Hospital care from 18 to 29 December 2016
15. Mr B went to hospital on 18 December with symptoms of high blood sugar levels, vomiting and pain in his side. Miss A says her family were originally told that Mr B had a bowel infection, but the Trust later said he was suffering from urosepsis, blocked kidney, and a kidney stone. The records indicate that Mr B was treated for potential urosepsis with antibiotics and intravenous (IV) fluids, and he was admitted to hospital.
16. Our urology adviser says urosepsis was an appropriate potential diagnosis for Mr B at this time and his treatment was in accordance with NICE guidance for sepsis recognition, diagnosis, and early management. We note that the Trust was still investigating Mr B’s symptoms at this time and other potential diagnoses were put forward in its complaint response, such as diverticular disease and renal pain.
17. The records indicate that Mr B decided to self-discharge from hospital overnight as he was unhappy, due to delays in the Emergency Department at Hospital A and because his mattress was uncomfortable. Mr B’s self-discharge went against the advice from the clinicians treating him, and our urology adviser says it had a negative impact on him. This is because when Mr B returned to hospital the following day, he had to be treated in the Intensive Care Unit (ICU).
18. It is noted that when Mr B returned to hospital, the Trust said he was profoundly unwell. In the ICU, he was treated as an emergency and had various investigations for his kidney problems which included a kidney stone. He was also given further IV fluids for potential urosepsis. Despite some challenges, the Trust felt that his condition improved over the next few days.
19. After Mr B was admitted to ICU on 19 December, our urology adviser says the correct sepsis protocol was followed in accordance with the relevant NICE guidance cited earlier. This included further antibiotics, IV fluids, taking his bloods, and measuring his oxygen saturation. Mr B’s kidney was also decompressed to relieve the pressure and pain of a build-up of infected urine.
20. Between 19 and 27 December, we consider that Mr B’s overall condition did improve due to the appropriate care he was receiving, as the Trust has indicated.
21. On 27 December, Mr B had a CT scan of his kidneys to see if his stone had migrated or passed through. The stone was still present, so the Trust said that Mr B now required a stent as part of a life-saving procedure.
22. The Trust said its preference would have been to remove a stent within six months, but the complexity of Mr B’s case, and the need for specialist input, meant he was not given a date for removal of his stent on discharge from hospital two days later. The Trust decided the safest option was to bypass the stone with a stent, allowing the ureter to heal, the kidney to recover and the infection to clear completely before embarking on definitive stone removal.
23. Our urology adviser says this was an appropriate course of action by the Trust, for the reasons it has highlighted above. Miss A says that Mr B’s stent was in place too long (until April 2017) and he was misdiagnosed before being discharged from hospital on 29 December.
24. As we have said, Mr B’s condition did improve between 19 and 27 December, but our urology adviser has pointed out that he was still recovering from urosepsis at this time. His overall fitness was still poor due to this, and the Trust also had to be cautious due to other clinical factors such as his historical heart problems. This meant that his kidney stone management, to eventually remove the stone, had to be dealt with cautiously especially as he would need a general anaesthetic.
25. Mr B needed a formal anaesthetic assessment and recovery time from his illness. He also needed a cardiological opinion, and all these factors delayed his management. Because of this, our urology adviser says it was not possible for the Trust to give Mr B a specific date for the removal of his stent, and a stone removal procedure, at that time. However, as his condition had been stabilised, it was an appropriate decision to discharge him on 29 December with a plan for follow-up in the coming months. There is no indication that Mr B’s stent was in place for too long or that he was misdiagnosed by the Trust.
Hospital care between 19 and 25 April 2017
26. When Mr B went to hospital on 19 April 2017, due to chest pain and breathing difficulties, we can see from the records that he was suffering from acute heart failure due to a severely leaking aortic valve. He was admitted to hospital.
27. He was treated by diuretic therapy, which is medication to help the kidneys get rid of unneeded water and salt. This makes it easier for the heart to pump blood as well as treating any blood pressure problems. Mr B also had oxygen therapy, catheterisation, blood tests, and he was given pain relief medication for his chest pain.
28. Our cardiology adviser says acute heart failure due to a severely leaking aortic valve was an appropriate diagnosis for Mr B. There was no indication that he suffered a heart attack even though the Trust thought this was a possibility at the time. His treatment was in accordance with the NICE guidance on recent-onset chest pain of suspected cardiac origin and acute heart failure. Mr B also had a possible infection, so the Trust correctly investigated if he was suffering from sepsis (as it had done in December 2016) in accordance with the relevant NICE guidance cited earlier.
29. Mr B again decided to self-discharge from hospital on 19 April, as he had done when he went to hospital in December 2016. Our cardiology adviser says Mr B’s condition was still serious and as a result he required ongoing inpatient care. Therefore, his self-discharge at this time was against medical advice. We cannot be sure of the impact this had on Mr B, but it is possible this led to inadequate treatment (because he discharged himself) and a deterioration in his overall condition.
