The Trust failed to investigate the symptoms Mrs A presented with in the consultation on 2 March 2020.
20. When we consider a complaint, we look at whether there are signs the organisation has got something wrong. We do this by comparing what should have happened with what did happen. We have done this and have not found any signs something went wrong with how the Trust conducted the consultation on 2 March 2020.
21. Mrs C tells us when Mrs A attended the appointment on 2 March 2020 she was concerned about a loss of weight and difficulty breathing, which got worse after minimal exertion. Mrs C believes the symptoms her sister presented with were not properly investigated.
22. In its complaint reply, the Trust tells Mrs C: ‘At the consultation Mrs A discussed that her main concern/symptom was the feeling of some sputum in the back of her throat which made her more short of breath, mostly when she walked up an incline or stairs, and occasionally on minimal exertion’.
23. The Trust also explained the consultant and Mrs A discussed her symptoms and these steps were taken: ‘Mrs A was referred to the […] Lung Service integrated COPD clinic for pulmonary rehab, that annual flu vaccine and up to date pneumococcal vaccine were arranged, and that lung function tests were arranged. It was also advised that Mrs A was commenced on a trial of Carbocisteine, and that Omeprazole was commenced whilst there was a possibility that gastro-oesophageal reflux disease was causing the symptoms.’ Carbocisteine is a medication used to clear sputum and Omeprazole is commonly prescribed to help with gastric reflux and other gastric issues.
24. The Trust also explained: ‘The management plan was discussed with Mrs A, who understood the plan and did not raise any more concerns. Mrs A was discharged from the clinic. Dr […] has reviewed the consultation and feels that the consultation and management plan were appropriate but would like to apologise if you feel that Mrs A's concerns were not investigated.’
25. Following the consultation, the consultant completed a letter to be sent to Mrs A’s GP, and a copy was also sent to Mrs A.
26. The letter to the GP says: ‘Thank you for referring this […] lady to our respiratory clinic who has got a 12-year history of COPD which has been worsening for the last eight months. The patient’s main symptom is the feeling of some sputum in the back of her throat which makes her more short of breath. The sputum is clear jelly colour. Her symptoms of shortness of breath are mostly when she goes up hills or stairs and occasionally on minimal exertion like changing her clothes and taking a shower. She uses three pillows to sleep which has not changed in the last 12 months. The patient does feel she has lost some weight as her clothes have gone looser. She is an ex-smoker 11 years ago. She has never been admitted with COPD to hospital but has the last 12 months had used rescue pack three times.’
27. The consultant also said: ‘I have discussed this case with Dr […] Consultant in the clinic who has advised that pulmonary rehab with the […] Lung Service (integrated COPD clinic) would be useful for this patient. Also, the GP to confirm that she is up to date with annual flu jab and once only pneumococcal vaccination as well. The patient also to have lung function tests to check for emphysema and also in the future she may require lung volume reduction procedure if she fulfils the criteria by lung function tests. We will write to the patient with the results of the lung function tests.’
28. Following the appointment, the consultant put together a six-point plan to confirm the actions needed to manage Mrs A’s condition:
1. refer for pulmonary rehab to lung service for integrated COPD clinic 2. give annual flu vaccine and check Mrs A has up-to-date pneumococcal vaccine 3. arrange lung function tests 4. trial with Carbocisteine 5. patient to commence Omeprazole (gastro-oesophageal reflux disease causing the symptoms) 6. patient has history of peptic ulcers (sores on the lining of the stomach), GP to discuss pros and cons of Omeprazole.
Our view
29. After Mrs A told her GP that her COPD symptoms were getting worse, they referred her to the respiratory clinic. When Mrs A attended the clinic on 2 March 2020 the consultant assessed her condition. The relevant guidelines for this assessment are the NICE guidelines NG115 for ‘Chronic obstructive pulmonary disease in over 16s: diagnosis and management’. Our Adviser tells us that the evidence shows observations were carried out and the action plan followed these guidelines. The guidelines say staff should develop an individualised self-management plan, explain the relevant points to the patient and review the plan at future appointments. The guidelines also say a multidisciplinary team should deliver COPD care. This was followed since the consultant referred Mrs A on for further treatment and advice. The evidence available to us therefore shows these guidelines have been followed.
