21 June admission
16. Mrs E says that on 21 June she experienced shortness of breath. She attended her GP practice and it referred her to the Trust. Mrs E is concerned that the Trust assessed her and discharged her home the same day. She says that 12 days after she was readmitted to the Trust and it conducted a CT scan. This scan confirmed she had a compressed lung.
17. The Trust said that when Mrs E presented to the ED on 21 June, an ED Associate Specialist reviewed her. They noted Mrs E’s recent bypass, her blood test results and a chest X-ray and referred her to the cardiothoracic team.
18. In reviewing Mrs E’s records, we can see that her chest required drainage following bypass surgery on 21 May. On 29 May, the Trust prescribed antibiotics as it was concerned, she could develop an infection. A CT scan conducted on the same day identified a haemothorax. This is a collection of blood in the space between the chest wall and the lung. On 31 May 2018, the Trust discharged Mrs E with further antibiotics. This shows that Mrs E was not responding to antibiotics or chest drainage.
19. British Thoracic Society pleural disease guideline 2010 says:
‘Patients with persistent sepsis and a residual pleural collection should undergo further radiological imaging.
In patients who do not respond to antibiotics and chest drainage with ongoing signs of sepsis in association with a persistent pleural collection, the diagnosis should be reviewed and a further chest x-ray and CT scan or thoracic ultrasound performed.’
20. We sought clinical advice on the visit to the ED. Our cardiology adviser said the clinical and X-ray findings on 21 June show possible residual pleural collection. This is a build-up of excess fluid on the lungs. Guidance says that patients with persistent sepsis, and a build-up of fluid on the lungs should undergo further radiological imaging.
21. The Trust should not have discharged Mrs E from the ED on 21 June. It should have admitted her for a CT scan. This would not have necessarily taken place on 21 June, but within one to two days of this date. We can say that if the Trust had conducted a CT scan earlier it would have confirmed the diagnosis of compressed lung earlier.
22. We understand how unwell Mrs E was at this admission and how concerning it must have been for her to be discharged when she was experiencing difficult symptoms. We have seen evidence that Mrs E was suffering from persistent pleural collection. This means the Trust should have conducted further investigations in line with guidance. We view the Trust’s decision to discharge Mrs E without further investigation on 21 June as a failing.
23. We next considered the impact this failing had on Mrs E. She said her treatment impacted her recovery and she has lost faith in the NHS.
24. We asked our cardiology adviser how the Trust’s decision to discharge Mrs E would have affected her. Our cardiology adviser explained that if the Trust had conducted a CT scan at the admission on the 21 June, or the following days. It would have likely found a compressed lung and the Trust could have started treating Mrs E up to 18 or 19 days earlier.
25. There are two procedures to re-expand a collapsed lung. A surgical approach called a thoracotomy or a less invasive ‘keyhole’ procedure called a video-assisted thoracoscopic surgery (VATS). The records show that Mrs E had a VATS, the less invasive treatment. Our adviser said that older, more advanced pleural collections with more scarring usually require a thoracotomy.
26. This means the delay in diagnosis did not affect the treatment Mrs E received, only when she received it.
27. In our work we have seen the Trust should have carried out a CT scan on 21 June or on the following days. It is likely that if the Trust carried out the CT scan around 21 June it would have been able to diagnose Mrs E with a compressed lung earlier and treatment could have commenced earlier. We did not see evidence that this delay meant that Mrs E needed to undergo a more invasive treatment.
28. We can conclude that the delay in diagnosis meant that treatment was delayed by 18 to 19 days, which impacted her recovery. We can understand that the Trust’s actions would cause Mrs E to lose faith in the NHS. We uphold this complaint.
MRSA
29. Mrs E says that when she was an inpatient at the Trust it left her leg wound exposed. She says it swabbed the wound during the admission and it told her there was no infection. However, when she was admitted to another Trust her leg was swabbed and it tested positive for MRSA.
30. The Trust has said that unfortunately it is very common for patients to acquire this type of infection whilst admitted to hospital. It said it is very difficult to explain how or when it was contracted.
31. Department of Health guidance says:
‘Trusts should identify and screen patients in high MRSA risk specialties. High risk specialties is defined as vascular, renal/dialysis, neurosurgery, cardiothoracic surgery, haematology/oncology/bone marrow transplant, orthopaedics/trauma, and all intensive care units (adult/paediatric ICUs, Neonatal Intensive Care Units, High dependency units, Coronary Care Units).’
32. Trust guidance on MRSA screening says: ‘Screening involves taking two painless swabs, one from inside your nose and one from your groin. These are the areas of the body where the MRSA is most likely to be found. The swabs are generally taken by a nurse but if you wish to and are able you can do your own swab. The swabs will be sent to the hospital laboratory to see if MRSA is present - it can take up to five days to get the results.’
33. On admission the Trust swabbed Mrs E’s nose and groin for MRSA, the results were negative. This is in line with Trust guidance.
34. When the Trust admitted Mrs E in July, she had a wound on her right leg from previous surgery. On 6 July, the records say the wound looked ‘sloughy’ and Trust staff thought it could be infected. It took a swab of the wound to see if it was infected. The swab results did not identify a bacterial infection. The records show that the Trust did not swab Mrs E for MRSA again between 3 and 15 July.
35. When the second Trust swabbed Mrs E on admission, MRSA was detected.
36. Our adviser explained that a positive MRSA swab result does not tell you how long the MRSA has been present for. This means we are unable to conclude when or how Mrs E contracted MRSA.
37. The records say the wound was ‘dry and intact’ or ‘redressed’ on a regular basis. In the records there are two days where the wound is not described. This is on the 4 and 5 July. However, we can see that the Trust redressed the wound on 3 July. Our adviser said that wound dressings are designed to stay on for up to seven days. We have not seen any evidence in the records to show that the Trust left Mrs E’s leg wound uncovered for a prolonged period.
38. We can understand how concerned Mrs E was to be told she had contracted MRSA. We have seen the Trust swabbed her on admission and this is in line with guidance. We have not seen any evidence that the Trust left Mrs E’s leg wound uncovered or that that this caused her to contract MRSA.