Treatment
14. Mrs D complains that Mr G declined after his AAA surgery and is concerned this was because the Trust perforated his bowel during surgery. She also complains he did not eat any food from before the surgery on 15 September. She says the Trust did not look after him and if the consultant had done the colostomy sooner Mr G would have survived.
15. GMC guidance says doctors, ‘must provide a good standard of practice and care’ to ‘assess, diagnose or treat patients’ and ‘refer a patient to another practitioner when this serves the patient’s needs’.
16. The records from surgery note no unusual events or complications during surgery. Mr G was vomiting and his stomach became bloated in the days after surgery and his condition declined.
17. Our adviser explained that it varies when oral intake can start again after surgery and this depends on the patient and the surgeon’s judgment. As Mr G was vomiting on 17 September, he continued as nil by mouth and the Trust made a referral for him to be seen by a dietician. This is in line with the GMC guidelines above because the Trust assessed his condition and took action to address this by referring him to a dietician.
18. The Trust did a CT scan on 22 September which showed there were no obstructions or perforation. The Trust started Mr G on total parenteral nutrition (a method of feeding where nutrition goes straight to the bloodstream) on the advice of the dietician. This action is in line with the GMC guidelines because the Trust continued to assess his condition to find the reason for his symptoms and it took action to maintain his nutritional intake.
19. The surgeon continued to assess Mr G’s symptoms and from 22 September considered fitting a colostomy bag to empty the stomach and reduce his stomach symptoms and pain. National Early Warning Score (NEWS) is a tool developed by the RCP to help clinicians detect and respond when a patient’s condition deteriorates. The records show Mr G’s NEWS score during his admission. His score was very high on 23 September.
20. GMC guidance says doctors should get the opinion of colleagues. The records show that between 22 and 29 September three consultants gave their opinion to the main surgeon involved. This is in line with the GMC guidelines. They advised the surgeon to take a conservative approach and wait to see if colostomy surgery was needed due to the risk involved with surgery.
21. The surgeon then used a risk adjustment score from their observations notes and blood tests that involves monitoring respiration (breathing), oxygen, blood pressure, pulse, consciousness and temperature. This is a scoring system used to predict the expected morbidity and mortality rate for a patient, before carrying out a procedure. Mr G’s score was very high on 27, 29 and 30 September.
22. In the early hours of 29 September, Mr G’s condition deteriorated and he had abdominal pain. The surgeon thought he was suffering from infarcted sigmoid colon, which is when the bowel does not have enough blood flow.
23. Our adviser explained that the blood supply to part of the colon is at risk with colostomy surgery and this type of complication after surgery unfortunately happens in about 1.2% of cases. This complication can happen even if there are no mistakes during surgery.
24. By 29 September the surgeon felt Mr G needed emergency surgery to fit a colostomy bag because his condition was changing and getting worse quickly. This is in line with the GMC guidelines to assess and treat patients. The Trust called Mrs D advising her Mr G needed emergency surgery to have a colostomy bag fitted and asked for her consent. It carried out the procedure as an emergency.
25. On the morning of 30 September Mr G was critically unwell. Mrs D says she called the ward for an appointment to visit Mr G and was told the consultant needed to speak to her first. The consultant told her Mr G was not going to live long. He sadly died at the beginning of October.
26. We have found the Trust acted in line with the GMC guidelines and Mr G’s bowel was not perforated during AAA surgery. He was given the nutrition he needed and the second surgery was done when it was safer to. Unfortunately, Mr G died due to complications which is a rare risk of this surgery. Our adviser explained that based on the results and observations in the records, if the Trust had done the second surgery sooner Mr G would sadly have died because he was too unwell at that time.
27. We recognise this caused Mrs D and Mr G’s family distress and they have been through a traumatic time. We hope our explanations have given some reassurance that what happened was not because of the Trust’s mistakes. We have not upheld this part of the complaint.
Communication
28. Mrs D complains about the communication she and Mr G’s family had with the Trust during his admission.
29. GMC guidelines say doctors must communicate effectively. They must listen to patients, take account of their views and respond honestly to their questions. They must give patients the information they want or need in a way they can understand. They must be considerate to those close to the patient and be sensitive and responsive in giving them information and support. GMC guidelines also say doctors must include in the records the information given to patients.
30. Mrs D says the Trust told her and Mr G before the AAA surgery that it could extend his life by 20 years. She says he was excited that he was starting a new life.
31. In the complaint response the Trust explained the consultant felt they were very clear and they did not promise Mr G 20 more years. The consultant said they explained there was a 97% survival rate and a 3% risk of death.
