ED attendances
26. Mr O complains that from September 2017 to February 2018, he attended the ED suffering with chronic pain. He says that each time, clinical staff sent him home and did not carry out full investigations of his symptoms. He complains this led to him developing a life threatening build-up of fluid in his chest.
27. The Trust said its staff carried out relevant tests and thoroughly assessed Mr O each time he attended the ED. It considered it managed Mr O’s condition appropriately during this time.
28. To help us reach a view on what took place from 15 to 17 November, we spoke to an emergency medicine adviser. We also referred to the GMC’s Good Medical Practice guidance which says the doctors who assess, diagnose, or treat patients must: a. ‘adequately assess the patient’s conditions, taking account of their history (…), their views and values; where necessary, examine the patient b. promptly provide or arrange suitable advice, investigations or treatment where necessary (…)’.
29. On 15 November 2017, Mr O attended the ED suffering with difficulty breathing and severe left sided chest pain. An ED doctor assessed him and arranged for a chest X-ray and blood tests. The test results did not show any obvious concern and Mr O was admitted to the acute medical unit for further assessment.
30. Mr O went on to have further tests and doctors suspected he had costochondritis and may be suffering a flare-up of arthritis. A chest CT scan was arranged to check for a possible blood clot in his lungs, or any other more serious underlying condition. The CT scan took place on 17 November and did not show evidence of any abnormalities.
31. Our emergency medicine adviser said that blood tests, assessments and a chest CT scan were all appropriate to investigate Mr O’s symptoms. This standard of care meets the GMC guidance set out in paragraph 28. The tests did not reveal any serious underlying concerns that meant Mr O should have been admitted to hospital for any further treatment. The CT scan result was normal and did not show any build-up of fluid in his chest.
32. In consideration of the advice we have received, and with reference to GMC guidance, we consider the ED team carried out appropriate investigations to decide what steps to take with Mr O’s care. The team agreed he should be admitted for further examination which took place on the medical ward. We do not have concerns with what took place during this admission.
33. Mr O next attended the ED on 4 February 2018, suffering with left sided chest and back pain that was affecting his breathing. He also had an ongoing sore throat and a fever. An ED doctor assessed Mr O, noted that he was under the care of a rheumatologist and had been suffering increasingly with his symptoms since November. The doctor reached a working diagnosis of a flare-up of arthritis and costochondritis.
34. Mr O underwent a chest X-ray, an Electrocardiogram (ECG) and blood tests. Mr O’s blood test results showed raised CRP levels. The chest X-ray showed Mr O’s heart was a normal size and there was no evidence of fluid on his lungs or anything more serious that may be causing his symptoms. If Mr O had any build-up of fluid in his chest at that time, it would have shown on the X-ray.
35. The ED doctor offered Mr O admission, but he wanted to return home. After further discussion, the doctor agreed Mr O could return home with increased pain relief and diazepam which is a sedative and muscle relaxant.
36. Our emergency medicine adviser has confirmed appropriate tests were carried out on this attendance. The results of the investigations supported a working diagnosis of a flare-up of arthritis and costochondritis.
37. In consideration of the advice we have received, and with reference to the GMC guidance quoted in paragraph 28, we are satisfied the ED team provided an appropriate standard of care to Mr O during this admission.
38. On 12 February, the records show Mr O attended the ED because he was struggling to manage his pain at home. He also had a temperature and an ongoing sore throat. We are sorry to hear of how unwell he was and of the pain he had been enduring for the months leading up to this date. We understand Mr O’s symptoms had a significant impact on him during this time.
39. An ED doctor assessed Mr O and noted his blood test results showed raised CRP levels. The doctor considered it likely Mr O was suffering with an acute flare-up of arthritis.
40. The records show the ED team spoke with a rheumatology doctor who advised that if Mr O was unable to manage his pain at home, he should be admitted for a rheumatology review. A referral was sent to the rheumatology team and Mr O was admitted to the medical ward to await review.
41. Our emergency medicine adviser has explained it was appropriate for the ED team to discuss Mr O’s case with the rheumatology team to discuss how to manage his care.
42. We consider the investigations carried out and the discussion with the relevant specialist team complies with the standard of care set out in the GMC guidance.
