Blood clot
20. Mrs E complains the Trust did not prescribe Mr E treatment for a blood clot in January 2020. She says to get a diagnosis he should have undergone a CT scan. Mrs E says because the Trust did not do this it missed an opportunity to provide treatment for Mr E.
21. Mrs E says Mr E had endoscopies (inserting a long, flexible tube down the throat with a small camera on the end) at the Trust in February 2015, March 2016 and November 2017. He did not receive a further endoscopy after this.
22. We asked our adviser if Mr E received appropriate investigation and treatment for his symptoms.
23. British Society of Gastroenterology: UK guidelines on the management of variceal haemorrhage in cirrhotic patients guidance says:
‘1.4 If Non-Selective Beta Blocker alone are used, there is no need to undertake further endoscopy unless clinically indicated.’
‘2.1 We recommend all patients with cirrhosis should be endoscoped at the time of diagnosis. There is no indication to repeat endoscopy in patients receiving non-Selective beta blocker.’
24. The records show Mr E was using non-selective beta blocker, propranolol (this medication slows down your heart rate and makes it easier for your heart to pump blood around your body). In line with the guidance set out above there was no requirement to undergo yearly endoscopies.
25. British Society of Gastroenterology; Anticoagulation for portal vein thrombosis guidance says: ‘Diagnosis: doppler ultrasonography of the abdomen is usually the initial test to diagnose portal vein thrombosis. Cross-sectional imaging, such as multiphase contrast-enhanced and MR cholangiography, helps in defining the extent and often the local cause of portal vein thrombosis. Most patients will benefit from an evaluation for systemic prothrombotic conditions, and the extent should be individualised and guided by clinical presentation.’ (MR cholangiography is the method of obtaining images of organs and ducts that make and store bile).
26. The MRI scan on 2 December 2019 report appeared to show a blood clot but it was not conclusive. Further tests were required to be sure a blood clot was identified. A doppler scan (an imaging test that uses sound waves to show blood moving through blood vessels) was performed on 15 January 2020. In line with guidance set out above doppler scan is usually the initial test to diagnose portal vein thrombosis.
27. The records show the scan on 15 January was inconclusive for portal vein thrombosis.
28. Our adviser says the Trust were trying to establish a diagnostic path to determine if there was portal vein thrombosis. The Trust were not able to establish a blood clot at this time, therefore no treatment was started.
29. We asked our adviser if PVT had been diagnosed should the Trust have prescribed medication for Mr E.
30. British Society of Gastroenterology, Anticoagulation for portal vein thrombosis guidance says: ‘In patients with cirrhosis, anticoagulation can be considered in symptomatic patients with extension of the clot to the SMV or a definite pro-coagulant risk factor. Despite limited evidence, anticoagulation according to the European Association for the Study of the Liver (EASL - guidelines2 and Baveno VI consensus3) may be used to support cirrhotic PVT patients while on the transplant waiting list. PVT progression can increase the complexity of surgery and adversely affect the post-transplant outcomes. The risks and benefits of anticoagulation in other settings remain unclear.’
(Anticoagulation medicines help prevent blood clots. SMV is the superior mesenteric vein which is a large blood vessel in the abdomen. PVT stands for portal vein thrombosis).
31. Our adviser says even if the Trust had diagnosed portal vein thrombosis, the British Society of Gastroenterology guidance says that it should be considered on a case-by-case basis and the risks and benefits of anticoagulation in settings outside of transplants remain unclear.
32. The evidence indicates the Trust were correct to pursue a systematic way of confirming if Mr E had a blood clot prior to providing medication.
33. In line with guidance, the Trust ordered a doppler scan following Mr E’s MRI scan in December 2019. The doppler scan took place in January 2020 and the records show a blood clot was not conclusive.
34. We understand what a difficult time it must have been for Mrs E and how challenging it was to see her husband’s health deteriorating. We have seen the correct investigations were carried out and he was treated in line with management of variceal haemorrhage in cirrhotic patients and Anticoagulation for portal vein thrombosis guidance. The Trust were unable to conclusively diagnose him following an MRI and doppler scan. Therefore, the Trust provided him with no treatment. We find no fallings in the care Mr E received.
