Medway NHS Foundation Trust

6. Mrs C complains about aspects of the care and treatment provided by the Trust to Mrs P, between 1 September 2019 to 28 February 2020. Specifically, Mrs C complains that the Trust failed to properly investigate or diagnose the cause of Mrs P’s rectal bleeding and abdominal pain during four inpatient admissions.

7. Mrs P sadly died in February 2020 from a bowel haemorrhage due to bowel ischaemia (a condition caused by the blood flow to the bowel being reduced or blocked). Mrs C believes if the Trust had provided better care and treatment, then Mrs P may have survived. Mrs C said the family are struggling to come to terms with Mrs P’s death due to the outstanding questions they have.

8. As an outcome to her complaint, Mrs C would like an acknowledgement of failings, an apology, service improvements and financial compensation.

9. Mrs P was in her early sixties at the time of these events. She had a previous medical history of peripheral vascular disease. This is a condition caused by a build-up of plaque inside the arteries, which narrows the blood vessels and results in poor circulation to various parts of the body. The legs are commonly affected, and records note Mrs P had surgery in 2010 to treat the circulation problem in her legs. This involved fitting a surgical graft, an aortic graft, to bypass the blockage she had in the major arteries leading to her legs.

10. Mrs P was admitted from the Trust’s A&E department on 1 September 2019 with a three-week history of cold sweats, vomiting and epigastric pain. This describes pain felt between the ribs and the belly button.

11. The Trust took a CT scan of the abdomen and pelvis, which showed her stomach was distended (swollen) and there was some narrowing of the duodenum. The duodenum is the top section of the small intestine. It receives partially digested food from the stomach and begins to absorb nutrients from that food.

12. The CT scan suggested a possible infection of the aortic graft. The Trust started Mrs P on antibiotics and inserted a naso-gastric (NG) tube to decompress the stomach and relieve her vomiting. An NG tube is a small flexible tube, passed through the nose, used to deliver food or medicine directly into the stomach.

13. On 3 September the Trust recorded a plan for oesophago-gastroduodenoscopy (OGD) under general anaesthetic (GA). An OGD, sometimes known more simply as a gastroscopy or endoscopy, involves inserting a flexible instrument with a camera and light at the tip, into the mouth. This allows examination of the oesophagus (gullet), stomach and duodenum.

14. OGD is usually performed under light sedation, using local anaesthetic. Records from a later admission document Mrs P said she needed a GA for this procedure. To allow this, Mrs P was put on the emergency theatre list to wait for the next available appointment, as the procedure under GA needed to be performed in a surgical theatre.

15. The planned OGD did not go ahead and instead, on 5 September, the Trust did a barium meal and follow through. This is a different type of examination of the same structures of the body. A contrast (barium) is mixed with water and swallowed by the patient, allowing the lining of the gullet, stomach and duodenum to be seen on X-ray. This test did not show any narrowing or obstruction.

16. The Trust requested a vascular review, and a vascular surgeon saw Mrs P on 7 September. The vascular surgeon documented there were no serious vascular problems, from a general surgical point of view Mrs P was fit for discharge, and she was later discharged home.

17. Mrs P was admitted from A&E on 13 November reporting several days of abdominal pain. Doctors suspected an aortic graft infection and repeated a CT scan. This showed a similar appearance to the scan taken in September and noted the bowel was stuck to the graft. This explained the narrowing of the duodenum seen on the scan taken in September.

18. The Trust started Mrs P on intravenous (IV) antibiotics and arranged a white blood cell scan, which shows up any inflammation within the body. The scan was performed on 19 November and confirmed the aortic graft was infected. The Trust decided to treat this with a six-week course of antibiotics, delivered by a long-term indwelling vascular catheter. This is a flexible tube, inserted through the skin, allowing medication to be delivered directly into the bloodstream.

19. Mrs P was discharged home on 23 November, with arrangements for the home IV therapy team to give those antibiotics for her, for the required period. The Trust also arranged for her to have a flexible sigmoidoscopy as an outpatient. This involves inserting a flexible instrument, with a camera and light at the tip, into the rectum, to enable examination of the rectum and colon for any abnormalities.

20. Mrs P was seen at a vascular outpatient clinic on 22 January 2020. The clinician noted Mrs P had no clinical features to suggest any ongoing infection or critical lower limb ischaemia, a condition when blood flow to the legs is severely restricted. The clinician felt there was no need for any further imaging or intervention at that time and discharged Mrs P back to the care of her GP.

21. Mrs P was admitted from A&E on 14 February reporting a six-day history of abdominal pain with tarry black stools. Doctors suspected internal bleeding along the upper gastrointestinal (GI) tract and discussed the outstanding OGD with a gastroenterologist. Records note Mrs P’s request to have this procedure under GA and she was placed on the emergency theatre list.

22. Mrs P’s bleeding settled, and she was no longer passing black stools. By 19 February doctors felt the bleeding had stopped and as there was no longer any urgency to have the OGD, Mrs P was discharged home with a plan for OGD as an outpatient.

