Delay in seeing the oncologist
17. We first looked at Mrs G’s concern there was a delay of several hours before the oncologist saw her husband.
18. Doctors admitted Mr G to A&E at 12.49pm on 19 September 2016. His records do not show when a doctor first saw him on this date. The clinical record shows when the doctor assessed him, their conclusion was Mr G needed a ‘surgical opinion’.
19. Our consultant colorectal surgeon adviser said the evidence shows it is reasonable to assume the first doctor to see Mr G was an oncologist. We can then see a surgeon saw Mr G at 4pm. Therefore, it is reasonable to conclude that the oncologist saw Mr G between his admission at 12.49pm and his assessment by the surgeon at 4pm. However, it is not possible to state exactly when. The Royal College of Surgeons Commissioning Guide sets a four-hour standard in emergency care. We can say it appears the oncologist saw Mr G within this timeframe, in line with the guidance.
20. The records confirm the Trust managed Mr G’s care within the four-hour standard. We have therefore not seen the Trust did anything wrong here.
Emergency surgery
21. Mrs G says, when her husband was admitted, the Trust told him he would have emergency surgery. However, she complains he waited two days before he underwent the surgery on 21 September.
22. The Trust acknowledged a wait but did not agree there was a delay. In terms of an explanation, it said where possible, surgery should not be performed late at night as it is an increased safety risk. It confirmed the surgeon would discuss each patient and produce a plan as to whether surgery was appropriate. It explained it would manage patients presenting with a blockage conservatively in the first instance. Conservative management is defined as the avoidance of intrusive measures, such as surgery or other invasive procedures. This is because often such blockages can resolve themselves. It said doctors conduct a further review after 24 hours, before considering the option of surgery. It apologised for not explaining this information to Mr or Mrs G and led them to believe there was a delay as opposed to a plan.
23. The Trust’s review panel agreed there was a lack of communication with Mr G and his family over the reasons for the apparent delay. After reviewing the clinical decision making, the Trust’s view was the length of time between Mr G’s admission and him having surgery was clinically appropriate.
24. Our consultant general surgeon adviser explained surgery for relief of a bowel obstruction is not considered to be high risk surgery and there is no immediate need to perform the operation.
25. NCEPOD guidelines classify urgent cases as those that need intervention for acute onset, or clinical deterioration of, potentially life-threatening conditions. It is also for those conditions that may threaten the survival of limb or organ, for fixation of many fractures, and for relief of pain or other distressing symptoms. The target time to theatre is normally within hours of the decision to operate. Mr G’s case did not meet these criteria. Our consultant general surgeon adviser confirmed the two-day wait would not have impacted Mr G’s recovery time. We recognise the waiting period was a really difficult time for Mr and Mrs G. The Trust carried out Mr G’s surgery within two days. This is in line with the appropriate guidelines.
Tissue Viability Nurse (TVN)
26. Mrs G then raised concerns that, despite a request on 21 September 2016, a TVN did not assess Mr G for several weeks.
27. The Trust accepted attendance by the community tissue viability team had been poor after Mr G’s discharge. The Trust explained the community nurses should have requested advice from the hospital, and a made a further referral back to the hospital for input from a TVN. The Trust confirmed it has shared this learning with its commissioners, who have addressed the concerns with the community team. The Trust acknowledged it may have been beneficial for a TVN to assess the wound. However, it said a build-up of fluid also led to the wound opening.
28. Prior to discharge Mr G was under the care of a stoma nurse. Our nurse adviser said it would not be a requirement for a TVN to be called to treat his wound. Association of Stoma Care Nurses UK, 2016, ‘Stoma Care Guidelines’ says, patients with a faecal/urinary fistula (a hole between the urethra (urinary channel) and the rectum), are seen and assessed by the stoma care nurse and an individualised care plan formulated. We can see from his medical notes Mr G was under the care of a stoma nurse whilst he was in hospital.
29. We have seen no evidence of any problems with the wound while Mr G was in hospital. Therefore, he would not have needed preventative measures.
30. Mr G had a laparotomy (a surgical incision into the abdominal cavity) wound which doctors closed with surgical clips. This is referred to as healing with primary intention (the healing of a wound in which the edges are closely closed). Our nurse adviser explained this kind of wound does not require a referral to a TVN unless there is a problem with wound healing.
31. On 26 September, staff noted no concerns with Mr G’s wound. Our nurse adviser said the referral to district nurses for wound care was sufficient. All nurses are taught fundamental wound management during their training. Post-surgical wounds, such as Mr G’s, are covered with a simple dry dressing and are observed by nurses for signs of post-surgical complication. This is set out in RACPG’s post-operative wound management guidance. This is fundamental wound care. Wound management falls under the remit of district nurses. The Queens Nursing Institute: district nurses guidance says district nurses lead teams of community nurses and support workers, as well as visiting house-bound patients to provide advice and care. This includes palliative care (caring for patients with a serious illness), wound management, catheter and continence care and medication support.
32. TVNs see patients with complex wound care needs and Mr G did not have such needs on his discharge on 26 September. Despite the acknowledgments from the Trust, we have not seen the Trust did anything wrong here. Mr G was cared for by a stoma nurse whilst he was in hospital and the Trust made an appropriate referral to the district nurses when he was discharged, in line with the appropriate guidelines. Therefore, we have not found any failings in relation to this part of the complaint.