43. A rheumatology doctor reviewed Mr O on the afternoon of 13 February and requested a chest X-ray, ECG, and blood tests. The X-ray on 14 February indicated Mr O had a pericardial effusion and an urgent follow-up ultrasound confirmed this. He went on to receive treatment for this condition before being discharged on 22 February.
44. Our emergency medicine adviser has explained that a build-up of fluid around the heart or lungs may not always cause a patient any symptoms until the fluid reaches such a volume that it affects the functioning of the organ.
45. The build-up of fluid around the heart can lead to symptoms of breathlessness, low blood pressure, and fluid retention. Fluid in the lungs can cause breathlessness. The records say that when the effusion was diagnosed on 14 February, it was not initially causing Mr O any symptoms.
46. Mr O attended cardiology and rheumatology appointments following his discharge from hospital. In a clinic letter from 28 February 2018, a cardiologist said Mr O’s pericardial effusion was likely a complication caused by his arthritis. This is because arthritis can cause inflammation in the body, and this can affect the heart and blood vessels. Inflammation of the tissue around the heart can lead to a build-up of fluid developing. However, the cardiologist also said they could not rule out a possible viral cause for the inflammation.
47. A rheumatologist, on 15 May 2018, commented it was ‘still not entirely clear’ what caused the pericardial effusion. They queried if Mr O’s arthritis medication may have triggered this.
48. We are sorry to hear how unwell Mr O was by 12 February. We can understand why he has questioned if clinicians could have recognised at an earlier time that he was becoming seriously unwell and if intervention could have prevented this.
49. Following careful review of the ED attendances leading up to this date, we consider the assessments and tests caried out on each attendance were appropriate to investigate Mr O’s symptoms. The diagnoses reached were clinically reasonable and supported by the investigation results.
50. The CT scan on 17 November and chest X-ray on 4 February did not show evidence of a more serious underlying cause for Mr O’s pain. The tests did not show evidence a pericardial effusion was present before his admission on 12 February. We do not consider ED clinicians missed opportunities to act at an earlier time, or that they should have provided alternative treatment that would have prevented the effusion from developing.
51. In careful consideration of the advice we have received, and with reference to GMC’s Good Medical Practice guidance, we have not found a failing in the care provided to Mr O during his ED attendances.
Rheumatology care
52. Mr O complains the rheumatology team did not do enough to treat his arthritis and manage his chronic pain. He complains the consultant appeared disinterested in helping him and did not recognise or react to his deteriorating condition. He feels it was a battle to get the rheumatologist to help him and considers his poorly managed arthritis may have increased his risk of suffering a pericardial effusion.
53. The Trust said towards the end of 2017, Mr O had a low white blood cell count. This meant treatment for his arthritis was delayed until the blood count returned to normal. The rheumatologist said it was important to give time to see if the drugs he was taking could be effective before considering alternatives. The Trust said Mr O was not showing signs he was developing a pericardial effusion at the appointments he attended.
54. In the summer of 2017, Mr O’s rheumatologist noted he was having a flare-up of arthritis, and his white blood cell count was low, and this needed to be monitored. The rheumatologist decided Mr O should have infusions of the biological drug Remicade on an eight-weekly cycle. Mr O was also prescribed a medication called Arcoxia that relieves pain and inflammation, and an opiate painkiller called dihydrocodeine.
55. At an appointment on 10 October 2017, the rheumatologist noted Mr O’s recent hospital admission for joint pain and that his last infusion of medication was on 15 July. The infusions had been paused due to concern about Mr O’s low white blood cell count. The NHS website for psoriatic arthritis explains that biologic treatments can make it ‘more likely’ for someone to suffer infections. This is because the medication affects the immune system.
56. At this appointment, Mr O explained the joints in his knees, shoulders, and hands had been causing him pain. The rheumatologist documented these were swollen. The doctor reviewed Mr O’s blood test results and decided that due to the significant pain he was suffering, the Remicade infusions should restart. He also referred Mr O’s case to a haematologist for advice about his recurring neutropenia.
