13. Mrs A told us it is impossible for her to forget the suffering her husband went through in the last few hours of his life. She finds it hard to accept that doctors decided to send her husband home when he needed medical care and observation. She says the possibility that her husband could have survived is something she will never get over.
14. GMC guidance says doctors must provide a good standard of care. This includes doing the right assessments, taking account of the patient’s history and examining them if necessary. Doctors should also arrange suitable and timely treatment and investigations or make referrals if needed.
15. The Pneumonia Guideline explains how doctors should recognise and treat pneumonia. It says they should do an assessment of the severity of pneumonia by calculating a CURB65 score. The CURB65 allows doctors to find out the risk of someone dying from pneumonia based on the patient’s level of confusion, raised levels of urea (a waste product from the body), nitrogen in the blood, respiratory rate, blood pressure and age. For those whose CURB65 score is high (three to five) more than 15% of patients are at risk of death. For patients who score three or more doctors should consider intensive care treatment. For those with a score of two or more doctors should consider hospital-based care.
16. Sepsis is the body’s overwhelming response to a severe infection causing injury to tissues and organs. It can be life threatening. The Sepsis Guideline explains how clinicians should recognise and treat signs of suspected sepsis. It says a raised respiratory rate of 25 breaths per minute or more and systolic blood pressure of 90mmHg or less are among the highrisk criteria for suspected sepsis.
17. The Sepsis Guideline says clinicians should arrange an immediate review by the senior clinical decision maker to assess a person who has suspected sepsis and one or more of the highrisk criteria. They should then arrange a series of tests and investigations and prescribe the recommended maximum dose of an antibiotic within one hour. For those who also have lactate levels of over 4mmol/litre and low blood pressure, they should provide intravenous fluid (into the veins) within one hour. Lactate is a chemical made in muscles or red blood cells which can suggest that organs in the body are not working properly.
18. The clinical records show Mr A attended the hospital with a sudden onset of breathlessness in late November 2021. He was coughing up sputum and was shivery. A clinician completed a sepsis review for Mr A in the emergency department (ED). They suspected Mr A could have sepsis.
19. Observation charts from the ED show Mr A had a consistently high respiratory rate (25 breaths per minute or more) and low blood pressure (systolic blood pressure below 90mmHg). These are some of the high-risk criteria for sepsis. Our clinical adviser says the clinician was right to recognise Mr A may have sepsis.
20. A doctor reviewed Mr A around six hours later. They diagnosed pneumonia with a background of pulmonary fibrosis based on blood test results and a chest X-ray. They prescribed intravenous antibiotics and fluids in line with the Sepsis Guideline. They also took appropriate blood samples to try and find the cause of the infection. The doctor followed the Sepsis Guideline by arranging the appropriate initial treatment and investigations for sepsis.
21. The doctor also calculated a CURB65 score for Mr A of two. But, our view is this was incorrect. Mr A had low blood pressure and a high respiratory rate. He also needed oxygen. His CURB65 score should have been three. When a consultant reviewed Mr A later in the morning, the systolic blood pressure was 56mmHg and the respiratory rate was 36 breaths per minute. Again, this should have led to a CURB65 score of three. This meant Mr A was at a high risk of death.
22. Our clinical adviser said it would not have been appropriate for doctors to admit Mr A to intensive care because of his underlying lung disease. But, Mr A should have stayed in hospital even with a CURB65 score of two and this did not happen. Doctors did not follow the Pneumonia Guideline.
23. The consultant also noted Mr A’s history and test results. They suspected Mr A had a blood clot because of the blood tests results. The consultant arranged a CTPA (a CT pulmonary angiogram is a way of scanning the arteries around the lungs to check for any blood clots). The consultant noted the plan was for Mr A to go home with oral antibiotics. The consultant did not document why they planned to discharge Mr A when he was at high risk of death from pneumonia and he appeared to have signs of sepsis. We cannot see evidence that the consultant planned to arrange suitable treatment for Mr A. They did not follow GMC guidance.
24. The CTPA did not show any clots. The doctors decided to change Mr A’s antibiotics to oral and discharged him. A clinician noted ‘patient had CTPA after result reviewed can be discharged to home IV antibiotics switched to oral.’ There is no record to show doctors did any more assessments or examinations of Mr A before he left the hospital. We find the assessment was below the expected standard and not in line with GMC guidance.
25. Our clinical adviser said there is no evidence Mr A’s oxygen levels reached an acceptable level for him to be sent home. Also, Mr A does not seem to have been medically fit enough to leave the hospital based on the observation charts. The charts suggest he still had sepsis and pneumonia. Doctors did not give Mr A the treatment he needed. Again, this was not in line with GMC guidance.
26. While doctors followed the Sepsis Guideline, they did not follow GMC guidance or the Pneumonia Guideline. Mrs A is right to say doctors should not have discharged her husband from the hospital.
27. We asked our clinical adviser what would have happened if Mr A had stayed in hospital. He said it is likely doctors would have continued to treat Mr A with intravenous fluids and antibiotics. This could have led to some improvement in his health, but his underlying lung condition was very significant. The episodes of sepsis and pneumonia would have increased his disability even if he had survived the admission, and he would have stayed in hospital for at least one week more and probably longer.
28. The early treatment of sepsis is associated with better outcomes. The chances of Mr A recovering would have been greater had he stayed in hospital. But his chances of survival were less than 50% even with a longer stay. This was because of his pneumonia and sepsis and background of pulmonary fibrosis. The mortality rate for sepsis in the UK is around one in five for the general population and this would have been much higher for Mr A.
29. Overall, we cannot say Mr A would have survived if there had been no failings by doctors at the hospital. But we can say there was an opportunity for him to have treatment that could have led to him living longer. He was denied this opportunity. This means Mrs A is now left with uncertainties about what might have happened if doctors had done more. This is a significant and ongoing injustice to her.
30. We can also see how the discharge and readmission would have been distressing for Mr A and his wife. This would have been avoided if he had stayed in hospital. He would also have had support from clinicians who would have been better able to manage his symptoms.
31. We partly uphold the complaint.