was achieved, and a ReSPECT form was completed, to say that there should be no further resuscitation attempts should D arrest again. He died later that day. 

A postmortem examination was held and cause of death was found to be:

1a) Bilateral pneumonia

1b) Metabolic acidosis and hypovolaemia

1c) Dehydration

2) Autism, learning disability, dysarthria, immobility

An inquest was held and the coroner ruled that Ds death was due to natural causes, contributed to by neglect. A Prevention of Future Deaths report, also known as a Regulation 28 report, was issued. These are made by a coroner in the United Kingdom to relevant authorities to attempt to prevent future deaths from causes uncovered during an inquest. In Ds case, this included issues relating to assessment and management of pain, reasonable adjustments to enable assessment, basic clinical examination, critical care intervention and learning from serious incidents. 

A note from Ds sister

D is missed every day.  He was a 40 year old man who should not have died.  His family feel he should still be here, getting into mischief with his nieces and nephew.  I am left haunted by how he was failed, but determined that lessons should be learnt from his story.  I hope that readers of this blog will reflect on their own clinical practice and what steps they can take to improve care for people with a learning disability in the ED.