57. Our rheumatology clinical adviser has said the rheumatologist carried out a thorough assessment of Mr O and made reasonable attempts to investigate his symptoms on this date. The consultant put an appropriate management plan in place and clearly documented the clinical rationale for the decisions made.
58. The GMC’s Good Medical Practice says that doctors should, ‘refer a patient to another practitioner when this serves the patient’s needs.’ The haematology referral was made to help the rheumatologist understand what might be causing the fluctuations in Mr O’s white blood cell count and how best to manage this. This action meets the standard set out in GMC guidance.
59. Our adviser has explained that when a treatment is no longer effective for a patient, there are different options available. A doctor could consider increasing the frequency of the dose of the medication or trying a drug that works in a different way. The NHS website for ‘psoriatic arthritis’ says an alternative biological treatment can be prescribed if one proves ineffective.
60. Mr O complains the rheumatologist did not check the levels of medication in his body to make sure the dosage was effective for him and that he was being given this frequently enough.
61. Our adviser has explained it would not be routine to assess the levels of medication in a person’s body. In Mr O’s case, it would not likely not have been beneficial to increase how often he was having infusions because there was concern the drugs may be affecting his white blood cell count. The rheumatologist changed the type of biological drug they were prescribing at the end of July 2017. For the following months, they then monitored Mr O’s response to this.
62. The rheumatologist continued to prescribe Mr O pain relief alongside the medication for his arthritis. By October 2017, he was prescribed Arcoxia at 90mg a day which meets the maximum dosage recommended in BNF 71 for the treatment of pain and inflammation caused by arthritis. He was also prescribed 90mg of dihydrocodeine twice a day. In line with the BNF 71, this was the maximum dosage to treat severe chronic pain.
63. Our adviser has confirmed the choices of pain relief were reasonable and the doses were appropriate to treat Mr O’s flare-up of arthritis. We are satisfied the dosages were prescribed in line with BNF guidance. We are sorry Mr O continued to suffer with pain and found this difficult to manage.
64. At the appointment on 11 October, we can see the rheumatologist identified Mr O was suffering with increasing pain and prescribed relevant treatment in response to this. They also arranged for investigation of what may be causing Mr O’s neutropenia. Following careful review of the advice we received, we consider the rheumatologist took appropriate steps to assess and treat Mr O’s symptoms. This standard of care meets the GMC guidance quoted in paragraph 28.
65. Mr O attended a nurse led rheumatology appointment on 13 November. The nurse noted his white blood cell count had slightly increased, but Mr O was suffering with constant pain which was affecting his sleep and mobility. The nurse reported these concerns to the consultant rheumatologist who queried if Mr O would benefit from referral to a psychologist.
66. On 5 December, Mr O told the rheumatologist he had been suffering with increasing pain all over his body for the past few weeks. He said he had been told he may have costochondritis at a recent hospital attendance. Mr O was unhappy with how the rheumatologist had been managing his condition and asked him to refer him to a different doctor for a second opinion.
67. The rheumatologist carried out an examination of Mr O’s lungs, and torso, and assessed his joints. They noted Mr O’s lungs were clear but he appeared to have developed a more widespread ‘polyarthritis’, this means multiple joints are affected by the condition. They requested further blood tests and an ultrasound scan of some of the joints in his right hand. The rheumatologist also asked Mr O if he wished to speak to a psychologist, but he declined this.
68. The plan was for the rheumatologist to see Mr O in six months’ time, and Mr O would see a different doctor in between for a second opinion.
69. In consideration of Mr O’s recent diagnosis of costochondritis, it was appropriate for the rheumatologist to assess Mr O’s respiratory system and his joints at this appointment. The ultrasound scan requested of Mr O’s hands would help the rheumatologist to assess the progression of the disease.
70. Mr O has questioned how the rheumatologist reached a conclusion that he was finding it difficult to accept his condition. He found the offer of input from a psychologist unhelpful and felt the rheumatologist was not helping him with his symptoms.
71. NICE TA199 guidance, ‘etanercept, infliximab [Remicade] and adalimumab for the treatment of psoriatic arthritis’ says psoriatic arthritis can have ‘a substantial impact on quality of life’. The condition can affect a person being able to work and carry out daily activities.
