Ms Q received sodium as part of her liver disease treatment but a lack of proper records meant the amount she received and how quickly is unknown. Her mother, Mrs U, complained on her behalf.
Ms Q was admitted to hospital and diagnosed with liver disease. She had a low potassium level and was given replacement potassium through a sodium solution. Daily blood tests monitored her sodium and potassium levels, but one crucial blood test was cancelled. There were no nursing records, which meant that the amounts of solution Ms Q received and when, along with the levels of fluid she excreted, are unknown.
Ms Q began to show signs of confusion and difficulty in speaking. A brain scan showed that she had central pontine myelinolysis (CPM), which can be caused by too rapid a rise in sodium levels. Ms Q deteriorated and died of CPM three weeks after she was admitted to hospital.
What we found
The Trust's record keeping was below standard, which severely hampered our investigation.
Without the records, we were unable to say whether Ms Q had received too rapid a rise in sodium. Her monitoring was not in line with the applicable standard and the cancelled blood test was contrary to established good practice. The Trust's complaint handling was poor and the lack of records prevented it from answering Mrs U's complaint. Because of the lack of records, we were unable to say what had caused the CPM, but there was a possibility that it had arisen spontaneously due to Ms Q's liver disease.
Putting it right
The Trust apologised to Mrs U and produced an action plan to prevent it happening again.
Nottingham University Hospitals NHS Trust
Nottingham
Did not apologise properly or do enough to put things right
Replied with inaccurate or incomplete information
Apology
Recommendation to learn lessons or draw up an action plan