Communication Mr I’s condition and CT scans
23. Before we decide if we should do a detailed investigation of 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 seen any signs that something has gone wrong.
24. Mrs I complains the Trust did not appropriately communicate her husband’s condition and deterioration with her and did not show or discuss his CT scan results with her.
25. The Trust said the clinicians who were treating Mr I felt they had a clear understanding with Mrs I, Mr I and their son and asked if she had any questions.
26. The Trust also said it tries to make sure patients and families are fully supported in difficult circumstances and it is very sorry this was not achieved.
27. GMC guidance for ‘Communication partnership and teamwork’ tells doctors:
‘You must be considerate to those close to the patient and be sensitive and responsive in giving them information and support’.
28. The medical records show staff discussed Mr I’s condition and deterioration with Mrs I when he was readmitted in October. The records say it was explained to Mrs I about the chances of Mr I surviving and about his deterioration in detail as well as the management plan.
29. The day after Mr I was readmitted, the Trust discussed his condition with Mrs I and her son. The records show that staff explained to Mrs I that Mr I was approaching the end of his life and they would try to control his pain through intravenous pain relief (given through the veins). The Trust explained its aim would be symptom control only and he had sadly deteriorated rapidly since the morning.
30. The clinicians also explained that as there was no possibility of survival, surgery was not an option and they put a plan in place to refer Mr I to the palliative care team for a syringe driver (a battery-operated machine that delivers medication steadily to the patient over a 24-hour period) and symptom control.
31. The notes do not specifically record whether the findings of the CT scan were discussed with Mrs I. But, the records suggest they were discussed because the scan led to the diagnosis of bowel perforation and this was discussed with Mrs I and her family.
32. Our adviser told us it is not normal practice to show patients or relatives CT scans unless they would help their understanding, for example, to show a mass or lump. In Mr I’s situation it is unlikely that showing the scan would have helped their understanding. This is because CT scans can be hard to interpret and the only finding visible on the scan would have been free air and fluid indicating the perforation. Had either of them asked to see the scan there would have been no reason not to show them, but there is no evidence in the records that they made such a request.
33. Based on the records we have seen it seems the Trust explained Mr I’s condition and deterioration to Mrs I and it was sensitive and responsive when giving the family this information. We have not seen any signs of failings as this was in line with the GMC guidance. We have also not seen any signs of failing in regards to the CT scan. Mrs I was given information relevant to Mr I’s condition and there was no need for staff to show her the CT scan.
34. We recognise the information doctors gave to Mrs I did not meet her needs or expectations and this has left her feeling that she was not prepared for Mr I’s death. We also recognise the conversation Mrs I had with a junior doctor did not feel compassionate.
35. This does not mean there was a failing but that staff may not have realised Mrs I needed or wanted more information.
36. The records suggest staff did try to explain what was going on with Mr I’s condition and we cannot say that the communication fell below the expected standard .
Explanation of survival, operation and treatment
37. Mrs I complains the Trust did not explain what was wrong with her husband or why he was not going to survive and did not discuss the reasons why they would not operate. She feels the Trust should have operated and this would have given him a chance of survival.
38. Mrs I also complains the Trust did not provide appropriate treatment to her husband during his admission in October and she says the clinicians withdrew all care.
39. In its final response the Trust said surgery was not an option because Mr I was unlikely to survive surgery or the recovery period. It said because of Mr I’s medical issues and his current clinical observations, surgery was unlikely to succeed. The medical records support this.
40. When Mr I was readmitted in October, a further CT scan was done and this showed features of a bowel perforation.
41. GMC guidance for ‘Knowledge skills and performance’ tells doctors:
‘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’.
42. It seems the Trust followed the GMC guidance as it assessed Mr I, considered his condition and history and arranged the treatment that was necessary.
43. The National Library of Medicine guidance says there is a higher risk of death in patients who have surgery for ischaemic colitis than those who are managed conservatively.
44. Our adviser told us the treatment of ischaemic colitis is conservative. This means with antibiotics, intravenous fluids and pain killers rather than surgery in most cases. We can see the Trust followed this guidance.
45. When Mr I was readmitted in October doctors considered surgery because of the perforation, which was in line with the guidance.
46. The RCS guidance uses a tool called The Portsmouth Physiological and Operative Severity Score (POSSOM). This tool has been authorised for estimating an individual patient’s risk of death within 30 days of emergency general surgery.
47. Our adviser told us the Trust correctly used this tool and it showed a very high risk of death if surgery was done. Based on what we have seen, it was correct and in Mr I’s best interests to not have surgery as this would have led to distress and discomfort with very little chance of survival or return to a reasonable level of function.
48. The high score was discussed with Mrs I in October. Staff told her Mr I was at a terminal stage in his illness and he would be referred to the palliative care team to provide appropriate treatment.
49. Our adviser said when Mr I was readmitted it was too late for treatment because of the perforation, his medical issues and frailty.
50. We think the Trust made the correct decision not to operate on Mr I and explained this to Mrs I and her family.
51. We appreciate this situation was distressing and upsetting for Mrs I and her family. Having carefully considered all the available evidence, we have not seen any signs that anything went wrong.
52. We thank Mrs I for bringing her complaint to us and we hope our explanation reassures her about the Trust’s actions.