A lady is dead

And, in another universe, she wouldn't be.

She had walked into the hospital for an ERCP, but she didn't walk out 2 days later.

Her serum amylase levels were over 5k and no one did a thing.

Acute pancreatitis.

Because no one knew.

Which is not exactly true.

The lab had phoned the clinical investigation unit (CIU) nurses to tell them about the blood results. The CIU nurse had phoned up my ward to relay what the lab people had just said. And the nurse on my ward had told...

A doctor

One of the doctors.

But who?

Which doctor?

Because none of us, the three doctors who were on the ward, can recall ever being told about this lady's amylase levels.

Could one of us have been told, a passing remark carelessly forgotten and set aside by a brain already flustered and overworked, a cursory sentence, that could have been:

'We've got this new lady coming in from the CIU doctor. Her amylase levels are 5k by the way.'

'Hmm? Uh, ok.'

And the doctor resumes what he or she was doing, not even looking up at the nurse to acknowledge that the message had gone home, too focused at the task at hand, which could have been as simple as trying to decide what antibiotic to prescribe, or whether or not Mr X should go home with some zopiclone to help him sleep.

And the lady feels perfectly fine, eating and chatting, not at all unwell, until 1900 when all the ward doctors are away, the last one having left a mere 30 minutes before, when her blood pressure drops and she loses consciousness. Yeah, she was feeling a bit of discomfort some time before she loses consciousness, but who doesn't feel a bit uncomfortable after a procedure.

And never regains it.

The on-call doctor is paged. He arrives and assesses the situation. He's a busy man. He still has 4 new admissions to the acute medicine ward to see. He takes a look at her observations chart. He asks the nurses about her. He writes her up for some fluids. Lady doesn't even have a cannula in her. Did he take a look at her blood results and conclude that she had acute pancreatitis?

I don't know.

Lady goes into cardiac arrest. Arrest team called. Lady dies. Despite their best efforts.

It's the weekend. Ward doctors find out about her death 2 days later.

And we ask ourselves the same question over and over again.

"Was I the one who was told about this lady's amylase levels?"

I don't know. It wasn't me. I don't think so. Can't remember ever being told that.

Malpractice? Mis-management? Negligence?

Who is to be blamed?

A lady is dead.

She should still be alive.