Test results
35. Mrs E says the Trust were unable to locate Mr E’s doppler scan results from 15 January on arrival to A&E on 5 February. She was alarmed and confused when told this. She says the Trust then confirmed they were inconclusive.
36. GMC good medical practice says: ‘You must be honest and trustworthy in all your communication with patients and colleagues. This means you must make clear the limits of your knowledge and make reasonable checks to make sure any information you give is accurate.’
37. The records show that the MRI scan on 2 December 2019 and doppler scan on 15 January 2020 did not conclude Mr E had a blood clot. In line with GMC guidance the Trust gave Mrs E accurate information.
38. We understand how important it is for patients and their family members to be informed promptly of any results. It would have been distressing for Mrs E to think that the Trust could not locate important scans. The Trust have apologised that the results of the scan could not initially be found. Mrs E has confirmed she was told the reports were inconclusive once they had been located. This information is accurate according to the medical records in line with GMC guidance. We therefore, find no failings in the communication of the scan results.
Fluid drain
39. Mrs E complains the Trust took too long to drain the pleural effusion (build-up of excess fluid between the layers of the pleura outside the lungs) from Mr E’s chest. The fluid was not drained until four days after his admission on 9 February 2020.
40. The Trust said a chest drain was inserted upon his admission to ICU as a chest X-ray had showed a significant amount of fluid around his lungs. A decision was taken to drain this fluid to support his breathing. When the drain was inserted, immediately 1800mls of fluid was drained and the drain was then clamped.
41. The records show the CT scan on 6 February noted ‘tiny amount of ascites seen in the right sub diaphragmatic space, but no significant ascites within the abdomen.’ Ascites is a condition in which fluid collects in spaces within your abdomen. The right sub diaphragmatic space is found below the diaphragm.
42. The same report says, ‘large right-sided pleural effusion’. Mr E did not have a build-up of fluid in his stomach but did outside his lungs.
43. At 3pm on 6 February his right sided pleural effusion was recorded in the notes. At 2.45pm on 7 February the records show further investigations were to be completed for his pleural effusion.
44. At 11.10pm on 8 February Mr E’s pleural effusion was worsening. The notes show the Trust were considering a pleural tap (drain).
45. The Trust performed a chest drain on Mr E on 9 February. The exact time has not been noted.
46. British Society of Gastroenterology: Guidelines on the management of ascites in cirrhosis says: ‘HH approximately affects 5–12% of patients with advanced liver disease. In patients with HH who are not undergoing a TIPSS and/or a liver transplant evaluation, alternative palliative interventions should be considered’. (HH stands for hepatic hydrothorax which is an accumulation of transudative fluid in the pleural space. TIPSS is a transjugular intrahepatic portosystemic shunt which is a tract created within the liver using X-ray guidance to connect two veins within the liver).
47. World Journal of Hepatology says: ‘Drainage of the pleural cavity: The installation of tubular drains into the pleural cavity for prolonged aspiration of the contents is undesirable in refractory HH. First, it is fraught with the development of a collapsed lung and a collection of pus in the pleural cavity. Second, a large loss of fluid may lead to renal dysfunction and electrolyte imbalance. Taken together, they significantly worsen the disease prognosis and increase the risk of death.’
48. Our adviser says fluid can come back quite quickly after a chest drain. To drain fluid in the lungs a doctor would have to go through two ribs. There is a blood vessel which is just beneath the rib which can be hit. The risk of bleeding is quite high, and blood does not clot properly in patients with liver disease.
49. In line with British Society of Gastroenterology guidance, Mr E was not undergoing a TIPSS or a liver transplant evaluation. The guidance notes that other interventions should be considered. The guidance does not recommend a chest drain.
50. World Journal of Hepatology guidance states installation of tubular drains is undesirable and could lead to further complications.
