14. Mrs C attended the Trust’s ED on 2 July 2021, with right sided abdominal pain, having been in intermittent pain for 4 weeks.
15. The Trust’s clinical assessment identified mild tenderness in her abdomen. Her blood test showed an increase in C-reactive protein (CRP) of 35 (CRP increases when there is inflammation in the body) and white blood cell count (WBC) of 12.8. The Trust carried out an abdominal ultrasound on 3 July, which showed gallstones.
16. Our adviser said Mrs C’s clinical and radiological presentation was characteristic of acute gallstone cholecystitis.
17. NICE guidance for gallstone disease says adults with acute cholecystitis should have laparoscopic cholecystectomy (surgical removal of the gallbladder) within one week of diagnosis.
18. This means, in line with the guidance, the Trust should have carried out surgery to remove Mrs C’s gallbladder within one week from 3 July. This did not happen. Instead, the Trust discharged her home with antibiotics and put her on the waiting list for surgery.
19. In its response to Mrs H’s complaint, the Trust explained it did not carry out surgery to remove Mrs C’s gallbladder during her first admission because there were no dedicated theatre lists for patients who required this surgery.
20. In our view, this is not an acceptable reason, as these patients can be placed on the emergency surgery list with other surgical emergencies.
21. We recognise this is a wider issue with a lot of NHS hospitals. They do not have adequate surgical facilities or the surgical expertise to perform emergency cholecystectomy, which is why patients are put on a waiting list.
22. However, both the NICE and RCSE guidance are clear that surgeons should proceed with laparoscopic cholecystectomy on the patient’s first admission to prevent sepsis and recurrent admission with acute cholecystitis. Unfortunately, this condition is what affected Mrs C.
23. Whilst the guidance is clear on what should happen to patients presenting with acute cholecystitis, we must also consider the individual circumstances of this case.
24. When Mrs C was first admitted, the ED documented a positive FIT test in her records. This examines stool samples and looks for blood which can be a sign of bowel cancer. The FIT test is used to decide which patients to investigate and how urgently to investigate them.
25. Given this important background information, our adviser said most surgeons would have advised against going directly ahead with emergency surgery, as recommended by NICE. In this case, it was appropriate for the Trust to treat the initial episode of cholecystitis with antibiotics.
26. Instead of discharging Mrs C home, the Trust should have arranged further urgent investigations in response to the positive FIT test, such as a CT scan to investigate her bowel symptoms. This would have been in line with NICE guidance DG30 and GMC good medical practice which says doctors must adequately assess a patient’s condition, taking account of their history, and promptly arrange suitable advice, investigation, or treatment.
27. This would also have allowed the Trust to make a more informed decision about whether to proceed with emergency surgery, as recommended by NICE and RCSE.
28. From the evidence we have seen, the Trust failed to take any action on the positive FIT test during Mrs C’s first admission. The clinical team appear to be unaware of both her bowel symptoms, the positive FIT test, and the need for further investigation. Instead, the Trust discharged her home where her condition worsened.
29. Mrs C was re-admitted to the Trust with continued abdominal pain on 14 July. By this time, she was at least two weeks into an episode of acute cholecystitis. Her blood test results showed persistent signs of sepsis and development of renal failure, despite the antibiotics.
30. Our adviser said proceeding with emergency surgery at this point was more high risk, had a very high mortality rate and is unlikely to have resolved the acute medical issue of renal failure.
31. Mrs C became more unwell with multi organ failure, and sepsis, and she sadly died on 23 July.
32. Had the Trust not discharged Mrs C home on 3 July whilst the urgent CT scan was being arranged, it would have been able to check for signs to see whether her gallbladder symptoms were improving.
33. When it became apparent the antibiotics were not working, treatment could have been escalated on an urgent basis. For example, the Trust could have tried a different choice of antibiotics and considered intensive care monitoring. Our adviser said there was also the option of a percutaneous cholecystostomy, which is a tube inserted through the skin into the gall bladder to drain the pus.
34. We know a CT scan from Mrs C’s second admission showed suspicion of bowel cancer. Her CEA (cancer marker) was grossly elevated, and the results suggested she had extensive abdominal lymph node enlargement. This suggests the cancer was already advanced.
35. However, Mrs C did not die from cancer. She died from multi organ failure and sepsis, more likely than not arising from the infected gallbladder as demonstrated on the death certificate. Given she had presented with similar symptoms in the previous admission, and had been discharged without it being fully resolved, it is very unlikely that something else caused her sepsis.
36. Our adviser said the chances of a person dying with an infected gallbladder in hospital are very small. If the Trust had not discharged Mrs C home on 3 July, it could have considered further treatment and investigations and, on balance, her death from sepsis and multi organ failure could have been avoided.
37. In summary, the Trust should not have discharged Mrs C home on 3 July. It should have taken appropriate action in response to her positive FIT test and arranged further urgent investigations.
38. While this was going on, the Trust would have been able to check for signs whether her gallbladder symptoms were improving and intervened at a much earlier stage. This would have prevented her re-admission, prolonged sepsis, renal failure, and death. The evidence suggests it is more likely than not Mrs C would have survived had she remained in hospital.
39. In thinking about the impact of the failing we have seen, we have taken into account the CT scan. Even if the Trust had resolved Mrs C’s gallbladder symptoms during her first admission, it is highly likely she would have presented at some point in the very near future with symptoms of bowel cancer.
40. Sadly, Mrs C died during her second admission to hospital, so the Trust were unable to carry out any further clinical investigations in relation to the cancer finding. Given the CT scan suggested the cancer was already advanced, it is unlikely it would have been curable by surgery.
41. Studies suggest the average survival rate for those with metastases is approximately two years. Whilst we cannot say exactly how much longer Mrs C would have lived for, what we can say is, on the balance of probabilities, she would have survived longer than she did had the Trust carried out surgery when it should have done.
42. This has left Mrs H with immense distress and compounded her grief, knowing she could have spent more quality time with her mother.