32. The above information and what was discussed with Mr G about his surgery was not clearly documented in the records we have seen. We cannot say what was actually discussed with them about the surgery or the risks involved. That said, Mr G did sign the consent form which detailed the risks involved.
33. The Trust did not meet the GMC guidelines to record discussions or to communicate clearly so it was understood that there were risks to the surgery. Sadly, the complications Mr G had were a rare risk of the surgery. We cannot link this poor communication to the impact of Mr G dying or the distress this caused.
34. Mrs D also complains about the communication between herself and staff. She says she felt the nurses were ignoring her when she asked about Mr G and she hardly saw a doctor. She says staff did not listen when she told them that Mr G was becoming more withdrawn and not answering his phone to his family. She says they did not listen to her concerns about how Mr G’s stomach was getting larger and bloated and they just kept telling her he was getting better.
35. The Trust got a psychiatric opinion to check Mr G’s mental condition after Mrs D’s concerns about him being withdrawn and when considering doing the second procedure.
36. There is little evidence in the records that the Trust discussed Mr G’s condition and what was being considered or that it listened to Mrs D’s concerns about his progress, before it decided to take him back to surgery. It did talk to Mrs D on 29 September just before his procedure, but there is not much detail about this.
37. Mrs D told us that in this discussion the Trust told her she must give consent because Mr G was in a bad way and needed emergency surgery. She told us she asked the nurse if she should call his son because she could see Mr G was deteriorating. She said the nurse told her not to, but she called his son anyway and told him how bad Mr G was on 29 September.
38. Based on the evidence, the Trust did not follow the GMC guidelines to record discussions and communicate clearly with Mr G, Mrs D and the family. But, as we have explained above this does not seem to have led to Mr G’s sad death or the impact this had on Mrs D. It is clear Mrs D’s concerns were listened to and acted on, but this was not communicated clearly with her.
39. Mrs D says when she got to the hospital on 30 September the Trust did not take her somewhere private to talk about Mr G’s condition. She says a consultant took her to a room that was not private. She says they said how unwell he was but did not tell her he was dying.
40. The Trust says Mr G deteriorated after the procedure and it did speak to Mrs D on 30 September. The Trust agreed the room the consultant took Mrs D to was not ideal and said it was sorry Mrs D had to be told this way.
41. This is not in line with the GMC guidance to be considerate to those close to the patient and be sensitive and responsive in giving them information and support. Our Principles say organisations should apologise when they get something wrong. We are pleased to see the Trust accepted it did not communicate with Mrs D about Mr G’s condition sensitively.
42. Mrs D says she got a call from the Trust shortly after the second surgery and was told to come straight away as Mr G was dying. She says they arrived 25 minutes later but sadly Mr G had died. Our adviser explained it is hard for the Trust to say exactly when a patient might die and unfortunately Mr G died before Mrs D and his son could get to see him. Unfortunately, it does not seem that the Trust could have anticipated that Mr G would die before his family got to the hospital.
43. Mrs D also complains that the Trust did not do a proper investigation of her complaint into Mr G’s death and it did not hold a face-to-face meeting.
44. Our adviser explained that all deaths after surgery should be discussed in a mortality and morbidity department meeting in line with RCS guidance. These meetings are carried out internally and privately and used for learning and reviewing cases at the Trust.
45. Our adviser said there are no other guidelines that say further investigation should take place. GMC guidance for action after a patient’s death, says to take time to give the family information. The Trust described what happened when it answered Mrs D’s questions.
46. Mrs D was unhappy with the response from the Trust. She wanted a face-to-face meeting. This was during the COVID-19 pandemic and face-to-face meetings were not taking place, so this is something the Trust could not do.
47. In summary, based on what we have seen, the Trust did not communicate clearly or in any detail with Mr G and Mrs D about the risks involved with the AAA surgery or Mr G’s condition and deterioration after this. We hope Mrs D is reassured by the fact that this does not seem to have affected his care or have any impact on his sad outcome.
48. The Trust listened to Mrs D when she reported changes in his behaviour, but it did not communicate this with her at the time. Again, this does not seem to have affected Mr G’s care or the outcome. It was hard for the Trust to say exactly when Mr G would die so Mrs D and his family could be with him. The Trust investigated the complaint and answered Mrs D’s questions. It was not able to meet her face-to-face due to the pandemic. We have not upheld this complaint.
49. We can see why Mrs D had concerns and we can see how what happened had a big impact on her. We hope our explanations have given her some answers about what happened.