30. The symptoms for COPD listed in these guidelines include: • breathlessness on exertion • chronic cough • regular sputum production • wheeze • weight loss • reduced exercise tolerance.
31. Comparing the list of COPD symptoms to those Mrs A reported to the consultant, we can see it was appropriate to reach the view that her deterioration was due to COPD, as it was supported by the evidence available to the Trust at that time.
32. In this case, the referral from the GP was for treatment of COPD, and the consultant therefore assessed Mrs A for COPD. Mrs C tells us she is unhappy because she believes more should have been done at this consultation to identify her sister had cancer, so we have looked at this point in particular detail.
33. NICE guidance NG12 ‘Suspected cancer: recognition and referral’ explains when someone should be referred for suspected cancer and lists the symptoms to look out for. The symptoms to consider for an urgent referral for suspected lung cancer include: • haemoptysis (coughing up blood) • lymphadenopathy (swelling of lymph nodes) • chest pain • chest infection • unexplained cough • finger clubbing (inflammation at the fingertips) • shortness of breath • fatigue.
34. Comparing the above list of symptoms to those Mrs A had on 2 March 2020 at her appointment, there was nothing to suggest to clinicians an urgent referral for possible lung cancer was needed.
35. The consultant’s action plan to manage Mrs A’s ongoing condition included further tests and a referral for pulmonary rehabilitation. This is in line with GMC ‘Good Medical Practice’ guidelines on knowledge, skills and performance.
36. Section 1.15 of these guidelines says:
‘You must provide a good standard of practice and care. If you assess, diagnose or treat patients, you must: a. 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 b. promptly provide or arrange suitable advice, investigations or treatment where necessary c. refer a patient to another practitioner when this serves the patient’s needs.’
37. The relevant medical records show Mrs A’s history and symptoms were considered during the assessment. Following the appointment, further investigations were requested and Mrs A was referred to other practitioners when this benefitted her needs.
38. The available evidence shows the Trust followed the relevant standards and guidelines when it completed Mrs A’s assessment in early March. Therefore, we have not seen any signs of mistakes by the Trust in the way it investigated Mrs A’s symptoms at that time, and so we will take no further action.
The Trust did not fully implement the care plan put together after the 2 March consultation, specifically the pulmonary rehabilitation or lung function test.
39. Mrs C tells us that following the appointment on 2 March 2020, the Trust produced an action plan but she does not believe it was fully implemented. Specifically, she believes the Trust did not carry out lung function tests and the pulmonary rehabilitation planned for her sister.
40. The Trust confirmed a six-point plan was produced following the consultation. In reply to our request for further information, the Trust gave us details of the six points set out in the plan. These were:
1. Refer for pulmonary rehab - the referral was sent on 5 March 2020. A phone consultation with a specialist nurse took place on 16 June 2020. The care plan discussed was typed and sent to Mrs A with an exercise booklet advising her to maintain activity while waiting to commence pulmonary rehabilitation.
2. Annual flu vaccine and pneumococcal vaccine – the GP rather than the Trust would have given these.
3. Arrange lung function tests - these were requested but could not be performed because of the COVID-19 outbreak, which had a huge impact on the Trust’s ability to offer its patients these tests. This was due to the need for new procedures because of concerns of COVID-19 contamination and transmission. As a result, for a while tests were only performed on urgent pre-operative cases.
4. Trial with Carbocisteine – a prescription would have been arranged via the GP, and this was requested again after the phone consultation on 16 June 2020. Mrs A was taking Carbocisteine on her admission to hospital in August, which shows it had been prescribed by her GP.
41. Points five and six were recommendations to the GP and would have been actioned by them, so we will not explore those further. Points one and three are those Mrs C complains the Trust did not complete.
Our view
42. The first point of the action plan related to the Trust referring Mrs A for pulmonary rehabilitation. Pulmonary rehabilitation is a supervised medical programme that helps people who have lung diseases live and breathe better. Patients may need pulmonary rehabilitation if they have a lung disease such as COPD, and the programme teaches them exercises and breathing techniques.
43. Section 1.2.81 of NICE guidelines NG115 for ‘Chronic obstructive pulmonary disease in over 16s: diagnosis and management’ says NHS organisations should offer pulmonary rehabilitation to everyone with COPD. Point 1.2.84 also explains pulmonary rehabilitation programmes should include multicomponent, multidisciplinary interventions tailored to a patient’s needs. The rehabilitation process should include physical training, disease education, and nutritional, psychological and behavioural intervention.
