Manchester University NHS Foundation Trust

6. Miss R complains about the care the Trust gave to her father before his sudden death in December 2022.

7. Mr R was admitted to the Trust after having a cardiac arrest. There was a delay in doing a procedure and Miss R felt it was too late to do any good and Mr R had another cardiac arrest during the procedure.

8. Miss R said the family were not told about the cardiac arrest until after the event. The Trust said it told the family at the time.

9. Miss R says her father was in his late fifties and his death was unexpected and affected the whole family.

10. Miss R wants justice and does not want this to happen to anyone else.

11. When Mr R arrived at the emergency department he was in cardiac arrest and had already been resuscitated.

12. On arrival to the emergency department, the medical records show that he again lost circulation and had another cardiac arrest. This time with a cardiac rhythm known as pulseless electrical activity (PEA). This is when the heart seems to be working but is not able to support the circulation with a sustainable cardiac output. Mr R was resuscitated again in the emergency department and regained cardiac output. He was intubated (putting a tube into the body to help breathing) and put into an induced coma state (a procedure to put someone into a deep state of unconsciousness), with protection of the airway.

13. Over the next few hours, further investigations were done to find the cause of collapse and blood loss. The medical records show there were recordings of very low blood pressure, and it is also noted that there was ongoing blood loss.

14. Mr R was moved to the intensive care unit. Mr R was reviewed and his blood pressure was stable. The Trust did a procedure to put a camera into the upper gastrointestinal tract to look for the cause of bleeding. Mr R sadly died soon after this procedure.

Delayed procedure and Mr R’s death

18. 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 found any signs that something has gone wrong.

19. NICE guidance says:

‘People with severe acute upper gastrointestinal bleeding who are haemodynamically unstable [unstable movement of blood causing poor blood flow] are given an endoscopy within 2 hours of optimal resuscitation.

People admitted to hospital with acute upper gastrointestinal bleeding who are haemodynamically stable are given an endoscopy within 24 hours of admission.’

20. ESGE guidance says after resuscitation a procedure using a camera on a thin tube (endoscopy) should be done within 24 hours:

‘ESGE recommends that following hemodynamic resuscitation, early (≤ 24 hours) upper gastrointestinal (GI) endoscopy should be performed.

ESGE does not recommend urgent (≤ 12 hours) upper GI endoscopy since as compared to early endoscopy, patient outcomes are not improved.

ESGE does not recommend emergent (≤ 6 hours) upper GI endoscopy since this may be associated with worse patient outcomes.’

21. The medical records noted a large amount of blood coming out of the airway tube suggesting a large upper GI (gastrointestinal) haemorrhage. Our adviser said in this setting the priority is to stabilise the patient and resuscitate them so that they are more haemodynamically stable (stable blood flow) and are better placed to have more tests to find the cause of the bleeding.

22. The test needed was an OGD (an oesophago-duodenoscopy). Our adviser said it is not something that can be done on a hospital ward or in the emergency department.

23. Our adviser said it is also a very difficult procedure to do effectively if there has been a large bleed. This is because it can be hard for the camera to see anything if the source of bleeding is hidden by a large volume of blood. From review of the medical records and the post-mortem findings there seemed to be a large amount of blood in the stomach.

24. Our adviser said Mr R was very unwell and the priority was to stabilise him after his heart had stopped and to make sure that he was supported from a breathing and circulation point of view. He was correctly transferred to the intensive care unit for this.

25. From review of the medical records, we do not think the procedure could have been done any sooner because Mr R was too unwell.

26. Our adviser said even when the procedure was done, there was a lot of blood in the stomach and Mr R was very poorly and unstable because of this. There was no easily visible source of bleeding that could be found or treated, so no treatment option was available. It was not possible to do the procedure earlier, it would not have made any difference to the treatment plan or second cardiac arrest and Mr R’s death.

27. Within the complaint response, the Trust said clinical interventions needed to be done at the time. Mr R was at high risk for a transfer to the CT scan room or the intensive care unit due to unstable blood pressure. To do the endoscopy, it tried to stabilise him. Sadly, it seems that Mr R’s clinical state was too advanced due to the blood loss.

28. Our adviser said giving the best treatment was difficult. It involved a large volume of blood products (red blood cells and fresh frozen plasma) to replace blood loss and medication to improve blood pressure. It also required investigations like the CT scans the Trust did. From what we have seen, the Trust’s actions were in line with what is recommended by NICE and ESGE.

29. We have not seen any signs of a failing or a delay in carrying out the procedure.

30. We do not underestimate the family’s upset and grief. We are sorry there was no possibility of any earlier treatment because Mr R was too unwell.

Communication

31. GMC guidance describes what it means to be a good doctor. It says a good doctor will make the care of patients their first concern.

32. From review of the medical records, it seems the family were brought in to see Mr R within 30 minutes of him sadly passing away. Our adviser said communication and the timing of giving families this information can be difficult.

33. The medical records say, ‘scoped patient at 7am. Whilst performing scope, patient went into cardiac arrest so procedure stopped, CPR commenced. After about 10 minutes, I went with E to talk to the relatives and explained he had arrested when they were performing CPR but they need to prepare themselves because his prognosis was very poor.’

34. It is also noted that resuscitation was stopped at 7.55am and time of death was reported. There is a note at 8.10am that Mr R was given personal care, his bed sheets and gown changed and at 8.25am the family was brought in.

35. Within its complaint response letter, the Trust apologised if there was any confusion.

36. We do not find any signs of a failing because the evidence suggests the family were told as soon as possible, once the Trust had tried to stabilise Mr R.

37. We do not underestimate how difficult this experience was for the family.

38. Complaints give us valuable insight into the organisations we investigate, so we thank Miss R for sharing her experience with us.

1. We have carefully considered Miss R’s complaint about Manchester University Trust (the Trust). We are sorry to hear about the events that led to her complaint.

2. We have decided not to consider the complaint further because we have seen no sign that anything went wrong with the care it gave to Miss R’s father, Mr R.

3. We do not underestimate the upset and grief caused to Mr R’s family. We are sorry that there was no possibility of any earlier treatment or investigation because Mr R was too unwell at the time.

4. We appreciate how upsetting it was for Mr R’s family to find out he had a cardiac arrest (heart attack) and died during a procedure. There is no evidence to suggest the family could have been told sooner and the Trust’s priority would have been to try to stabilise Mr R.

5. We have explained the reason for our decision in this statement.