72. Our rheumatology adviser has explained it is not unreasonable to discuss the psychological effects of pain and chronic disease with a patient who has a long-term condition. It was appropriate to suggest a review with a specialist if the doctor considered this would be helpful. This was not the only treatment offered to Mr O, and there is no evidence to suggest the doctor disbelieved Mr O’s accounts of the pain he was suffering.
73. In consideration of the advice we have received, and the NICE guidance, in our view it was appropriate for the rheumatologist to check if Mr O felt he may benefit from psychological support.
74. To help Mr O manage his pain, he was still being prescribed Arcoxia and dihydrocodeine. He was also prescribed the morphine-based pain medication oramorph, when needed. Our adviser has noted there was no consideration of steroids to treat the pain. However, some steroids can affect the white blood cells and so it is sensible to be cautious in prescribing these to someone with neutropenia. For this reason, we are not critical that steroids were not considered.
75. Mr O did not report any symptoms on 5 December that indicated he had pericarditis, such as chest pain that gets worse when leaning forward. Pericarditis is the swelling of the tissue surrounding the heart. A pericardial effusion can be a complication of this condition.
76. Following careful consideration of the evidence, we consider the documented management plan was appropriate on this date. There was no indication Mr O was becoming unwell with a pericardial effusion, and we consider the actions taken by the rheumatologist were appropriate to help Mr O manage his symptoms. We consider the standard of care provided meets the GMC guidelines.
77. Unfortunately, Mr O could not attend the ultrasound scan planned for 10 January 2018 because he was very unwell with joint pain. The consultant rheumatologist documented Mr O’s mother called on this date to explain his absence and they were very concerned. The rheumatologist suggested Mr O could attend a review appointment that day, but Mrs O said her son could not make this. The rheumatologist noted he would wait to hear from Mr O.
78. On 18 January 2018, the rheumatologist wrote to Mr O to say he had received advice from the haematology team. The team suggested he likely had one of two conditions that caused varying white blood cell counts and these did not need any specific action to manage. Mr O would need to undergo continued monitoring and he should seek urgent medical help if he had any symptoms of infection.
79. The records show Mr O attended an appointment with a private rheumatologist on 29 January 2018. The doctor requested further investigations and discussed different medication options with Mr O. It was agreed the doctor would continue to treat Mr O going forward.
80. Taking into account the advice we have received, and the NICE and GMC guidance referred to above, we consider Mr O received appropriate care from the rheumatology team. The rheumatologist identified Mr O was suffering a flare-up of arthritis and could see how this was impacting him. We consider the rheumatologist took relevant action to manage this and put suitable plans in place. Appropriate referrals were made to investigate Mr O’s symptoms to help inform the rheumatologist’s approach to his care.
81. The records do not indicate Mr O was presenting with the symptoms of a pericardial effusion when he attended the rheumatology appointments. We have not seen that the rheumatologist missed an opportunity to identify or prevent this condition before Mr O’s hospital attendance on 12 February. We have not found failings in this area of the complaint.
82. It is clear from the records, and from what Mr O has told us, that he was finding the symptoms of his condition very difficult to manage at the end of 2017 and early 2018. We are very sorry to hear of the pain and distress he was suffering. We hope we have been able to clearly explain why we do not have concern about the treatment he received.
Pain management
83. Mr O complains that when he attended an appointment at the pain clinic on 18 January 2018, the pain management consultant did not examine him, and instead suggested he was depressed. He said the consultant prescribed the antidepressant mirtazapine at such a low dosage that it did not help Mr O with his anxiety. Mr O complains the consultant did not help him manage his pain and he found the appointment unhelpful.
84. The Trust said that for patients with widespread pain, the most successful approach is to focus on managing the issues caused by this pain, rather than on the pain itself. It said there would have been little benefit to the consultant physically examining Mr O on this date. The Trust said the focus at this appointment was to help manage the effects of the pain and to help address his difficulty sleeping.
85. The clinic letter from this appointment says Mr O told the pain consultant the pain he was suffering was causing him significant anxiety, it was affecting his sleep and he had a poor appetite.