44. Our Adviser explained that the evidence shows the Trust followed these guidelines when making the referral for pulmonary rehabilitation for Mrs A. The guidelines do not set out specific time limits for the completion of the rehabilitation, but explain that places should be available within a reasonable time. At the time the initial referral was made, the COVID-19 pandemic had just started, so we have taken into account the impact this had on the Trust and its ability to provide services within its usual timeframes.
45. The relevant medical records confirm the Trust sent the initial referral for pulmonary rehabilitation on 5 March 2020, just three days after the consultation, which is prompt action. As such, there was no evidence of any delay in the referral being made. The first appointment took place on 16 June 2020, just over three months after the initial referral.
46. Considering the strain COVID-19 had begun to put on the Trust and NHS services nationally, the evidence suggests to us this is a reasonable time for the rehabilitation to have begun. Our Principles of Good Administration say: ‘Public bodies should behave helpfully, dealing with people promptly, within reasonable timescales and within any published time limits.’ The Trust acted in line with this commitment.
47. Rather than an in-person appointment at the Trust lung service, a phone consultation was arranged for Mrs A due to COVID-19. This was in line with national guidance at the time as hospitals were limiting the number of patients attending in person. In Mrs A’s case, there was a further risk as she was clinically vulnerable and was shielding because of COPD.
48. Public Health England’s ‘Guidance on shielding and protecting people who are clinically extremely vulnerable from COVID-19’ was in place at the time of the consultation. On a national level, doctors in England had identified specific medical conditions that, based on what was known about the virus at the time, placed some people at greater risk of severe illness from COVID-19. This guidance confirms a person suffering from COPD would be classed as extremely vulnerable.
49. Public Health England updated the guidance on 5 June 2020 and it was in place at the time of the consultation. It advises people classed as clinically extremely vulnerable to take additional precautions to avoid coming into contact with the virus, including staying at home as much as possible.
50. The guidance also gives information on attending hospital appointments: ‘Everyone should access medical assistance online or by phone wherever possible.’ It was therefore reasonable for the Trust to have arranged a phone consultation for Mrs A.
51. Point three of the action plan relates to the Trust arranging lung function tests. The Trust planned to arrange spirometry testing (a test that measures how much air a patient can breathe out) to help diagnose and monitor Mrs A’s condition.
52. Following the onset of COVID-19, spirometry testing was mostly suspended across the NHS. This was because spirometry tests often generate aerosols in the form of droplets due to patients coughing and therefore pose a considerable risk for the spread of infection.
53. The Association for Respiratory Technology and Physiology guidelines for respiratory function tests during COVID-19 say: ‘Routine respiratory function testing should no longer occur in primary care practices unless part of a coordinated Hub, based around PCNs [primary care networks] with all the appropriate precautions.’
54. In light of this, hospital trusts at the time were only completing these tests for the most urgent cases. The Trust confirmed it was only performing tests for urgent pre-operative cases at the time of Mrs A’s referral.
55. We understand from this, and from our discussions with our Adviser, that although not all tests were completed as planned for Mrs A, the Trust acted in line with guidance in suspending the testing, especially for the clinically vulnerable.
56. Based on the evidence available to us, the Trust followed the relevant standards and guidelines when acting on the action plan to the extent possible. Therefore, we have seen no evidence of mistakes by the Trust on this matter and we will take no further action.
The Trust missed a further opportunity to investigate Mrs A’s symptoms fully when she went to the local ED on 16 June 2020.
57. Mrs C tells us: ‘Another chance was missed when she called 999 in June, because of severe back pain she was seen in A and E but sent home.’
58. In her complaint to the Trust Mrs C also says: ‘In June Mrs A was experiencing severe pain in her back and having failed to get through to her GP rang 999, the ambulance took her to A and E at ROH [Royal Orthopaedic Hospital] where she was discharged from later that day with a diagnosis of anxiety.’
59. In its reply to Mrs C’ complaint, the Trust tells her: ‘Dr […] has reviewed the records relating to Mrs A’s attendance to A&E. Mrs A attended the Emergency Department on 12 June 2020 with a history of back pain radiating into her chest; she was not complaining of any shortness of breath or dizziness. At triage (initial assessment) her physiological observations were all within normal parameters.