Wound
33. Turning now to Mrs G’s concern the Trust discharged her husband on 26 September with a wound that had not been correctly looked after. She explained the wound was wet on discharge and when he went home, the wound opened.
34. The Trust explained staff were assessing Mr G’s wound as part of his daily nursing care and daily doctors ward round. It confirmed that at all times, the surgical wound was documented as clean and dry. It said there was only a concern about his sacrum (a bony structure located at the base of the lumbar region) which staff appropriately reviewed and referred for further care. The Trust said a build-up in moisture was a factor in the wound opening.
35. There are no notes to suggest the wound was wet when Mr G was discharged from the hospital. It is therefore difficult for us to reconcile the two different accounts.
36. We therefore looked at what other evidence is available. We know there were reports of the wound being wet on 30 September and 1 October.
37. Our consultant general surgeon adviser said this would be an indication it may have opened. However, it would not have been possible to prevent it. The wound opening occurred two weeks after surgery and after Mr G’s discharge from the hospital. This is rare but is a risk. GMC’s Good Medical Practice says: a. In providing clinical care you [doctors] must: prescribe drugs or treatment, including repeat prescriptions, only when you have adequate knowledge of the patient’s needs b. Provide effective treatments based on the best available evidence.
38. The consultant general surgeon adviser said, in the absence of the wound opening, there is no preventable action that could have been taken whilst Mr G was in the hospital. As above, we have not seen evidence of problems with his wound while he was in hospital, and therefore he did not need preventative measures. As a result, there is no evidence the Trust did not provide effective treatment, as set out in Good Medical Practice. We fully accept the issues with Mr G’s wound were distressing. This being said, we have not seen this was as a result of any failings on the part of the Trust.
Punctured lung
39. Mrs G complains Mr G’s lung was punctured when he had a catheter fitted. She is concerned this went unnoticed and the Trust did not report it as a clinical incident.
40. The Trust identified the pneumothorax (collapsed lung) after Mr G’s line insertion. It explained it managed this appropriately during emergency surgery for wound dehiscence (a partial or total separation of previously closed wound edges). It explained there was no evidence of a pneumothorax at the time of Mr G’s discharge.
41. Our consultant radiologist adviser explained a pneumothorax is a recognised complication which can happen with this procedure. The procedure report does not indicate there were any complications or that it took too long. There is no indication in the report to suggest Mr G was in pain, breathless or distressed at the time.
42. We cannot comment on whether Mr G felt excruciating pain during the procedure as Mrs G’s and the operator’s statement differ. There is no indication anything went wrong during the procedure. CIRSE Quality Assurance Document and Standards for Classification of complications says complications are an inevitable risk of every procedure, and these are classified by their severity and the speed of onset.
43. Pneumothorax is a well-recognised complication of a Portacath type central venous access device (used to give intravenous fluids, blood transfusions, chemotherapy, and other drugs). The risk of this is small, quoted at around 1 in 1,000 to 1,600 procedures. In itself it does not immediately constitute a clinical incident. Our consultant radiologist adviser said if the pneumothorax was not immediately evident it would not have been reported as a clinical incident at the time of the procedure on 29 September.
44. The management of pneumothorax is a very basic and well understood pathway. Depending on the size of the air leak into the chest and more importantly the patient’s degree of respiratory compromise (a decrease in respiratory (breathing) function), it consists of either observation or insertion of a chest drain.
45. We fully acknowledge Mr G suffered a pneumothorax, and this will have been painful and distressing. This being said, we are not able to link this to the procedure. This is because we have seen no evidence the procedure was carried out incorrectly. Also, it is a recognised complication. We have not therefore found any failings here. Nevertheless, we fully appreciate how painful this was to Mr G, and how distressing this was to them both.
Further surgery
46. Moving to Mrs G’s concerns that further surgery on Mr G’s wound on 3 October was the same procedure using clips, which proved unsuccessful the first time he had surgery. She says the Trust knew he had poor healing qualities because of the cancer.
47. We can clarify the operation on 3 October did not use the same technique as the original operation. The wound was closed using ‘interrupted buttress sutures’. This means the Trust used deep tension sutures, which closed the muscular layer. Staff left the skin wound open, which is consistent with Section 15 of GMC’s Good Medical Practice, which says doctors should provide effective treatments based on the best available evidence. Our consultant general surgeon adviser explained leaving the skin open can prevent the collection of fluid in the closed wound, and the subsequent development of infection. The Trust did not use clips in the second operation. On this basis we have not seen any failings in the stitches the Trust used.
Sutures were left in for 28 days
48. Lastly, Mrs G complains the Trust left sutures in place for 28 days. The Trust explained some sutures are dissolvable. It said it is acceptable for stitches to be kept in for three to four weeks. It said unfortunately, Mr G’s ascites (the presence of excess fluid in the abdominal cavity) could have affected the healing of his wound. Whilst there are specific guidelines to identify when skin sutures in different areas of the body should be removed, there is no standard for the removal of deep tension sutures.
49. Our consultant general surgeon adviser said keeping them in for three to four weeks would be reasonable. We agree the Trust left the stitches in place but have not found failings in relation to this decision.
Conclusion
50. We do not underestimate how distressing Mrs G’s experience has been. We can appreciate the distress and upset to her, Mr G, and the family. We have not found failings by the Trust in the care it provided.