Trust A
Diamox
23. Ms D complains the ophthalmologist should not have prescribed Diamox as Mr M was over 65 years old, had high blood pressure, took medication to thin his blood and he also had gout (causes swelling and severe pain in the joints).
24. We considered this issue with help from our ophthalmologist adviser.
25. Trust A explained to us that before SLT, Mr M’s intraocular pressure (IOP is fluid pressure inside the eye) was higher than normal. It said SLT can cause a short-term pressure spike and due to Mr M’s advanced visual field loss he would have been vulnerable to the effects of this, which could have had a sudden and lasting effect on his vision.
26. It said the ophthalmologist considered his age and medical background and they felt it was clinically appropriate to prescribe Diamox to Mr M to prevent potential loss of vision from a pressure spike in his eye after SLT.
27. GMC guidelines explain that in providing clinical care, doctors must prescribe drugs or treatment, including repeat prescriptions, only when they have enough knowledge of the patient’s health and are satisfied that the drugs or treatment serve the patient’s needs.
28. BNF explains that Diamox is normally given as a short-term treatment to reduce pressure in the eye and this is normally given if eye pressure has risen and in an acute situation.
29. SLT can sometimes cause a temporary rise or spike in pressure after the procedure. This can range from being mild to rising greatly which may cause a change or reduction in vision.
30. In Mr M’s medical records, the ophthalmologist has documented that he had significant visual field loss. Our ophthalmologist adviser explained that because of this, a pressure spike in the eye may cause complications and blindness.
31. After SLT, Mr M was given iopidine drops that can help to prevent a pressure spike, but the addition of Diamox would also help this. This is because it is a short-term treatment often given to lower pressure in the eyes.
32. We recognise BNF suggests that Diamox is normally given to reduce pressure in the eye, but we think there was a good reason for it to be prescribed as a precaution after SLT. This is because there was a risk of a pressure spike that could have caused Mr M serious complications. And due to this, we think the addition of Diamox would have helped to counteract any potential rise of pressure in Mr M’s eye.
33. We understand Ms D’s concern that the pharmacist at the Trust queried if Mr M should be given Diamox and Mr M queried this himself. There are no clear reasons why it should not be given to Mr M (considering his medical history and the medication he was taking) and the ophthalmologist prescribed it for a short amount of time. And, none of the medications Mr M was taking are in the list of contraindications or interactions with Diamox as explained in the BNF.
34. We can see why Ms D was concerned that shortly after taking Diamox, Mr M fell ill. We are sorry to hear this happened and recognise the shock and sadness it must have caused.
35. The evidence we have seen shows it was appropriate for the ophthalmologist to give Mr M Diamox to prevent a rise in eye pressure that could have caused serious complications for him. This was in line with the relevant guidelines. There is no failing here.
Trust B
Mr M’s symptoms and treatment
36. Ms D says that Trust B did not properly investigate or treat Mr M’s symptoms when he was admitted on 20 February with vomiting.
37. In its complaint response, Trust B said the medical plan was for Mr M to have an OGD, blood tests and a chest X-ray. Trust B said Mr M was monitored and the medical team prescribed IV antibiotics.
38. GMC guidelines say doctors must provide a good standard of practice and care. If they assess, diagnose or treat patients, they must:
• ‘adequately assess the patient’s condition, 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 • refer a patient to another practitioner when this serves the patient’s needs.’
39. When Mr M was admitted to Trust B, it is noted in his medical records that he had many episodes of ‘coffee ground’ brown vomiting since the evening before. This is often a sign of an UGIB. His observations were taken, which were normal, and he was examined. His abdomen did not show anything unusual, and he also had a rectal examination that showed no evidence of black sticky stools (which can be a sign of an UGIB).
40. A chest examination was also carried out that showed crackles. These can be found in several conditions, including chest infections. This was followed by a chest X-ray that showed changes consistent with a chest infection. Mr M also had blood tests that showed evidence of an infection and potential bleeding.
41. After the tests, the medical team felt Mr M had an UGIB and suspected aspiration pneumonia. It seems this may have been caused by vomiting. We recognise this was a worrying time for Ms D.
42. The evidence so far suggests the medical team at first noted Mr M’s symptoms, examined them and did several investigations to try and find a cause. This is in line with the GMC guidelines.
43. NICE pneumonia guideline says that antibiotic treatment should be started as soon as possible after finding a diagnosis of community-acquired pneumonia, and within four hours.
44. After Mr M’s diagnosis of suspected aspiration pneumonia, Trust B gave IV antibiotics to treat pneumonia and IV pantoprazole (medication that reduces acid production in the stomach and helps to stop bleeding). Staff also gave him oxygen due to his rapid breathing rate and low oxygen levels (likely to have been caused by pneumonia). This means he had treatment in line with the GMC and NICE pneumonia guidelines.
45. NICE upper bleeding guidance explains that a risk assessment should be done for all patients with an UGIB.
46. On 21 February, after the diagnosis of an UGIB, the medical team referred Mr M for an OGD. This is done to try and find a cause for suspected bleeding.
