20. The Trust’s final response letter states it did routine blood tests to look at the composition of blood and the electrolytes (salts and minerals). It states the result of these did not raise any concerns. Mrs R’s son also had a ddimer test, a test to see if there are any raised markers in the blood which would suggest further tests are needed for deep vein thrombosis or pulmonary embolism (blood clots). It states the result of this was also normal.
21. The response advises the only blood result that was high was alkaline phosphatase (an enzyme to break down protein) which is not always related to an underlying condition and is generally found in children, as it is related to growth spurts.
22. The Trust confirms no blood tests were done on 12 January to test for diabetes or blood glucose. It recognised this was Mrs R’s concern because her son was admitted three days after discharge in a diabetic emergency, diabetic ketoacidosis (DKA). It does not give an explanation for why these tests were not done.
23. DKA is a serious complication of diabetes. The condition develops when the body cannot produce enough insulin. Insulin plays a key role in helping sugar, a major source of energy for muscles and other tissues, enter cells in the body. Without enough insulin, the body begins to break down fat as fuel. This causes a buildup of acids in the bloodstream called ketones. If it is left untreated, the build-up can lead to DKA.
24. We considered with our consultant adviser whether the Trust acted correctly after Mrs R’s son was admitted to its on-call medical team and reviewed by senior medical staff. The relevant medical records show that the staff did extra blood tests, an ultrasound scan of his liver and a V/Q scan (a test carried out to show blood flow and airflow distribution to the lungs) which ruled out a pulmonary embolism (blockage in the lungs) as the cause of the symptoms. Her son was then given a diagnosis of long COVID and discharged home.
25. Our consultant adviser explained the Trust’s diagnostic process relied on Mrs R’s son’s history, his abnormal observations and his abnormal d-dimer result.
26. But, NICE guidance says that:
‘The (guideline development) group specifically recommended that healthcare professionals should measure capillary blood glucose at presentation in children and young people without known diabetes who have increased thirst, polyuria, recent unexplained weight loss or excessive tiredness and any of the following: • nausea or vomiting • abdominal pain • hyperventilation • dehydration • reduced level of consciousness.’
27. We can see from Mrs R’s son’s medical records that it was repeatedly documented by the ED and medical teams that he was complaining of lethargy, nausea and vomiting. He also reported breathlessness and had a raised respiratory rate several times.
28. We asked for the Trust to give us its relevant policies for blood tests and investigation of patients attending the ED and those being admitted to hospital. The ED matron confirmed it is developing a collection of policies for this. Currently decisions are made based on the clinical impression of the staff member assessing the patient and what they think is needed for the clinical symptoms the patient has.
29. Our consultant adviser explained it is very surprising that Mrs R’s son’s blood or urine glucose were not measured at any point.
30. It is our decision that because Mrs R’s son’s symptoms were lethargy, nausea, breathlessness and a raised respiratory rate, the Trust should have tested for potential diabetes. It should have followed the NICE guidance and checked the blood glucose level. It did not do this and this is a failing.
Impact
31. Mrs R’s son was re-admitted to hospital by ambulance on 18 January 2022 because he was struggling to breathe. He was found to have high level of ketones in his blood and needed treatment in ITU.
32. The relevant medical records show he was found to be in DKA, he showed worsening acidosis (when your blood becomes too acidic) and severe hypokalaemia (low blood potassium levels) which led to him being intubated, ventilated and moved to ITU .
33. We considered with our endocrinologist adviser whether Mrs R’s son’s diagnosis of DKA could have been made earlier if the Trust had done different tests.
34. Our endocrinologist adviser explained there are several tests which would probably have led to a diagnosis of diabetes during the first admission. They explained common tests could be a fingerprick glucose, HbA1c (blood test used to diagnose diabetes) or blood/urine ketone tests.
35. They stated a fingerprick glucose is the most commonly used and can be done on its own, but would also be part of point of caring tests (tests done at the point of care without the need to send samples to a lab). After a review of Mrs R’s son’s medical records, we can see no record of him having any point of care tests during his first admission.
36. NICE guidance lists tiredness, polyuria (passing excessive amounts of urine) and polydipsia (excessive thirst) as symptoms of a diabetes diagnosis. Our adviser also explained that although breathlessness is not listed it is associated with diabetes.
37. Because of his symptoms, we think he was showing signs of potential DKA which could have been found sooner if the correct tests had been done during his first admission.
38. We also considered if being diagnosed with DKA during the first admission could have meant he may not have been re-admitted and needed intensive care.
39. Our endocrinologist adviser explained if someone was to be admitted with a new diagnosis of diabetes and they were drinking, showing a Glasgow Coma Scale score of 15 (a score to measure the level of consciousness of a patient, with 15 being the highest) and they were treated - it would be very unusual for them to deteriorate to the point of needing ITU admission. The relevant medical history shows Mrs R’s son matched this criteria.
40. Based on this evidence and the advice, we have found that if her son had been treated on 12 January 2022, he may still have needed IV therapy to give fluids and medicine (given direct into the veins). He may also have been admitted for a while but it is likely the ITU admission could have been avoided. We are pleased to learn that Mrs R’s son has shown no long-term effects from his second admission despite his diabetes diagnosis.
41. Mrs R says she has also been affected by the events. She explains she still thinks about seeing her son, who was under 18 at the time, in a critical condition and being treated in ITU. She says this caused her a great amount of distress and caused feelings of guilt and helplessness.
42. We are sorry to hear about this and appreciate it must have been extremely concerning and distressing for Mrs R. We have found that Mrs R would not have had these experiences if her son had been diagnosed and treated during his first admission to the Trust.