51. The Trust were aware of the fluid in Mr E’s chest. The records note that it was monitoring this condition. He complained of worsening symptoms late on 8 February 2020 and the Trust performed the chest drain the next day.
52. Our adviser says draining the fluid was an acceptable thing to do, however you need to be careful and considered, especially given his condition. Mr E had COPD which made this a complicated situation.
53. We do not underestimate what a difficult time this was for Mrs E and how worried she was about her husband. The evidence shows the actions taken by the Trust were in line with guidance from British Society of Gastroenterology and World Journal of Hepatology. The records show that the Trust were monitoring his fluid and the guidance states that a chest drain should only be considered in certain situations. Only once his condition worsened did the Trust feel it appropriate to perform a chest drain. Therefore, we find no failings in fluid drain care.
Oxygen and ward movements
54. Mrs E says on 8 February she asked a nurse on the ward if Mr E could be assisted with oxygen to help with his breathing. She was told by the Trust he was within COPD limits. She says he should have been moved to Ward A, which can accommodate high dependency respiratory patients, sooner than he was. She says when he was moved it was too late.
55. Mr E’s NEWS (National Early Warning Score) observation chart shows his oxygen saturation was monitored daily. The records show that after his admission on 5 February his oxygen levels were noted every few hours.
56. British Medical Journal Respiratory Research, British Thoracic Society Guideline for oxygen use in adults in healthcare and emergency settings says: ‘For most patients with known COPD or other known risk factors for hypercapnic respiratory failure a target saturation range of 88-92% is suggested pending the availability of blood gas results.’ (Hypercapnic respiratory failure means there is too much carbon dioxide in the blood).
57. Between 5 February and the afternoon on 8 February his observation chart shows that he remained on or above 88-92% target saturation range. During this time the medical records show Mr E did not require oxygen. Mr E was within the target range as set out in the guidance above and so there was no justification to move him to a high dependency respiratory ward.
58. The first time his oxygen level fell below the guidance level was at 10.50pm on 8 February. His oxygen level dropped to 84-85% saturation range and the Trust gave him oxygen. After the Trust commenced him on oxygen, by 11.05pm his levels were back to normal and remained, at 88-92% in line with guidance.
59. The Trust informed Mrs E at 4am on 9 February that Mr E was now on oxygen and he would be moved wards to Ward A.
60. Our adviser said that the decision to move wards was a clinical judgment issue. He was moved to a high dependency respiratory ward because his oxygen levels dropped. It seems to be reasonable that he was moved as there was a requirement for specific respiratory care.
61. It was unfortunate on the day Mrs E asked the Trust to assist with his breathing he later needed oxygen. This understandably caused her to worry about his care. We have found the information given to her at that time was correct. Mr E’s oxygen levels were in line with guidance. Once his oxygen levels had dropped the Trust acted promptly by administering oxygen and moving him the next morning to an appropriate ward. His records show within 15 minutes the Trust brought his oxygen saturation back within the guidance target. We therefore find no failings in his respiratory care.
Drip
62. Mrs E says on 8 February while Mr E was still on Ward B the Trust placed him on a drip which came out of his hand. It took two hours to be put back in.
63. His medical records show on 8 February the Trust were encouraging him to take his medication orally. His IV medications had been changed to oral and he was not prescribed any IV medication between 11am on 7 February and 6pm on 8 February.
64. The Trust have apologised for the period it took to reinsert Mr E’s IV drip.
65. NMC professional standards of practice and behaviour for nurses, midwives and nursing associates guidance says: ‘Make sure that any treatment, assistance or care for which you are responsible is delivered without undue delay.’
66. Our adviser says that whilst it is not good that Mr E’s drip fell out and took two hours to be replaced, he was not on a continuous infusion at that point. There was no delay of treatment, as his medication was oral at this time.
67. We recognise it was worrying for Mrs E as it appeared Mr E was not receiving his medication for two hours. We are pleased to see the Trust have apologised for the two hours it took to re-connect the IV drip. The evidence shows that he was not receiving medication through a drip at that time. Therefore, there was no clinical impact to Mr E. Treatment in line with the NMC standards is to be provided without undue delay. While there was a delay in reconnecting the IV drip there is no evidence other care was not provided. Therefore, we cannot say the care fell so far below what it should have been to be a failing.
