Mid Yorkshire Hospitals NHS Trust

7. Mr A complains about aspects of the care and treatment Mid Yorkshire Hospitals NHS Trust (the Trust) provided to his brother, Mr R, from 26 to 28 January 2020, when he sadly died. Specifically, Mr A complains the Trust: • missed or ignored signs of a gastrointestinal bleed (bleeding coming from either the food pipe, stomach, or bowels) on 26 and 27 January and diagnosed him with an infection, despite Mr R taking medication that put him at higher risk of bleeding • tried to discharge Mr R on 27 January when he was still unwell, involving a security guard when Mr R could not get onto his electric scooter • should have arranged a medical review before 28 January.

8. Mr A says Mr R would not have died from gastrointestinal bleeding if the Trust had found it sooner. He says the concerns about Mr R’s death are upsetting and made it harder for him to grieve. It was also distressing for Mr A to witness the attempts to discharge Mr R on 27 January.

9. Mr A wants the Trust to provide an acknowledgment of what went wrong, an apology, and service improvements to prevent a repeat of what happened.

10. Mr R had several medical problems including chronic obstructive pulmonary disease (a progressive lung condition that makes breathing difficult) and peripheral neuropathy (problems with the nerve in the arms and legs which makes movement difficult). He could not walk so he used an electric scooter to get around and had support from family and carers at home.

11. Mr R went to hospital by ambulance the evening of 26 January feeling increasingly short of breath, shaky and hot. He had also recently had an infection in an ulcer on his ankle.

12. The doctor in the Trust’s emergency department (the ED doctor) assessed Mr R a couple of hours later and diagnosed him with an infection. He was treated with fluids, paracetamol and antibiotics. They decided Mr R needed to be admitted to a ward and he moved to the Trust’s acute medical unit (AMU) in the early hours of 27 January.

13. A doctor in the AMU (the AMU doctor) reviewed Mr R shortly after, and also diagnosed him with an infection. They continued the treatment plan. Later that day a consultant reviewed Mr R and decided he was stable and could continue antibiotic treatment at home.

14. Mr R moved to the discharge ward later that afternoon. At around 6pm Mr A brought Mr R’s electric scooter in for him. This is what he normally used to get around, so needed to be able to get on this to go home.

15. Mr R was unable to get out of bed and onto the scooter, even with help. He could normally do this by himself. He became breathless and confused. The staff continued to try to get Mr R onto the scooter over the next few hours, but they were unsuccessful. The nurse looking after Mr R decided to keep him in overnight.

16. Mr R had an unsettled night and at some point he had an episode of vomiting. It appears that this was brown, and the nurses said the colour of the vomit was due to drinking cola so took no further action.

17. In the morning of 28 January the nurse that came on the day shift asked the doctors to review Mr R. A doctor saw him and noted he was unwell and may have had a GI bleed. Sadly, Mr R deteriorated and shortly after he became unresponsive and died. The cause of death was a GI bleed.

21. We have set out our findings about what happened, in the order they happened. We first consider the events in the emergency department, then the acute medical unit (AMU), then the discharge ward.

The emergency department

22. Mr A complains the Trust missed or ignored signs of GI bleeding when Mr R was in the emergency department.

23. GMC good medical practice says that when assessing a patient doctors must take into account their history and symptoms and perform an examination. Any diagnosis made should be based on the outcome of the assessment.

24. Mr A says his brother had diarrhoea before he got to hospital on 26 January and his sister, who went with Mr R, made staff aware of this. The ED doctor that assessed Mr R documented the history they took from Mr R and his sister. They wrote that they were told Mr R’s bowels had been ‘OK’ recently although he is normally constipated, and he had no abdominal pain.

25. There are two different accounts of what the Trust was told. We cannot reconcile these two accounts because there is no other evidence of what happened. For us to say the Trust missed that Mr R had diarrhoea or failed to take account this, we would need sufficient evidence to support that, and we do not have it here.

26. We do not disbelieve Mr A’s account of what his sister told the staff. However, we have to balance both accounts and we have conflicting evidence from the Trust that it did not do anything wrong. We hope that explains why we have proceeded on the basis the Trust was not aware of the diarrhoea.

