The biopsy
10. Mrs E told us she was concerned about the way the Trust did the biopsy. She told us it should not have been done while there was still fluid draining, as this might cause an infection.
11. We looked at what the BSG guidance says about doing a biopsy when there is fluid (ascites). It says if a patient has ascites, a biopsy can be done once the ascites have been drained.
12. The guidance explains a liver biopsy should not be done when there is ascites because this is technically challenging and there is a risk of uncontrollable bleeding into the ascites. It says there is no evidence to suggest the presence of ascites increases the risk of infection after liver biopsy.
13. The records show Mr E had ascites. The Trust inserted a drain on 23 July to drain it and the drain was left in place. Mr E was booked for the biopsy on 25 July, but this was postponed because he still had ascites. The biopsy took place on 26 July when ascites was further drained. There is no evidence in the records to show the biopsy took place when Mr E had ascites.
14. The guidance recognises that both ascitic drainage and liver biopsy each carry a small risk of infection. This was included in the ‘serious or frequently occurring risks’ section in the consent forms for both the draining and the biopsy.
15. The ascites was drained before the biopsy and the risks were explained to Mr E. This was in line with the BSG guidance and we do not see any failings.
16. Mrs E was also concerned about the way the biopsy was done. She told us Mr E experienced a lot of pain. We understand why this raised her concerns.
17. The procedure notes do not record the site of the biopsy. Our radiology adviser told us there is nothing in the records to show it was in the wrong site. The BSG guidance is not rigid about the site of a biopsy, stating ‘where possible, the biopsies should be done under direct ultra-sound guidance’. This happened so it was in line with the guidance.
18. The records show the entry point for the biopsy was plugged with gel foam. This is recommended by the BSG guidance as a safety measure to reduce the chance of bleeding. It is unfortunate that Mr E experienced pain. Our adviser told us this is common with liver biopsies and does not mean that anything went wrong.
19. For these reasons we did not find any failings in the way the biopsy was done.
20. Mrs E told us the Trust had Mr E lying in the wrong position after the biopsy. She said if the doctor had not said anything when he spotted it, they would have left him lying on his back.
21. The BSG guideline states ‘you are expected to lie on your side and are observed for at least 3 hours to check there is no further bleeding’. The plan for Mr E, written in his records, was in line with this guidance.
22. We do not know why Mr E was initially on his back. The Trust’s post-biopsy care plan is clear that the intention was for Mr E to lie on his right side for four hours, then be allowed to sit up, before being allowed to get out of bed after six hours. The medical records show this plan was followed.
23. We understand Mrs E was concerned as she thought the doctor had to tell staff to put Mr E on his side. As this was clearly written in the post-procedure plan, there is no suggestion this would not have happened anyway, without the doctor’s instruction.
24. To give further reassurance, the BSG guidance also explains there is no evidence to suggest a link between post-biopsy patient position and complication rate. Our radiology adviser told us the policy on the position the patient should be nursed in after a liver biopsy varies in different centres and on a case-to-case basis. The common positions patients are instructed to lie in after a liver biopsy include lying on the side or back.
25. For these reasons we did not find any failings in this part of the complaint.
Infection and antibiotics
26. Mrs E told us she was worried Mr E was discharged from hospital when he was on the verge of ‘full-blown sepsis’. She explained to us that she understood the Trust knew this. She said this led to him becoming physically weaker.
27. Sepsis is a life-threatening reaction to an infection. It happens when the immune system overreacts to an infection and starts to damage the body's own tissues and organs. Signs include symptoms such as confusion, changes to skin, a high temperature and breathing difficulties.
28. We did not see any evidence in the medical records or the complaint file to show Mr E had sepsis, or that the Trust had said this.
29. The records show Mr E did not have any clinical signs of sepsis when he was discharged. The Trust recorded he was alert, orientated, moving independently, self-caring, and had a normal NEWS score (a method of judging acute illness such as sepsis, or signs of deterioration).
30. The DoH guidance says the decision to discharge a patient who is medically fit can be made by the consultant. We can see this happened and Mr E was reviewed by a consultant and the nursing team. Our adviser said that the discharge was well prepared with complete information on the discharge summary.
31. For these reasons we did not see any failings in the decision to discharge Mr E.
32. While there were no clinical signs of sepsis, the records show there was a rise in the markers (C-reactive protein, CRP, which increases when there is inflammation in the body) that showed a possible infection on the day of discharge. As Mr E had other risk factors including chronic lymphatic leukaemia, type 2 diabetes, a recent abdominal drain in place for seven days and a liver biopsy, the Trust decided to give Mr E antibiotics.
33. This decision was in line with the GMC guidance which says:
‘You must provide a good standard of practice and care. If you assess, diagnose or treat patients, you must:
• adequately assess the patient’s conditions, taking account of their history (including the symptoms and psychological, spiritual, social and cultural factors), their views and values; where necessary, examine the patient • promptly provide or arrange suitable advice, investigations or treatment where necessary’.
34. Mrs E was concerned the antibiotics the Trust gave to Mr E were incorrect because they encourage C. diff infection.
35. The Trust gave Mr E antibiotics on the day of discharge. It was not proven at this point that Mr E had an infection. The drain had been removed 24 hours before and so there was no fluid available to carry out a test to confirm this.
36. Our hepatology adviser explained that based on suspicion (rather than proven infection) the Trust used empirical antibiotic therapy. This is where the doctor decides the most likely cause of the possible infection and the appropriate antibiotic for that possible infection.
37. It was on this basis that the Trust decided to use co-amoxiclav. Our adviser explained this is frequently used to treat ascitic fluid infection. The Trust’s ‘Antimicrobial treatment guidelines for adults’ supports this. For this reason, we do not find any failings in the decision to give antibiotics.
38. It is important to stress again that Mr E did not have any signs of sepsis and the antibiotics were to prevent any infection that might lead to sepsis.
39. We were sorry to hear Mr E developed an infection and was unable to start his chemotherapy. We have not found that this was because of any failings by the Trust so we do not uphold this part of the complaint.
40. We appreciate the time Mrs E took to share her concerns. We understand the impact this experience had on them and we do not underestimate how challenging it has been for her to raise her complaint.
41. We would like to take this opportunity to thank her for bringing this complaint to our attention. All complaints we consider help in taking forward improvements for the wider public.