23. Mrs P was admitted six days later, on 25 February, with worsening abdominal pain, darker stools and having found fresh blood on toilet paper that day. She was put on the emergency theatre list for an urgent OGD. This went ahead on 26 February and reported as normal, finding no abnormality.

24. This suggested the bleeding was coming from further down the GI tract, and an urgent inpatient colonoscopy was requested. OGD involves inserting a flexible instrument with a camera into the mouth to look at the structures below, and colonoscopy involves inserting a flexible instrument through the anus to look inside the bowels.

25. The Trust gave Mrs P blood transfusions but she continued to experience bleeding. Before the colonoscopy could go ahead Mrs P had a large bleed then a cardiac arrest. An emergency call was made and, despite attempts, Mrs P could not be resuscitated and very sadly died.

29. To address Mrs C’s complaint that the Trust failed to properly investigate or diagnose the cause of Mrs P’s rectal bleeding and abdominal pain, we considered the events of each of the four admissions in question very carefully.

30. While we recognise Mrs C’s concern is about the symptoms of both rectal bleeding and abdominal pain, at the first two admissions in September and November 2019, Mrs P was admitted for symptoms of abdominal pain and vomiting, not rectal bleeding.

31. The abdominal pain and vomiting symptoms were investigated with a CT scan on both occasions. Our adviser explains this is the best investigation for patients presenting with abdominal pain. This action was in line with RCS guidance which says:

‘In patients over the age of 50 presenting with abdominal pain but no sepsis, CT (either on an inpatient or early outpatient basis) is advisable…’.

32. RCS guidance also contains an acute abdominal pain flowchart, further recommending investigation by CT for a patient admitted with acute abdominal pain that may require attention. Both CTs suggested a possible infection of the aortic graft and some narrowing of the duodenum, which our adviser suggests was related to inflammation secondary to the infection. A white cell count scan performed during the second admission confirmed this diagnosis, and records show this was explained to Mrs P. This was considered the main cause of her symptoms.

33. In response to these findings, a vascular review was requested during the first admission, and Mrs P was admitted under the care of the vascular team during the second admission. Our adviser confirms this was appropriate. This action was in line with GMC guidance which says:

‘You must provide a good standard of practice and care. If you assess, diagnose or treat patients, you must… refer a patient to another practitioner when this serves the patient’s needs’.

34. The duodenal narrowing identified on CT was considered the likely cause of Mrs P’s vomiting. An OGD was requested to investigate further. NHS website information confirms this was an appropriate investigation to request.

35. OGDs are usually performed under local anaesthetic, however we find an entry in the records that says: ‘Pt [patient] clearly states that she needs GA for OGD’. This put limits on the OGD going ahead, as it meant Mrs P had to be put on the emergency theatre list and wait for the next time allocation available, as the procedure under GA needed to be performed in a surgical theatre.

36. These restrictions caused a delay. Our adviser says as records suggest the GA was at Mrs P’s request and therefore her, any delay in the OGD proceeding was for good reason. This was in line with 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…’

‘You must listen to patients, take account of their views…’

‘Work in partnership with patients. Listen to, and respond to, their concerns and preferences… Respect patients’ right to reach decisions with you about their treatment and care’.

37. During that delay, the Trust performed a barium meal and follow through test which found no evidence of any blockage. This is an acceptable alternative investigation to OGD, as explained in the Trust’s own patient leaflet, ‘Understanding Gastroscopy (Upper GI Endoscopy)’.

38. Mrs P was also being treated with an NG tube, to decompress the stomach and relieve her vomiting. Our adviser says this is a known and appropriate action to take, as explained in the Sigmon and An publication, which says:

‘Whether decompressing the stomach, providing enteral [passing through the intestine] access for nutrition and medications in a patient unable to tolerate them orally, or ruling out an upper GI source of bleeding in the setting of massive hematochezia [rectal bleeding]; nasogastric tubes are part of the standard of care for many routine health issues’.

39. Antibiotics were also given to Mrs P, ciprofloxacin during the first admission and gentamicin during the second. This was appropriate treatment for the aortic graft infection, in line with Hodgkiss-Harlow and Bandyk publication recommendations.

40. Records of the first admission clearly document: ‘No PR [per rectum] bleed’, indicating this was checked by the Trust, and not observed or reported by Mrs P during the admission in September. There is no record of any rectal bleeding at the time of Mrs P’s second admission on 13 November. We do find one entry, on 16 November, where Mrs P reported rectal bleeding. The on-call surgeon was bleeped and informed, giving immediate advice about Mrs P’s medication before attending to do a review.

41. This appears to have been a one-off episode. There is no further entry of rectal bleeding in the later detailed entries, which document Mrs P passing bowel movements without problem and raising no further reported concerns about this. Our adviser suggests this one-off episode could have been related to an abnormal clotting level, documented at that same time.

42. Records show the Trust arranged for Mrs P to have an outpatient flexible sigmoidoscopy after discharge. Given the immediate consideration of the reported bleeding at the time, there was no further report of bleeding at any other time, and there was a reasonable explanation for it happening on this one occasion, our adviser says this was this a reasonable decision. There are no clinical guidelines for this, as it is more a matter of clinical judgement. Our adviser gives assurance there is nothing to suggest any further investigation was needed.