27. The records show the ED doctor also noted the following when they assessed Mr R:

• He was breathless.

• He had a high temperature.

• He had a recent infection in an ulcer on his ankle, and this ulcer was now oozing fluid.

• His abdomen was not tender when examined.

• Blood tests showed he had a high white cell count, which occurs in response to an infection.

28. Based on these findings, the ED doctor diagnosed Mr R with an infection.

29. We considered whether the ED doctor’s assessment and conclusions were supported by the clinical findings and in line with the GMC guidance. We also asked our A&E and physician advisers about this.

30. Having done that, our view is that the ED doctor’s assessment was in line with the GMC guidance because they took a history, considered Mr R’s symptoms, and did a physical examination. We also found that the diagnosis was in keeping with the clinical picture, which pointed towards Mr R having an infection. For this reason, we have not identified any failure to diagnose a GI bleed.

31. Mr R had an episode of coffee ground vomiting while he was waiting to move to the AMU. This is vomit that contains blood and appears dark brown and grainy. The ED doctor reviewed him and spoke to their senior for advice. They still suspected Mr R had an infection. They prescribed further fluids for him and arranged for the doctor in the AMU to see Mr R as soon as he moved there, which would be happening very soon.

32. Coffee ground vomit can occur in many serious illnesses. Our ED adviser has said it can result from inflammation of the stomach or oesophagus due to the body’s widespread reaction to infection, such as the infection Mr R had.

33. They also told us that a one-off episode like this, when the clinical picture is consistent with an ongoing infection, would not trigger any alternative action being taken.

34. We therefore consider that although Mr R had this episode of coffee ground vomit, it was not a sign of an acute GI bleed. We consider the doctors acted in line with the GMC guidance when they reassessed Mr R, got advice and reviewed the plan. We have not seen any evidence the Trust should have done anything different at this stage.

35. Mr A also raised a concern that his brother was taking steroid medication which put him at higher risk of GI bleeding, so he thinks it was even more important for the Trust to diagnose this. We asked our physician adviser about this. They explained that steroids can make GI bleeding worse. However, as there was no reason to suspect or diagnose GI bleeding in the ED there was no reason to stop or change these medications.

36. We appreciate Mr A’s concerns about what happened in the emergency department, and we hope our explanation brings him some reassurance. We have not found any failings in the care the Trust provided when Mr R was in the ED. We do not uphold this part of the complaint.

The acute medical unit

37. Mr A complains the Trust missed signs of GI bleeding when Mr R was on the AMU, and that he was not well enough to be discharged.

38. Doctors need to perform an assessment to see if someone is ‘medically fit’ for discharge. This is when they are in a condition where they no longer require treatment that can only be given in hospital and are safe and ready to go home.

39. As set out in the previous section, GMC guidance says an assessment should take account of the patient’s condition, their history and include an examination. Any diagnosis or decision made should be based on the outcome of the assessment.

40. When the AMU doctor assessed Mr R, they noted his history and reason for admission. They performed an examination, checked his observations and noted his blood test results. The AMU doctor also diagnosed Mr R with an infection and continued treatment for this.

41. When the consultant saw Mr R later that day they also noted his symptoms, test results, and examined him. They concluded that Mr R had an ongoing infection but was medically fit and could continue oral antibiotic treatment for the infection at home.

42. The findings of the assessment in the AMU were consistent with those in the ED, and as set out in the previous section of our report we consider the working diagnosis of infection was supported by the clinical evidence.

43. We know, with the benefit of hindsight, that Mr R had a GI bleed the following day. We have considered whether there were any signs of GI bleeding that the Trust missed in the AMU.

44. As set out above, coffee ground vomiting could have been due to the infection, and when the clinical picture indicated an infection, a one-off episode of this type of vomiting would not have changed the diagnosis or plan. We therefore do not think the Trust missed signs of GI bleeding or should have taken any different action at this time.

45. In terms of whether Mr R was well enough for the doctor to find him medically fit, we consider the consultant’s decision at midday on 27 January was appropriate. The outcome of their assessment showed he was stable and could continue treatment for the infection at home. This was in line with the GMC guidance.