Mrs A was examined by Dr […], Registrar, who noted the history of back pain radiating through the chest after leaning over the kitchen counter. It was also noted that the pain settled with aspirin and Mrs A was pain free at the time of assessment. He requested blood tests and a chest x-ray which were all within normal parameters. On review of the GP discharge letter it was documented that the pain was likely to be musculoskeletal. Please accept our apologies if Mrs A felt the ED doctor thought the pain was related to anxiety, this was not the case, or his intention to convey.’
Our view
60. On examining the relevant medical records, we can see Mrs A attended the ED complaining of pain in her chest on 12 June 2020. On arrival, a triage nurse saw and assessed her. The nurse recorded her symptoms as back pain radiating into her chest but no breathlessness. It was noted that the pain had eased at that time and she had taken an aspirin.
61. An ED doctor then assessed Mrs A and noted her pain had begun suddenly when she bent forward over a counter, and she had also felt faint and sweaty. The notes show Mrs A informed the ED doctor that the pain had begun to ease after 40 to 60 minutes. The ED doctor noted Mrs A’s past medical history of COPD, hypertension and an allergy to penicillin.
62. Paragraph 15 of the GMC ‘Good Medical Practice’ guidelines states doctors must:
a. 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.
b. promptly provide or arrange suitable advice, investigations or treatment where necessary.
63. NICE guidance CG95 ‘Recent-onset chest pain of suspected cardiac origin: assessment and diagnosis’ also explains what should happen in assessing and diagnosing recent chest pain in people aged 18 and over and managing symptoms while a diagnosis is made.
64. Based on the evidence, we consider the Trust followed these guidelines as Mrs A was assessed appropriately and consideration was given to her past medical history.
65. Staff at the Trust then carried out relevant investigations, including an ECG that showed no significant abnormalities.
66. Staff also ordered blood tests. The results of these tests can help hospital staff work out what is wrong with a patient and decide if they need treatment urgently. The blood tests taken at the time showed no abnormalities.
67. The Trust carried out a chest X-ray. Chest X-rays are a good way to look at bones and can show changes caused by cancer or other medical conditions. X-rays can also show changes in other organs, such as the lungs. A patient will usually have X-rays in the imaging department of the hospital, taken by a radiographer.
68. The Trust described the results of the chest X-ray taken at the time as ‘unremarkable’. We understand that if clinical staff do not see anything concerning, they may describe the images as normal or unremarkable. Our ED Adviser has seen the images taken at the time and tells us there is nothing in the images that would give cause for concern. Most lung tumours appear on X-rays as a white-grey mass, and the chest X-ray detected no such sign.
69. All the relevant investigations were completed, and by the time the results were known Mrs A told staff her pain had eased. As such, the ED doctor diagnosed musculoskeletal pain. We can see this was supported by the evidence available to them at that time. The decision to discharge Mrs A was therefore evidence-based and in line with GMC ‘Good Medical Practice’ section 15.
70. Mrs C complained to the Trust and explained she believed the diagnosis from this visit to the ED was anxiety. We have looked carefully at the medical records and there is nothing to suggest this diagnosis was given. The Trust also told Mrs C in its complaint replies this was not the diagnosis it had given, and it apologised if Mrs A had been confused in any way about what the diagnosis had been.
71. There are no signs from Mrs A’s symptoms, or the investigations completed, that the Trust should have suspected she had lung cancer at that time or taken any further or different action. There is no evidence to suggest the Trust missed an opportunity to diagnose Mrs A’s subsequent lung cancer during this visit to the ED, and the steps it took appear to be in line with applicable guidelines and standards.
72. Therefore, we have seen no signs of mistakes by the Trust on this matter and we will take no further action.
A nurse made insensitive and hurtful comments to the daughter of Mrs A the morning she died and the Trust did not do enough to identify the member of staff. This meant the Trust was unable to take any action relating to the comments the complainant reported to it.
73. Mrs C tells us following the diagnosis of stage 4 lung cancer, Mrs A was on end-of-life care and her daughter, Ms E, came from another part of the country to be with her. In the second half of August 2020, Mrs A had become extremely poorly and the family knew there would not be much time left with her. Her daughter stayed in the hospital overnight but the next morning, Mrs C says a nurse told Ms E she would need to leave the ward for a while and she would contact her if Mrs A’s condition became any worse.