47. Medical staff did a risk assessment that considered the examination findings and a score of five was given. This meant an OGD should be done within 24 hours of admission (as highlighted in NICE upper bleeding guidance).
48. At the time there were no slots left for an OGD to be done on the same day and it was felt to be non-urgent.
49. Because the OGD should be done within 24 hours of admission, it should have been completed by 21 February. This did not happen and this was a failing. We have considered any potential impact from this below.
50. While Mr M was waiting for the OGD, a speech and language therapist saw him due to his swallowing difficulties. He could not be fully assessed at this time because he was nil by mouth (where you cannot eat any form of food or drink or take medication orally). The documentation does not mention that Mr M seemed unwell at this time.
51. On 22 February, Mr M was moved to another ward and the documentation described him as being settled that evening.
52. Unfortunately, despite treatment, Mr M’s condition deteriorated and he sadly died shortly after this. We understand this was a distressing time for Ms D and her family.
53. Overall, the evidence shows Trust B investigated Mr M’s symptoms and he had appropriate treatment for an UGIB and suspected aspiration pneumonia. This was in line with the guidelines. He should have had an OGD within 24 hours of admission and this did not happen. We have considered the impact from this failing below.
Impact
54. We thought about any potential impact of this with our physician adviser by reviewing Mr M’s medical records.
55. We know Trust B felt Mr M had an UGIB. Having considered his examination findings, we do not think there is any significant evidence of a large gastrointestinal bleed. This is because there was no drop in his blood pressure, no rise in his heart rate, no fall in his haemoglobin level (a drop in this could mean a significant bleed) and no large elevation of urea (waste product from the kidneys, the level goes up with a large bleed).
56. People who have a large gastrointestinal bleed usually also tend to have an obvious large volume of bleeding, which is shown by vomiting fresh blood or passing large amounts of melena (black stools) or blood. Mr M did not have any evidence of these symptoms during the admission.
57. Given there is no evidence that Mr M had a large gastrointestinal bleed, we do not think having an OGD within 24 hours of his admission would have made a difference to the sad outcome. Trust B were already treating Mr M appropriately for the bleed, but unfortunately his health deteriorated. We understand the upset this caused Ms D.
58. We do not think there was any impact on Mr M from not having an OGD within 24 hours.
Nutrition and hydration
59. Ms D complains that staff did not give Mr M proper hydration or nutrition.
60. In its complaint response, Trust B explained that Mr M stayed on IV fluids during his stay. It said in relation to his nutrition, some of the records are incomplete so it is unable to comment on any oral intake or output. It also said the malnutrition universal screening tool assessment (this helps to identify adults who are malnourished or at risk of malnutrition) was incomplete with an expectation of weight being recorded.
61. We reviewed this issue with help from our physician adviser.
62. NICE nutritional guidelines explain healthcare professionals should make sure care includes food and fluid of the right quantity and quality is given in a comfortable environment. It also says that screening for malnutrition and the risk of malnutrition, should be done by staff with appropriate skills and training.
63. Ms D was concerned that Mr M was not kept hydrated during the admission, so we considered what IV fluids were given to him.
64. The medical records show the IV fluids that staff gave to Mr M during the admission. This was important as he was nil by mouth for some of the admission and giving IV fluids is important for hydration. The records show he was provided with the correct level of IV fluids and was kept hydrated during the admission. This is in line with the NICE nutritional guidelines.
65. The evidence also shows us that staff did not complete records of some of Mr M’s oral intake and output. This is an error in record keeping and Trust B has accepted this.
66. There is evidence of a malnutrition screening tool in Mr M’s medical records. But, this only documents his weight and staff did not fully complete it. There is also no detailed documentation of Mr M’s nutritional intake or that he received any nutritional support during the admission.
67. This suggests that Mr M did not have an appropriate screening for malnutrition. But, without a record of his nutritional intake and support, we are unable to say what nutrition or nutritional support he was given. This is a failing. We have considered any impact from this below.
Impact
68. NICE nutritional guidelines explain that nutritional support should be considered in people at risk of malnutrition, who have eaten little or nothing for more than five days and/or are likely to eat little or nothing for the next five days or more.
69. Mr M was admitted to Trust B on 20 February and died later that month. This was a short amount of time. The lack of nutritional intake and support is unlikely to have had an impact on the sad outcome and did not contribute to his death. This is because he was unwell due to an UGIB and suspected aspiration pneumonia and not because of a lack of nutritional intake or support.
70. We understand this is likely to be upsetting for Ms D and we have considered what Trust B have already done to address this failing.
71. Our standards say organisations should give fair and accountable responses that take action to make sure any learning is identified and used to improve services.
72. In its complaint response, Trust B accepted the issues with its record keeping and apologised to Ms D that staff did not fully complete records. It also escalated the concerns and shared them with the relevant team for learning. This means that staff have had the opportunity to reflect on what happened and use this when dealing with future patients.
73. We think the steps taken are reasonable to prevent the same thing from happening to another patient. These steps are in line with our standards and we hope this provides some reassurance to Ms D. We would not expect Trust B to take any further action.