46. We understand why Mr A is concerned about the care on the AMU because of what happened next. However, we have seen no evidence the Trust missed signs of a GI bleed and our view is that it was appropriate to decide that Mr R was medically fit for discharge.

47. As set out in the previous section, Mr A also raised a concern that his brother was taking steroid medication which put him at higher risk of GI bleeding, so he thinks it was even more important for the Trust to diagnose this. We considered this issue here, and similar to our findings about the care in the ED, because there was no reason to suspect or diagnose GI bleeding on the AMU, we consider there was no reason to stop or change this medication.

48. We have seen no failings in this aspect of Mr R’s care, and we will do not uphold this part of the complaint.

The discharge ward

49. Mr A complains the Trust tried to send Mr R home from the discharge ward despite a change in his condition. He is unhappy that staff repeatedly tried to get Mr R onto his scooter when he was struggling, and even involved a security guard. He also says the nurses should have asked for a medical review sooner than they did.

50. The NMC code says nurses should identify and respond to signs of worsening health in their patient. Nurses should make timely referrals to other suitably qualified practitioners when their patients need care and treatment outside their limits of competence.

51. This means that if a doctor has decided a patient is well enough to go home, but a nurse sees that patient has since become unwell, the nurse should respond to this worsening health by referring the patient back to the doctors for review. Nurses should also regularly monitor patients in their care to check for any further changes in their condition.

52. We understand from Mr A’s account, and the limited information in the records, that the nurses were attempting to get Mr R out of bed and onto his electric scooter from around for several hours. He could not manage it because he was increasingly breathless and confused. The Trust explained to us that these attempts went on for so long because Mr R asked staff if he could try again.

53. Mr A says he was there for most of this time and, as well as these symptoms, he saw that his brother had diarrhoea which he helped clean up. The Trust’s notes do not mention this.

54. At one stage the nurses called for assistance. Mr A says they called a security guard. The Trust says it was the site manager, who the person responsible for the flow of patients throughout the hospital. It is not clear from the notes who came, or if this person offered any assistance to move Mr R.

55. The nurses decided to keep Mr R in hospital overnight. The Trust says this was because he could not transfer, but our understanding of the records is that the staff also thought there was a change in his condition.

56. There are limited records about what happened overnight, and whether Mr R remained breathless as the staff did not document any observations. The nurses noted early that morning, Mr R was agitated unsettled and had vomited.

57. Our view is that Mr R’s confusion, increasing breathlessness and agitation overnight were all things that indicated a change in his condition. Although Mr R had shortness of breath when he was admitted, the records suggest this was improving, so the increasing breathlessness was a change. Confusion and agitation were also new symptoms for Mr R.

58. We consider the nurses did not act in line with the NMC code when they continued with attempts to get Mr R onto his scooter and did not escalate to a doctor.

59. In line with the NMC code, the nurses should have identified there was a change in his condition and asked the doctors to review him. In addition to this, our view is that when Mr R vomited brown liquid the nurses should not have dismissed this given the recent coffee ground vomit in the AMU, and this was another reason for escalation.

60. We found it was not appropriate for the staff to continue with attempts to get Mr R onto his scooter, and it was unnecessary to seek more assistance with this. It was clear that his condition changed, and in line with the NMC code the nurses should have asked for a medical review.

61. We understand why Mr A was concerned about these events. As set out, we consider these actions were not in line with what should have happened, and there are failings here.

The impact of the failings

62. Mr A says his brother might have survived if the Trust had diagnosed the GI bleed sooner. He told us this concern is upsetting and made it harder for him to grieve. He also says it was distressing to witness the attempts to discharge him.

63. As set out above, the nurses should not have made repeated attempts to get Mr R out of bed and onto his scooter when he was unwell, and they did not escalate his care to the doctors when they should have.

64. We can understand why witnessing this would cause distress to Mr A, particularly as his brother was unwell and the attempts went on for many hours. He had to leave hospital at one point, but returned as he was concerned about his brother and saw attempts were ongoing. This was clearly a distressing experience which should have been avoided.