43. The two admissions in February 2020 were different, as there were signs of GI bleeding from the outset. Records note the reasons for Mrs P’s admissions in February were also due to abdominal pain and vomiting. However, on these occasions she also reported black tarry stools and, at the second admission, fresh blood on toilet paper that day.

44. From Mrs P’s admission on 14 February, OGD was again considered appropriate to look into the possible cause. Records make clear Mrs P told doctors she needed GA for this procedure, and entries show the Trust acted in line with her preference, by putting her on the emergency theatre list. As happened when OGD was considered at the first admission, the logistical requirements for this being done under GA caused a delay in this being completed.

45. In the meantime, Mrs P’s bleeding settled, meaning she was no longer seen as a medical emergency. It was no longer needed for her to be put on the emergency theatre list ahead of patients who had more urgent clinical needs. Our adviser explains this is good practice nationally, in terms of the prioritisation of patient needs, and is set out in the Trust’s own patient leaflet ‘Understanding Gastroscopy (Upper GI Endoscopy)’, which says:

‘If emergencies occur, these patients will obviously be given priority over the less urgent cases’.

46. When it became clear the bleeding had settled and the OGD under GA would not go ahead, Mrs P was discharged home. NICE CG141 suggests all patients with GI bleeding should have upper GI endoscopy within 24 hours of admission. The Trust therefore did not comply with this guidance. We do not consider this a failing, because we have taken account of the reasons for this. OGD was decided on by doctors soon after Mrs P’s admission, and the reason it did not go ahead in line with NICE CG141 was for good reason. The Trust acted in line with Mrs P’s views and preference for how she wanted treatment.

47. While NICE CG141 may not have been followed for the reasons explained, BSG guidelines were. They do allow for some patients with GI bleeding to be discharged without an inpatient endoscopy, provided those patients are stable and meet certain criteria. BSG guidelines say these patients can be discharged along with plans for outpatient endoscopy.

48. By the time Mrs P was discharged her bleeding had settled, her blood flow was considered stable, and plans were documented for an outpatient procedure to be arranged to investigate further. Our adviser confirms this action was in line with the criteria in BSG guidelines.

49. Records from Mrs P’s admission on 25 February again show OGD was considered appropriate, and the Trust put her on the emergency theatre list. The OGD went ahead within 24 hours of this admission, in line with NICE CG141. Findings from this investigation were normal, so the Trust planned for an urgent colonoscopy. Unfortunately, Mrs P suffered a significant bleed and cardiac arrest before this could go ahead.

50. In summary, we hope to assure Mrs C we find evidence that at each admission, the Trust did appropriate investigations into Mrs P’s symptoms of rectal bleeding and abdominal pain, as relevant. Our adviser confirms these investigations did identify the cause of Mrs P’s problems at the initial admissions, namely the aortic graft infection and associated inflammation of the duodenum, for which she had treatment.

51. The Trust tried to perform an OGD, and due to patient choice in the method and the associated logistical challenges of this proceeding, there were understandable and unavoidable delays. That said, at the first admission the Trust did an appropriate alternative test, and at the third admission Mrs P’s bleeding settled, meaning she no longer needed an OGD urgently. The Trust made appropriate arrangements for this to go ahead on an outpatient basis.

52. Before that could take place, Mrs P was readmitted. The Trust again took the appropriate action by listing Mrs P on the emergency theatre list, and this time the OGD did proceed within 24 hours of admission. The results were normal, so they did not give the Trust enough information to identify the cause or reach a clear diagnosis. Appropriately, the Trust planned for further investigation lower down the GI tract. Very sadly, events overtook the management plan in place.

53. We do not see anything to suggest service failure occurred, and we have not upheld this complaint.

1. Mrs C complains Medway NHS Foundation Trust (the Trust) failed to properly investigate or diagnose the cause of her mother-in-law’s, Mrs P’s, rectal bleeding and abdominal pain, during four inpatient admissions between September 2019 and February 2020. Mrs P sadly died at the Trust in February 2020. We extend our sincere condolences to Mrs C, recognising that these events continue to cause her and the wider family considerable upset and distress.

2. From the evidence we have seen, we are satisfied the Trust performed appropriate investigations into Mrs P’s symptoms of rectal bleeding and abdominal pain. We find the symptom of abdominal pain was present at all admissions and the main cause identified was an infection of the aortic graft (used to replace the aorta).

3. We find no evidence of rectal bleeding during the first admission, and a one-off episode during the second admission. Evidence shows the Trust considered this accordingly, and we see a reasonable explanation, given abnormal clotting factors at the time. There is no evidence of any further rectal bleeding and nothing to suggest investigation was needed.

4. When rectal bleeding was present at the third and fourth admissions, we find the Trust took appropriate steps to investigate, while also acting in line with Mrs P’s preference to have the relevant procedure under general anaesthetic. When this test went ahead, the results were normal, and the Trust made appropriate plans to investigate further. Very sadly, events overtook those investigations, and Mrs P died before anything more could take place.

5. We do not see anything to suggest service failure happened, and we have not upheld this complaint.