Carvedilol
68. Mrs E complains on 10 February she found a box of medication, carvedilol, in Mr E’s possessions. The leaflet enclosed reads ‘do not take if you have liver disease’.
69. The Trust say it was decided that Mr E’s regular beta blocker propranolol should be changed to carvedilol.
70. The records show that he was prescribed carvedilol, 6.25mg, on 6 February and took the medication between 6 and 9 February.
71. British Society of Gastroenterology, UK guidelines on the management of variceal haemorrhage in cirrhotic patients says: ‘we recommend non-cardioselective β blockers (NSBB) or variceal band ligation (VBL). We suggest pharmacological treatment with propranolol as first line. VBL is offered if there are contraindications to NSBB. The choice of VBL or NSBB should also take into account patient choice. We suggest carvedilol or nadolol as alternatives to propranolol’.
72. The guidance further says, ‘carvedilol resulted in significantly lower variceal bleeding compared with VBL, and haemodynamic responders to carvedilol or propranolol had significantly lower mortality than those treated with VBL.’
73. Carvedilol is the recommended drug for Mr E’s condition in line with guidance.
74. It is understandable why Mrs E was worried about the prescription of carvedilol given its warning. The British Society of Gastroenterology guidance states that it is a safe medication for someone with Mr E’s condition. It also states that carvedilol results in significantly lower variceal bleeding in comparison to other medications. The evidence shows there are no failings in the prescription of carvedilol.
Treatment for three bleeding varices
75. Mrs E complains the Trust told her on 8 June that Mr E’s oesophagogastroduodenoscopy (visual examination of the upper intestinal tract) on 5 February showed no points of bleeding. She says the coroner’s report says the same report showed three varices and bands were applied to stop the bleeding. Mrs E says the coroner’s report contradicts the Trust’s report.
76. The Trust performed an oesophagogastroduodenoscopy on 5 February at 2.58pm. The records show the report confirms ‘large amount of 'coffee ground' residue in the stomach and small amount in the oesophagus on intubation. No source of active/recent bleed seen up to distal duodenum. In view of the above, presume variceal source of bleeding. Three bands applied in the distal oesophagus’.
77. The report indicated there was no bleeding at the time of the procedure. Our adviser said that the coffee ground residue that is noted would indicate that there had been bleeding at some point. As a result the Trust put bands in the distal oesophagus to reduce the chance of this bleeding again.
78. British Society of Gastroenterology, UK guidelines on the management of variceal haemorrhage in cirrhotic patients guidance says, ‘Control of bleeding: Variceal band ligation is recommended as the preferred endoscopic method.’
79. The records show that the Trust provided treatment in line with guidance. Three bands were applied to prevent bleeding occurring again.
80. The corners report on 18 February says ‘An oesophagogastroduodenoscopy was conducted on 05/02/20 at 14:58, which showed three varices bands were applied to stop the bleeding.’
81. The Trust’s letter to Mrs E on 8 June says, ‘the varices were small and no points of bleeding could be seen.’
82. Both the Trust’s own report and the coroner’s report confirm that treatment was given in line with guidance. Bands were applied in the distal oesophagus.
83. The coroner’s report does not contradict the report by the Trust in relation to active bleeding. The coroner’s report reads ‘which showed three varices and bands were applied to stop the bleeding’. Our adviser says as there had been coffee ground residue in the stomach, at some point there had been bleeding. It does not mean it was bleeding on 5 February.
84. We recognise this must have been upsetting for Mrs E. There has been confusion regarding if there was or was not an active bleed on 5 February. The Trust acted in line with British Society of Gastroenterology guidance when it provided treatment by applying three bands on 5 February. The two reports do not contradict each other. Bands were applied to stop any further bleeding occurring. We cannot find a failing in the actions of the Trust.