86. Our pain management adviser has explained that by the time Mr O attended the appointment on 18 January, he had a diagnosis of costochondritis. He had also been suffering with increasing widespread pain due to his psoriatic arthritis. Mr O did not attend the pain clinic for a diagnosis because the rheumatology team had already determined this. The records show a rheumatology consultant had physically examined Mr O on many occasions leading up to this date.
87. The purpose of Mr O attending the pain clinic was for the team to see if there were ways to help him better manage his pain. There was no reason for the pain consultant to re-examine Mr O again because his diagnosis was already clear.
88. The GMC’s, Good Medical Practice says doctors must, ‘recognise and work within the limits of [their] competence. The approach to Mr O’s care taken by the pain consultant complies with this guidance because their role was to help address the pain the medication he was already taking was not effectively managing.
89. The clinic letter does not refer to any discussion of depression with Mr O, but the Trust’s complaint response confirms the pain consultant did discuss this with him. It says this is because depression is often linked to patients with chronic pain. The pain consultant commented that directly questioning a patient about depression can be important, particularly with male patients who may be less likely to volunteer this information.
90. NICE guidance for ‘Depression in adults with a chronic physical health problem: recognition and management’, says that ‘a chronic health problem can both cause and exacerbate depression’. Depression is ‘two to three times more common in patients with a chronic physical health problem’.
91. We are sorry Mr O did not find it helpful for the pain consultant to ask him about depression. In consideration of NICE guidance, that says depression is more likely to be experienced by patients suffering with chronic pain, it is our view that it was appropriate for the consultant to discuss this with him.
92. After discussing the symptoms Mr O was struggling with, the pain consultant noted he had pain all over his body and was reporting that morphine was only taking the ‘edge off’ this. The consultant decided to try an alternative treatment that would have an overall effect on his experience of the pain.
93. Our pain management adviser has explained that when a patient is experiencing widespread pain, it can be better to try to address the overall quality of pain control. This can be done with the use of drugs that affect the way pain messages are processed in the body. Mirtazapine is a drug that works in this way and so can be effective to help reduce a patient’s pain.
94. If a patient’s pain is under better control, this can in turn help to reduce anxiety levels and overall quality of life. Our pain management adviser has commented a specific anti-anxiety medication could have later been considered if the mirtazapine did not help with this.
95. The NHS website for the uses of antidepressants says that whilst antidepressants were not initially designed to be prescribed as painkillers, they ‘can also be used to treat chronic non-neuropathic pain’. The way they work in the body means that it can be clinically appropriate to prescribe if a clinician considers this could be of benefit.
96. In terms of mirtazapine helping with sleep, the BNF lists ‘drowsiness’ as a common or very common side-effect of the drug. Its sedative properties can therefore be helpful for patients suffering with difficulty sleeping.
97. Our pain management adviser has explained that a high dose of mirtazapine was not required to treat pain and 15mg was appropriate to trial Mr O on. Although Mr O was not being prescribed mirtazapine to treat depression, the BNF confirms the initial starting dose for this medication is 15-30mg.
98. Our pain management adviser has explained that it can be very difficult to treat arthritis because it is a long-term condition, and the symptoms can be hard to control. That Mr O sadly continued to suffer pain throughout this period does not mean that something went wrong in how clinicians responded to this. It is unfortunately due to the nature of the disease that it is not always possible to fully manage the symptoms.
99. We recognise that Mr O found the appointment at the pain clinic unhelpful, and we appreciate it must have been very difficult to cope with his chronic pain. We have carefully considered the actions taken by the pain management consultant and in view of the advice we received, and with reference to relevant guidance quoted above, we have not found failings in the care provided.
Conclusion
100. We acknowledge Mr O has been through a very difficult time and we are sorry to hear of how unwell he became in February 2018. We can appreciate why he has questioned if clinicians treating him in the months leading up to this date should have done more to investigate his symptoms.
101. We have carefully reviewed the care Mr O received from the ED, rheumatology, and pain management team. Following this work, we are satisfied he received an appropriate standard of care and clinicians did not miss indications of a more serious complication. We hope that our report helps reassure Mr O he did receive the appropriate care and treatment. We are grateful to him for bringing his complaint to our attention.