65. We next considered whether the failings affected Mr R’s chances of survival.

66. When the doctors came to see Mr R in the morning, they suspected straight away that he had a GI bleed. This was based on his continued deterioration, abdominal tenderness, and signs of a recent coffee ground vomit.

67. Due to the limited records about Mr R’s condition and the lack of a medical review earlier, we cannot say whether there were signs of GI bleeding overnight that the Trust missed.

68. However, as the GI bleed was suspected as soon as Mr R was reviewed in the morning, we consider there was a missed opportunity for the doctors to assess Mr R and potentially suspect a GI bleed sooner.

69. We thought about whether an earlier review would have changed the outcome for Mr R. We have seen that Mr R had an infection and complex health issues. Our physician adviser told us this most likely meant Mr R unfortunately did not have the reserves to fight and recover from a complication like a GI bleed.

70. Our physician adviser also explained to us that based on Mr R’s presentation the morning the doctor saw him, he did not have severe bleeding but would have needed further tests to look for the cause of it within the next 24 hours. It is therefore likely that these tests would not have been arranged or taken place before Mr R died, even if he had seen a doctor sooner.

71. We therefore found that although things went wrong in Mr R’s care, it is likely that they did not cause or contribute to his death. We acknowledge that this aspect of the complaint is very important to Mr A.

72. We understand that his concerns about his brother’s care made him wonder whether his brother could have survived, which has added to the distress he was feeling at a difficult time when he was grieving for his brother. We hope our findings bring him some reassurance now. We partly uphold the complaint about the discharge ward. We will make recommendations to the Trust to take action in response to our findings.

1. We have considered Mr A’s complaint about the care Mid Yorkshire Hospitals NHS Trust (the Trust) provided to his brother, Mr R, before he died from a gastrointestinal (GI) bleed. We were sorry to hear of Mr A’s brother’s death and of the impact this had on him.

2. We found the care Mr R received in the emergency department, and acute medical unit, was appropriate. We could not see that the Trust missed signs of a GI bleed and we found the doctor’s decision that Mr R had an infection, but was well enough to go home, was supported by the clinical evidence. We do not uphold these parts of the complaint.

3. We found that attempts to discharge Mr R once he moved to the Trust’s discharge ward should not have continued. Mr R’s condition had changed, and the nurses did not escalate this to the medical team when they should have.

4. As a result, there was a delay in a doctor coming to see Mr R. We considered whether this meant Mr R’s death could have been prevented, and we found it did not.

5. We can see that this was upsetting for Mr A and left him questioning whether his brother could have survived. This caused him additional distress at an already difficult time when he was grieving.

6. We therefore partly uphold the complaint about the Trust. We ask it to apologise to Mr A and to improve its services to prevent a repeat of what happened. We understand these matters are very important to Mr A and we hope our findings and recommendations help to resolve his concerns.

73. In considering our recommendations, we have referred to our ‘Principles for Remedy’. These state that where poor service or maladministration has led to injustice or hardship, the organisation responsible should take steps to put things right.

74. The Trust’s failings caused upset and distress for Mr A at a difficult time. We think the Trust should write to Mr A to acknowledge what went wrong and apologise for the impact this had on him. The Trust should do this within four weeks of the date of our final report.

75. While the Trust’s actions did not lead to Mr R’s death, they could have had serious consequences in other circumstances. Our principles also say that public organisations should look for continuous improvement and should use the lessons learnt from complaints to make sure they do not repeat maladministration (fault) or poor service.

76. We therefore recommend the Trust completes an action plan that sets out what it will do to prevent a recurrence of the failings. The action plan should say who is responsible for each action, when they will be done, and how the impact of them is being monitored. The Trust should do this within three months of the date of our final report. It should share a copy of the report with us, the complainant, the CQC, and NHS improvement.

77. We understand Mr A has been deeply affected by the sad and unexpected death of his brother. We appreciate our decision will not change his experience, but we hope it helps to resolve some of his concerns and he is reassured that the Trust will take action to prevent the mistakes it made from happening again.