Croydon Health Services NHS Trust

5. Ms L complains about aspects of the care and treatment doctors at the Hospital gave to her father between 14 March and 10 April 2019. Specifically, she says doctors failed to identify and treat infections and sepsis (the body’s overwhelming response to an infection which can lead to organ failure and death).

6. Ms L disputes the Trust’s view that lymphoma (cancer of the lymphatic system) caused her father’s death. She believes his illness would have been treatable if doctors had taken appropriate action. She says her father’s death was avoidable. She says these events were shocking for her family to experience and they feel let down by the Trust and think there has been a cover up.

7. Ms L wants the Trust to acknowledge its failings. She wants it to take action to improve services so other patients and families do not have the same experience.

8. On 14 March 2019, Mr L attended the emergency department at the Hospital. Doctors noted he had been experiencing breathlessness for around three months. They documented he had lost weight and had a reduced appetite. A chest X-ray showed a large pleural effusion (a collection of fluid around on the lungs) on his right side. This had worsened when compared to an X-ray taken a week earlier.

9. Doctors drained the fluid around Mr L’s lungs on 15 March 2019. On 17 March he had a CT scan. A CT scan is a series of X-ray images from different angles to provide a detailed image of a specific area of the body. The CT scan showed thickening of the lining of the lungs, which suggested cancer. Doctors then tested fluid from Mr L’s lungs, but this did not confirm any evidence of cancerous cells.

10. Doctors then arranged a biopsy, which took place on 29 March. They discharged Mr L on 1 April 2019, while they awaited the biopsy results. The biopsy results and further analysis confirmed Mr L had lymphoma.

11. On 6 April 2019, Mr L returned to the Hospital by ambulance because his health appeared to be worsening. A doctor met the family and explained Mr L had lymphoma and further tests were needed.

12. Mr L had a second CT scan on 8 April 2019. This showed the lining around the lungs had thickened as well as other indications Mr L’s illness was worsening. On the next day, a doctor met family members and confirmed Mr L was critically unwell and unlikely to recover.

13. Sadly, Mr L died on 10 April 2019. Doctors recorded lymphoma as the cause of his death.

16. Ms L complains her father developed an infection. This later became sepsis, which doctors failed to treat. She says there was evidence from blood tests which indicated sepsis. She questions whether the area around his drain became infected.

17. The Clinical Adviser told us doctors should have followed the BTS Guideline. This explains how they should manage pleural effusions. It says when and how X-rays, and other scans, should be performed, and when drainage should be attempted. It says when clinicians suspect cancer they should arrange for testing of the pleural fluid.

18. The Clinical Adviser told us doctors should also have followed Good Medical Practice. This says doctors must carry out adequate assessments of patients and arrange any investigations or treatments that are necessary.

19. Doctors should also have considered the NEWS Guideline. The NEWS aims to improve the detection of, and response to, clinical deterioration in patients with acute illness. It is based on a simple scoring system where scores are allocated to specific physiological measurements (breathing rate, levels of oxygen in the blood, blood pressure, pulse, consciousness and temperature). The NEWS tells clinicians how they should respond when the total score is between specific values.

20. We considered the clinical records. These clearly show doctors managed Mr L’s pleural effusion in line with the BTS Guidelines. The Clinical Adviser told us doctors carried out adequate assessments and arranged the investigations and treatment Mr L needed. They followed Good Medical Practice.

21. There is evidence Mr L had an infection during his first admission to the Hospital. The Clinical Adviser said this was probably hospital acquired pneumonia. There is also reference to Mr L having an infection associated with the site of his drain. Doctors treated these problems appropriately with antibiotics. The evidence shows Mr L’s inflammatory markers reduced during the admission, which suggests the antibiotics were effective in treating the infections.

22. The records show there was a definitive diagnosis of lymphoma. The Clinical Adviser said this cannot be disputed. Doctors made the diagnosis following a biopsy.

23. When Mr L returned to the Hospital on 6 April 2019, he had a high lactate level. Lactate is a substance made by muscle tissue and red blood cells. A high lactate level shows someone is generally unwell. It can be used to indicate the presence of sepsis. But in this case, it could also have been high because of Mr L’s lymphoma and infection. The Clinical Adviser said the cause of Mr L’s problems was likely a combination of an infection and the lymphoma. There is no definitive evidence Mr L had sepsis during his admissions to the Hospital.

24. The records show doctors treated Mr L with ceftazidime. This is a broad-spectrum antibiotic. The Clinical Adviser said this was appropriate for the infection doctors suspected. It should be noted doctors sent two samples of pleural fluid for analysis during the first admission. Neither showed evidence of any infection.

25. Staff at the Hospital regularly monitored Mr L’s physiological observations, in line with the NEWS Guideline. In the last three days of his first admission, Mr L’s NEWS score was between three and six. This suggests he needed continued medical treatment. The Clinical Adviser told us the decision to discharge Mr L from hospital at that point risked a deterioration. On balance, our view is doctors fell below the requirements set out in the NEWS Guideline in this respect.

26. The Clinical Adviser said Mr L should have remained in the Hospital on 1 April 2019, but infection markers showed signs of improvement. For example, the levels of CRP (C-reactive protein, which indicates inflammation) had fallen from over 300mg/L to 60mg/L. The volume of Mr L’s white blood cells, which is a marker of infection, was stable during this period. These results suggest Mr L’s health was improving before he left the Hospital.

27. The records suggest doctors discharged Mr L with antibiotics. They would have given him broadly the same treatment had he remained in the Hospital. When Mr L returned to the Hospital, he had similar CRP levels and white cell count. His physiological observations were also similar on readmission. This means there is no evidence the decision to discharge Mr L had any impact on his health.

28. We find the doctors generally treated Mr L in line with the relevant guidelines. The exception was the decision to discharge him from the Hospital on 1 April 2019. In this respect, doctors fell below the requirements in the NEWS Guideline. This failing did not have any impact on Mr L’s health.

29. We have seen no evidence doctors failed to treat Mr L appropriately for his infections. We do not consider his death was avoidable. Neither can we see any evidence that staff have attempted to ‘cover up’ what happened. We recognise Ms L is likely to dispute this view, but hope she is reassured we have carefully considered her concerns. We partly uphold Ms L’s complaint.

1. Ms L complains about how doctors treated her father, Mr L, at Hospital A (the Hospital), which is part of the Trust, in the last month of his life. We can see how devastating these events have been for Ms L and her family. We offer our sincere condolences for their loss.

2. We find doctors generally followed the relevant guidelines when treating Mr L during his admissions to the Hospital. We have seen no evidence the doctors failed to treat infections or tried to cover up failings. Ms L believes her father’s death could have been avoided. We have not seen any evidence this was the case.

3. We have seen evidence of a failing relating to the doctor’s decision to discharge Mr L from the Hospital when his observations suggested he needed continued medical treatment. We do not consider this failing had any impact on Mr L’s health.

4. We partly uphold Ms L’s complaint. We recommend the Trust takes action to ensure there is learning from what happened, relating to Mr L’s discharge.

30. In considering our recommendations, we have referred to our ‘Principles for Remedy’. These state that where poor service or maladministration has led to injustice or hardship, the organisation responsible should take steps to put things right.

31. Our principles say public organisations should look for continuous improvement and should use the lessons learned from complaints to make sure they do not repeat maladministration or poor service. In line with this, we recommend the Trust should show how it intends to learn from the issues we have identified relating to the NEWS Guideline to try and ensure the failing we have seen is not repeated. It should do this within two months of this report. The Trust should share this information with us, Ms L, NHS Improvement, and the Care Quality Commission.