Time taken to complete pleural effusion chest drain procedure
18. Miss G complains Manchester University NHS Foundation Trust (the Trust) took too long to complete a pleural effusion chest drain procedure after it was arranged on 27 March 2020. The Trust said there was an initial delay as Miss G wanted to think about the risk and benefits of the procedure. After this, there was a further delay due to a consent form being withdrawn. The Trust said the 2 April 2020 procedure had to be stopped due to the risks posed by Miss G’s unstable spine fracture. The Trust said it was not safe to continue with the procedure but reassessed this a week later and decided to proceed.
19. Points 31 and 32 of the General Medical Council (GMC) Good Medical Practice guidance states doctors must listen to patients, give them the information they need to make decisions, take account of their views. In this instance, (as outlined in the Background section above) staff had extensive conversations with Miss G to try and put her mind at ease.
20. The pleural effusion chest drain procedure was suggested on 27 March 2020 and this was subsequently discussed again with Miss G over the next few days. As noted, there was a small delay on 30 March as Miss G wanted to discuss the procedure and her resuscitation wishes with her family. This is understandable as these situations can be quite daunting. The issues raised with us about resuscitation are explored in the sections below.
21. On 31 March 2020, the medical records note Miss G was still unsure whether she wanted the procedure to be completed. More discussions were had with staff, and this continued through to 1 April 2020. It appears this was also related to Miss G’s resuscitation wishes. Once Miss G was comfortable with having the procedure completed, it was arranged for 2 April 2020. While we recognise these discussions slightly delayed the procedure, staff acted in line with GMC guidance when listening to Miss G’s concerns.
22. The Trust said the procedure was stopped on 2 April 2020, due to concerns about Miss G’s spinal fracture. Point 25 of the GMC, Good Medical Guidance states doctors must take prompt action if they think a patient’s safety is at risk.
23. Miss G’s cancer had spread to her spine, and this was causing instability of her spine. Our adviser explained that, in these situations, minor movements of the spine can cut the spinal cord, potentially leading to paralysis or death. They also explained that the assessment of safety during a procedure is the responsibility of the doctor performing the procedure. Here, there was concern that the equipment used to insert the drain could cause damage to Miss G if there was too much movement. Therefore, as staff were concerned about Miss G’s safety, it was appropriate to stop the procedure. This decision was in line with GMC guidance.
24. On 6 April 2020, the Trust decided against attempting the pleural effusion drain again. The medical records show this was due to safety concerns. The British Thoracic Society, Pleural Disease Guidelines, 2010 states if a patient is not showing symptoms, they can be observed by doctors, and an effusion does not need to be performed.
25. Our adviser explained Miss G had breathlessness on exertion, but her oxygen levels and respiratory rate were stable. They said this meant there was not an urgent need to complete the chest drain procedure. Therefore, while we recognise Miss G’s worries about the delay to the procedure, the Trust’s decision was in line with the British Thoracic Society guidelines
26. We note it took 14 days for Miss G’s chest drain to be completed. This time must have been very difficult for her. While we do not want to diminish Miss G’s experience, the above shows the Trust acted in line with GMC and British Thoracic Society guidelines when treating her. Therefore, there are no indications that anything went wrong in this part of the complaint.
Itemised invoice
27. Miss G complains the Trust did not provide an itemised invoice for her treatment charges. The Trust said it is not possible to provide an itemised invoice as this facility is not available at the Trust. It said the NHS charges overseas patients according to the English National Tariff, and a total care package price is calculated, not individual items of care.
28. The ‘Rights and pledges covering access to health services’ section of the Handbook to the NHS Constitution for England states NHS services are generally free of charge apart from in certain exceptions. It outlines one of these exceptions as being overseas visitors. This is in line with Section 175 of the National Health Service Act, 2006, which states non-UK residents may be charged for NHS treatment. The Department for Health and Social Care, guidance for ‘How charges for NHS healthcare apply to overseas visitors’, states people living outside the UK will be charged at 150% of the National Tariff unless an exemption applies.
29. As outlined in the Background section above, Miss G was previously admitted to the Trust in December 2019. We appreciate this and the subsequent admission in March 2020 must have been very upsetting for Miss G. During the December admission, Miss G was informed she would have to pay for her care as she was an overseas visitor. We note the Trust’s Overseas Chargeable Patient’s Service did not meet with Miss G during her March 2020 admission. However, we consider she would be aware of the need to pay for her care in March 2020, as she was an overseas visitor, much like in December 2019.
30. The guidance and legislation listed above does not state an itemised invoice must be provided to a patient. While we recognise this may help Miss G better understand the charges applied to her care, the Trust has acted in line with guidance when not providing one. Therefore, there are no indications that anything went wrong in this part of the complaint.
Consent form and resuscitation wishes
31. Miss G also complains the Trust pressured her into signing a consent form for the procedure and would not include a statement on the form which detailed her resuscitation wishes. The Trust said Miss G was treated with respect throughout the March 2020 hospital admission and has apologised for any distress she experienced. The Trust also said Miss G’s resuscitation wishes were recorded in her medical records.
32. Point 17 of the GMC, Good Medical Practice guidance, states doctors must be satisfied they have consent to carry out any examination, investigation or provide treatment. Point 31 of the GMC guidance states doctors must listen to patients and take account of their views.
33. As outlined in the Background section above, several discussions were had with Miss G about the procedure, consent for this, and her resuscitation wishes. The Trust took the time to explain the procedure and ensure Miss G had given her consent before completing it. The Trust also recorded her resuscitation wishes. These actions are in line with the GMC guidance.
34. We recognise time in hospital can be upsetting and distressing, particularly during the COVID-19 pandemic. Discussions about the drain procedure may have been difficult for Miss G and we do not wish to diminish her experience of events. The medical records show the Trust took time to discuss issues with Miss G before obtaining her consent. While we cannot say whether the Trust pressured her into signing the document, we are pleased to see it has apologised for any distress she experienced.
35. We also appreciate this period was very difficult for Miss G and acknowledge her view that she wanted the consent form to detail her resuscitation wishes. While this would have given her more reassurance, these wishes were already recorded in her medical records, so there was not a requirement to document on the consent form. Therefore, as the Trust acted in line with GMC guidance, there are no indications that anything went wrong in this part of the complaint.