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As winter pressures combined with COVID-19 create more stress for the NHS, hospitals could look at reducing exacerbating factors such as acute kidney injury, says Dr Mark Ratnarajah, managing director, UK, of digital health company C2-Ai. A study by researchers at University Hospital Southampton NHS Foundation Trust, found that Acute Kidney Infection (AKI) was a significant factor for COVID-19 admissions to Intensive Care Units (ICU) and deaths. AKI was present in 31 per cent of Covid-19 hospital patients, and the condition was associated with 27 per cent of admissions to ICU. The findings also showed that more than twice the number of COVID-19 patients with AKI died, compared to those without it. As AKI can commonly be acquired in hospital, it would be beneficial to both patients and hospitals if clinicians are able to consider the likelihood of anyone contracting the condition. For this, an individualised risk-assessment of a patient is needed, rather than a generalised catch-all approach. Click on the link below to read the full article, published in the Journal of mHealth.

On the 3 July 2023, Susan Pollitt was admitted to the Royal Oldham Hospital following a collapse at her home. She was treated for a number of medical issues including acute kidney injury. During her admission, she developed ascites—a condition in which fluid collects in spaces within the abdomen. The Consultants involved in her care decided an ascitic drain was not required at that time. Subsequently on the 11 July, a junior doctor reviewed Mrs Pollitt and decided that an ascitic drain should be placed. The Physician Associate who undertook the procedure was not aware of the local guidance on the insertion of ascitic drains or that the drain should remain in place for no longer than six hours. Mrs Pollitt’s drain remained in place for 21 hours before being removed. She subsequently developed bacterial peritonitis and died on 16 July. Further to the details in the summary above, the Coroner noted that in this case: The junior doctor who reviewed Mrs Pollitt decided that an ascitic drain should be placed. However, the Court found that this procedure was not clinically indicated at that time. The Physician Associate who undertook the procedure also directed that the drain be clamped due to a concern that the loss of fluid could cause a drop in blood pressure. This was unwarranted given the moderate level of fluid which had been drained and the Court heard that the Physician Associate did not appreciate that clamping a drain increased the risk of infection. The situation was compounded by Mrs Pollitt’s placement on a respiratory ward rather than a gastroenterology ward since there was a lack of understanding and awareness across all the staff on the respiratory ward including the medical team as to the management of ascitic drains. The Coroner set out their matters of concern as follows: There is no regulatory body with oversight of Physician Associates. It is understood that this is currently the subject of a consultation by the General Medical Council. The Physicians Associate Managed Voluntary Register held by the Faculty of Physician Associates (FPA) is voluntary. Whilst employers are encouraged to check the register there is no duty to do so, nor is it clear how the FPA would be made aware of any concerns relating to an individual Physician Associate. There is no national framework as to how Physician Associates should be trained, supervised and deemed competent. This is placing both patients, Physician Associates and their employers at risk. The court heard that since the death of Mrs Pollitt the Northern Care Alliance have put in place a local trust framework. Unlike all other clinical roles there is no national guidance save for very recent guidance issued by the British Medical Association (March 2024). There remains limited understanding and awareness of the role of a Physician Associate both amongst medical colleagues, patients and their families. The lack of a distinct uniform and the title “Physician” gives rise to confusion as to whether the practitioner is a doctor. In June 2022 the Physicians Associate had been signed off as competent for the insertion of ascetic drains. This sign off was completed by a liver nurse specialist using a competency form which was provided by the FPA. Whilst the competency form assessed the technical aspect of placing the drain, it did not include competency around the wider aspects of care such as taking consent, risk factors and after care.

This case study summarises the story of Evadney Dawkins, a 77 year-old living in East London who died on 23 August 2018 as a result of treatment errors and poor care received at Newham University Hospital. Following a fall at home, Evadney was taken to the hospital on 22nd July 2018, where she was initially treated for a chest infection and fast atrial fibrillation (an irregular and abnormally fast heart rate). As she had other co-morbidities that included chronic renal failure, a treatment plan including renal monitoring was agreed, but the hospital failed to monitor her renal function and she sustained a profound acute kidney injury. Following intensive treatment, the acute kidney injury resolved but she sustained a cardiac arrest on 23rd August 2018 and died later that day. This case study outlines how Action Against Medical Accidents (AvMA) helped Evadney's family convince the Coroner to open an inquest. The inquest found that there were ‘gross failures’ in the care provided to Evadney which led to her renal deterioration, including a failure in the frequency of blood tests, a failure in fluid monitoring and a failure to carry out renal ultrasound. The Coroner also criticised Bart's Health NHS Trust's systems of governance for not identifying for two years that Evadney’s case was a serious incident which required investigation.