16. 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 we have not seen any signs that staff did not do appropriate or timely tests, that they should have prescribed antibiotics or diagnosed neutropenic sepsis.
Antibiotics and neutropenic sepsis
17. Mrs U is concerned that ED staff missed signs she was developing neutropenic sepsis and did not follow the guidance on her protocol card to give her antibiotic treatment. NICE defines neutropenic sepsis as ‘as a temperature of greater than 38°C or any symptoms and/or signs of sepsis, in a person with an absolute neutrophil count of 0.5 x 109/L or lower’.
18. In response to her complaint, the Trust said the Christie advised Mrs U to attend the ED to rule out MSCC. This was ruled out and staff also considered and ruled out neutropenic sepsis. To reach these decisions, the Trust said its staff also got the opinion of the Christie’s on-call oncologist. It concluded that her symptoms seemed to be caused by the recent chemotherapy and made worse by COVID19.
19. The protocol card includes the following guidance for clinicians:
‘The treatment is potentially myelosuppressive [it reduces the ability of the bone marrow to make blood cells].
Antibiotic Guidance • If patient is unwell and/or pyrexial with a temp of 37.5C or above, give IV antibiotic.
• Do not wait for blood test results, adhere to one hour to antibiotic target.’
20. There is no doubt Mrs U was unwell when she attended the ED. The ANP recorded that she had been experiencing her usual chemotherapy side effects of nausea and tiredness. Two days earlier she had felt feverish and had a dry cough, so she took a test for COVID-19 which gave a positive result. At the time when she went to ED she was feeling achy all over and had back pain.
21. Mrs U’s temperature was recorded as 35.5°C on admission. Later observations recorded temperatures of 36.6°C, 35.0°C, and 35.1°C. These are all within a normal range, so Mrs U was apyrexial (she did not have a high temperature) while she was at the ED. Staff also noted that her chest X-ray showed no evidence of pneumonia (inflammation of the lungs, usually caused by infection).
22. The results from Mrs U’s blood tests were returned (just) within an hour. Our adviser explained that her neutrophil and lactate counts were within the normal range suggesting there was no infection because these counts increase when bacterial infection is present. Mrs U did have COVID-19, which is a virus and not treated with antibiotics.
23. Neutrophils are made in the bone marrow and released into the blood stream in response to infection. Mrs U’s blood test result included a note that her neutrophils appeared ‘toxic and left shifted’. She told us she was concerned that staff overlooked this when they considered whether she had neutropenic sepsis.
24. Our adviser explained that in this situation, ‘toxic’ means a change in the shape and size of the neutrophils, caused by conditions that intensely stimulate neutrophil production and shorten the time neutrophils spend maturing in the bone. The accelerated maturation is caused by cytokine stimulation, which is usually a response to inflammation. It does not mean there is a toxic effect on the patient and our adviser said that this result was not clinically significant for Mrs U.
25. The NMC Code says nurses should:
• ‘13.1 accurately identify, observe and assess signs of normal or worsening physical and mental health in the person receiving care’ • ‘8.1 respect the skills, expertise and contributions of your colleagues, referring matters to them when appropriate’ • ‘13.2 make a timely referral to another practitioner when any action, care or treatment is required’ • ‘13.3 ask for help from a suitably qualified and experienced professional to carry out any action or procedure that is beyond the limits of your competence’.
26. When Mrs U complained to the Trust, she asked why she was not seen by the on-call oncologist. The Trust explained it does not employ oncologists, but during the week it did have a team of acute oncology nurses. When it needed an oncological opinion, it made use of the on-call oncologists at the Christie.
27. In Mrs U’s case, the ANP spoke to the on-call oncologist and discussed the outcome of the examination and test results and potential diagnoses. This means they met the requirements of the NMC by working within the limits of their competence and speaking to a suitably qualified doctor.
28. Mrs U was unwell and the protocol card suggests that antibiotics should be given, even if her temperature was not raised. But, the oncologist’s clinical opinion was that her symptoms were likely explained by her recent chemotherapy and by COVID-19. This was supported by the results of her blood test and chest X-ray, which did not suggest an infection. As the oncologist does not work for the Trust, we have not investigated their actions.
29. Mrs U later developed neutropenic sepsis, so it is understandable why she felt that a diagnosis should have been reached sooner and she should have had antibiotics at the ED. We hope she is reassured that we saw no sign that anything went wrong here.
Timely tests
30. Mrs U is concerned that staff took too long to carry out the tests they did, mainly the ECG taking several hours.
31. In its responses the Trust said that the tests seemed to have happened more quickly than Mrs U recalled. She was admitted at 5.48am and the ECG had been carried out at 7am.
32. Our adviser explained that EDs in England triage patients on arrival using either the Manchester Triage System or the Australasian Triage Scale. Mrs U’s record notes that on arrival she was triaged as category two, where one would be most urgent and five the least. In either triage system, a category two patient should have their vital signs assessed within ten minutes.
33. We can see from the notes that Mrs U at first declined to have observations taken at triage as she had COVID-19 and wanted staff to wear more PPE. After this the records show regular observations were taken. Staff tried to check vital signs immediately and may still have achieved this within the ten-minute target. This is in line with the timescale required for a category two patient.
34. The main reason the Christie advised Mrs U to attend the ED was because she had symptoms of MSCC.
35. NICE guidance for spinal cord compression in adults says that patients with past or current cancer and with any of the following symptoms should be referred for urgent oncology opinion to rule out spinal cord compression: • ‘pain in the middle (thoracic) or upper (cervical) spine • progressive lower (lumbar) spinal pain • severe unremitting lower spinal pain • spinal pain aggravated by straining (for example, at stool, or when coughing or sneezing) • localised spinal tenderness • nocturnal spinal pain preventing sleep.
• neurological symptoms including radicular pain, any limb weakness, difficulty in walking, sensory loss or bladder or bowel dysfunction • neurological signs of spinal cord or cauda equina compression.’
36. The adviser noted that the ANP did a thorough examination and documented that Mrs U had full power to the limbs, no weakness, normal coordination with some tenderness down the paraspinal muscles (muscle groups that support your back). Staff also did regular observations and a blood test. Our adviser said this was in line with point 13.1 of the NMC Code. The ANP also got an opinion from the on-call oncologist at the Christie. This was in line with the NICE guidance which says to get an urgent oncology opinion. We cannot comment on what the oncologist said or did as they are not employed by the Trust that we are investigating.
37. It is understandable that Mrs U felt the Trust had an opportunity to give her a better outcome, since she is still affected by some of the symptoms caused by her illness today. Having considered the evidence, we saw no sign that appropriate tests were not done in good time. This means we have decided not to take any further action on Mrs U’s complaint.