74. Ms E tells us she wanted to stay with her mum, but the nurse insisted she leave. Ms E tells us the nurse then said if they ‘turned the oxygen off it would speed things up’. Ms E tells us this comment caused her great distress and still upsets her now when she thinks about it. Ms E says she still gets distressed when she thinks that the nurse sent her away and she was not able to be with her mum when she died a short time later.
75. In her complaint to the Trust, Mrs C says: ‘When the day staff came on duty the senior member of staff in charge of the ward came in to see Ms E and told her she had to leave and that “it would quicken things up” if the oxygen was switched off. Ms E left and my sister passed away, again Mrs A was denied the compassion she deserved.’ Mrs C also commented she had never heard of such poor, unsympathetic and uncompassionate treatment.
76. In its complaint reply, the Trust says: ‘The ward Manager has been unable to identify the senior member of staff who spoke with Mrs A’s daughter regarding the oxygen therapy. Sister […] is deeply upset that any staff member would have communicated in this way and would like to offer her sincere apologies for any upset and distress this caused. Nursing staff had documented that Mrs A’s daughter was present throughout the morning in August 2020 and went home to freshen up late morning.’
Our view
77. The Trust confirmed to us it had not been able to identify the staff member who spoke to Ms E.
78. We asked the Trust what actions had been taken to identify the member of staff. In reply to this request, the Trust apologised and explained it did not believe there had initially been a thorough investigation to identify the member of staff, but the Trust had now identified the nurse in question and spoken to them. The nurse confirmed they had discussed her mother’s care with Ms E at the time. They have been asked to reflect on the feedback of the complaint and to consider the impact of their communication. The Trust has also confirmed that following the incident, the ward manager spoke to all staff on the ward to reiterate the importance of clear communication with families.
79. As the Trust did eventually identify the staff member in question, we cannot say it did not do enough on this front, even if there was an initial delay. However, by not carrying out a thorough and timely investigation, it did not act in line with its Complaints Handling Policy 2019 - section 5.5.5 ‘Complaint Investigation’ and 5.5.2 ‘Formal Complaints’. These say a written response will be provided within 25 working days, or up to 60 if the matter is complex (which this complaint is not). As such, this is a sign of a failing, which we can see caused frustration to the family.
80. The Trust has not accepted the exact wording Ms E tells us the nurse used, and we cannot know for sure what was said, given the lack of direct evidence available to us. However, all parties agreed a comment of some kind was made and it proved very upsetting to Ms E.
81. As the comment caused Ms E considerable distress, we consider this to be a breach of the NMC Code, section 1.1 on the commitment to ‘treat people with kindness, respect and compassion’. It is clear communication was inappropriate in this particular instance and left Ms E feeling unsupported and distressed.
82. As there is a sign of a failing in this part of the complaint, we have considered what would be an appropriate outcome for the family.
83. We discussed this matter with Ms E, and she reiterated how upset she was about the comment made to her and tells us she still thinks about it.
84. Our enquiries to the Trust led to a further investigation and identification of the member of staff, which in turn allowed for a more informed and direct apology. Ms E was pleased we could now tell her the person responsible had been identified and spoken to. She says she hopes they have fully considered the impact this had on the family at a very distressing time. Ms E also indicated she would accept an apology from the Trust in relation to this incident.
85. Ms E says she would like the Trust to accept the impact the comment had and give a sincere apology, considering the added stress and upset this caused her and the family.
86. The Trust has accepted the initial investigation to identify the member of staff was not thorough enough and agreed to issue a further apology to Ms E and the family for this and the distress caused by poor communication. All parties have now agreed to an apology, and the Trust has already taken action to make staff aware of the impact incidents like this can have on a family. In our view, the action it has agreed to take puts things right for Mrs A’s family.
87. In line with our Principles for Remedy, the Trust has now taken action to put things right and learn from the complaint. These principles state an appropriate outcome should include an apology, explanation and acceptance of responsibility.
88. We believe the action the Trust has now taken resolves this aspect of the complaint, so we will take no further action. We hope where the clinical care and treatment is concerned, our independent view has reassured Mrs A’s family there is nothing to suggest she was denied the care she needed. We know this continues to be a source of distress and worry for them, so we hope the above explanations are helpful.