30. When the Trust advised Mr B to go back to hospital on 20 April, he was transferred to a cardiac ward due to his leaking heart valve. On 21 April, Mr B’s temperature, heart rate and CRP increased, indicating he had a possible infection.
31. The records indicate Mr B was given ongoing diuretic and oxygen therapy when he returned to hospital to manage his ongoing heart failure. He was also given antibiotics to treat an infection which was appropriate, although there was some uncertainty about the origin of his infection. It could have been due to sepsis, but it could also have been a heart valve infection as Mr B had a history of this. Therefore, our cardiology adviser says it was an appropriate decision to transfer him to the cardiac ward as his heart failure condition was now deteriorating. The cardiac ward was the best setting for the Trust to continue treating Mr B and he was given echo scans/ultrasound tests to further investigate his heart and its nearby blood vessels. These were appropriate investigations.
32. The Trust wanted Mr B to be transferred to another nearby Trust on 22 April as it had a specialist heart centre. This was discussed by the relevant consultants but, unfortunately, there were bed availability issues at the nearby Trust. Mr B was also still significantly unwell from his infection and heart failure, and it was established that he was severely anaemic. This required further investigation before any heart surgery could be carried out.
33. Our cardiology adviser says it was appropriate for the Trust to consider a transfer for Mr B. This is because there was a nearby specialist heart centre that offered the type of treatment Mr B needed to repair or replace his leaking heart valve. If Mr B had been considered clinically fit enough for this procedure, he could have had valve replacement by open heart surgery. This type of treatment was not available at Hospital A.
34. As for whether the Trust should have looked elsewhere, if there were bed availability issues at their preferred facility, we are aware that each hospital has its own referral base so it is possible the Trust should have looked elsewhere. However, even if Mr B had been transferred elsewhere, we have to take into account that he was very poorly at the time due to his infection and heart failure. Therefore, our cardiology adviser says it is unlikely Mr B was clinically fit for immediate surgery. The receiving hospital would still needed to have stabilised Mr B before contemplating any surgery which would have taken time.
35. Anaemia is a condition that can be caused by bleeding from somewhere in the body. Our cardiology adviser has commented that this could have been an emergency condition for Mr B and therefore it needed identifying and correcting before surgery could be considered, which takes time. Mr B also had an infection. As such, an endoscopy procedure was appropriate to check for bleeding and infection in areas like Mr B’s stomach and bowel, in accordance with BCSH guidance for assessment of bleeding prior to surgery.
36. Mr B’s treatment was escalated on 23 April as his urine output had diminished. The Trust said that even with hindsight, it is not certain that if Mr B had been transferred on 23 April this would have saved his life. By the time Mr B reached ITU (24 April), his heart function was deteriorating very quickly, and it was accepted that he was now at the end of his life.
37. Unfortunately, the Trust said there was not enough time to insert a drain to deal with the fluid that had built up around Mr B’s heart. Due to the seriousness of Mr B’s condition, inserting a drain at this stage could have caused a cardiac arrest. He had to be cardioverted, resuscitated, and intubated which made his situation more complex. Very sadly, Mr B died on 25 April 2017. The causes of his death were congestive cardiac failure, aortic regurgitation, and septicaemia.
38. Despite conventional measures to treat Mr B’s heart failure, as outlined earlier in this report, these were unsuccessful. This is because Mr B had intractable heart failure. This means his leaking valve was so severe it was resistant to these conventional measures. Therefore, escalating Mr B to ITU by 23 April was the Trust’s only option. This gave him intensive support in his breathing (intubation) and adrenaline to support his blood pressure, both of which were necessary by this stage. The Trust’s approach is supported by ESC guidelines for the diagnosis and treatment of acute and chronic heart failure.
39. Even if Mr B had been transferred to another specialist heart centre on 23 April, our cardiology adviser says it is highly unlikely he would have been clinically fit enough to have had a complex heart procedure such as open-heart surgery. He was too unwell at this point and would still have required stabilisation of his condition before any operation could have taken place. In-hospital mortality for acute heart failure, with resultant cardiogenic shock and multiorgan failure, carries a greater than 50% chance of mortality despite the treatments commonly administered, as outlined above. This is supported by the ADHERE study on in-hospital mortality in patients with acute decompensated heart failure requiring intravenous vasoactive medications.
40. In summary, we agree with the Trust that by 24 April Mr B was at the end of his life. Therefore, the decision by the Trust to withdraw treatment and begin palliative care was appropriate. Mr B was given the maximum possible therapy when he was in hospital but, very sadly, the heart failure he had suffered, due a severely leaking valve, turned out to be fatal for him.
Conclusion
41. We have thoroughly and impartially investigated this complaint and come to a decision from careful consideration of the evidence. Based on the evidence we have seen, it is our view that there were no failings in the hospital care the Trust provided in December 2016 or April 2017 to Mr B for kidney issues, sepsis, or cardiac issues. We have not found any evidence that the care provided to Mr B at these times was inadequate, as Miss A has suggested. For these reasons, we have not upheld Miss A’s complaint.