Liver cirrhosis 16. Miss L says doctors did not thoroughly investigate the cause of her mother’s liver cirrhosis and discounted her concerns it may have been caused by flucloxacillin (an antibiotic).
17. Miss L says her mother’s GP prescribed flucloxacillin for a couple of weeks in late 2019 and again in the ‘first months’ of 2020. She says six courses in total were prescribed to treat suspected cellulitis (a skin infection) and this could have led to a drug induced liver injury (DILI).
18. The Trust says it correctly investigated Mrs L’s symptoms and diagnosed liver cirrhosis. While its complaint responses do not clearly set out what it felt had caused this condition, it is clear from the records doctors suspected it may be alcohol related.
19. The Trust says it cannot access Mrs L’s GP records and is therefore unable to comment on the use of flucloxacillin. It did, however, say Mrs L suffered from long term (chronic) liver disease whereas a DILI is characterised by more sudden liver damage. It said this would indicate flucloxacillin was not the cause of Mrs L’s liver cirrhosis.
20. BSG blood test guidance sets out how clinicians should use liver functions tests (LFTs). LFTs are used to check whether someone’s liver is functioning correctly.
21. This guidance says LFTs should involve blood tests to consider whether viral, metabolic (the conversion of food and drink into energy) or immunological (the body’s resistance to invasion by other organisms) problems have caused liver damage. It also recommends an ultrasound scan. An ultrasound scan uses sound waves to produce images of internal organs.
22. NICE cirrhosis assessment and management guidance says if a patient is diagnosed with cirrhosis, they should receive a gastroscopy to check for oesophageal varices. Oesophageal varices are enlarged veins in the oesophagus and most often occur in people with serious liver disease. A gastroscopy involves inserting a camera, held on a flexible tube (an endoscope) into the patient’s mouth to inspect their throat, oesophagus and stomach.
23. GMC guidance sets out how a doctor can provide good care. Under section 15, it says doctors must provide suitable advice, investigation and treatment where necessary.
24. We can see doctors carried out LFTs in March 2021. These tests correctly considered whether, for example, hepatitis B or C, an iron overload in the blood, or an immunological reaction had caused Mrs L’s liver damage. We can also see an abdominal ultrasound was carried out at this time. All of this is in line with BSG blood test guidance.
25. There is not enough evidence to understand how much alcohol Mrs L consumed and whether this caused or contributed to her liver cirrhosis, but we see doctors acted in line with GMC guidance by not discounting it as a potential cause. Their advice that Mrs L should abstain from further alcohol was something we would expect to see under the circumstances.
26. We can also see doctors requested a gastroscopy in line with NICE cirrhosis assessment and management guidance. We acknowledge the gastroscopy, originally planned for 21 April, did not go ahead until 7 July. We will consider this in the next section of our final report.
27. We are satisfied doctors investigated Mrs L’s liver cirrhosis in line with BSG blood test guidance, GMC Guidance and NICE cirrhosis assessment and management guidance.
28. We will now consider the Trust’s view around the likely cause of Mrs L’s liver cirrhosis and whether it is supported by the clinical evidence.
29. We can see Mrs L suffered with a fatty liver since 2014. A fatty liver occurs when there is an excessive build-up of fat in the liver and can lead to liver cirrhosis. This indicates Mrs L had long standing liver problems which significantly predate her use of flucloxacillin. This appears to support the Trust’s view that Mrs L’s liver cirrhosis stemmed from her chronic condition, rather than a DILI.
30. We are therefore satisfied the Trust’s view concerning the development of Mrs L’s cirrhosis is reasonable and supported by the clinical evidence.
Delayed gastroscopy 31. Miss L says the Trust delayed arranging her mother’s gastroscopy. She says her mother’s internal bleed could have been avoided and her life could have been saved had the Trust carried out this procedure sooner.
32. The Trust says it initially planned the gastroscopy to go ahead on 21 April to check for oesophageal varices. It says it made an administrative error which meant a COVID-19 swab test was not arranged beforehand, which delayed the procedure. The Trust also says Mrs L asked for the procedure to be re-arranged, and this contributed to the delays.
33. BMJ guidance recommends carvedilol for patients who suffer from oesophageal varices. Carvedilol lowers blood pressure within the varices in the hope this will reduce the chance of them bleeding. This guidance also says, however, that there is no clinical evidence that a reduction in blood pressure leads to a reduction in bleeding or an increase in survival rates.
34. Our Principles say public bodies should handle and process information properly and appropriately. Our Principles also say public bodies should acknowledge what went wrong and put things right.
35. The Trust agrees it made a mistake by booking Mrs L’s gastroscopy without arranging her COVID-19 swab test first, which delayed the procedure. We see this as a failing as it is not in line with our Principles.
36. We must also take into account, however, that Mrs L appears to have asked for the procedure to be rearranged on two occasions. This does not cancel out the Trust’s mistake but does mean any delay in arranging the procure was not caused by the Trust’s actions alone.
37. We have carefully considered whether the overall delay in arranging the gastroscopy had a clinical impact upon Mrs L.
38. As described earlier in this section of our report, carvedilol is the treatment for oesophageal varices. Therefore, had Mrs L received her gastroscopy at an earlier date and had it indicated treatment was required for her oesophageal varices, doctors would likely have prescribed carvedilol.
39. We can see Mrs L had already been prescribed carvedilol on 23 June. She was therefore already on the correct treatment for her oesophageal varices for over two weeks before they haemorrhaged.
40. As set out in paragraph 33 of our final report, carvedilol is the recognised treatment for oesophageal varices, but there is no clinical evidence available which shows it is likely to have prevented Mrs L’s spontaneous gastrointestinal haemorrhage and death.
41. Therefore, for the reasons set out above, we do not see any delay in arranging the gastroscopy links to the spontaneous gastrointestinal haemorrhage Mrs L suffered and sadly died from on 8 July.
42. We do, however, recognise the emotional distress these events caused to Miss L. We understand she was worried about her mother and wanted tests to go ahead as quickly as possible. We are pleased the Trust acknowledged it could have done more to arrange the COVID-19 swabs in a timely manner and offered an apology for this.
43. We are satisfied the Trust’s apology is in line with our Principles and is proportionate to put right the distress its mistake caused Miss L.
Bed rails 44. Miss L says her mother’s bedrails should have been up because she suffered from dizziness and there was a risk she may fall out of bed. She says staff did not manage her bedrails effectively and this led to her fall on 13 June.
45. The Trust apologised for the incident and the injury her mother suffered. It said Mrs L had been ‘mobilising independently’ (though only for short distances) before her fall and staff would not routinely put the bed rails up for patients who are able to mobilise.
46. It said there was no clinical reason why the bedrails needed to be used on the day she fell, though it acknowledges a bed rails risk assessment on 10 June was incomplete and this was not in line with its bed rails guidance.
47. In order to understand whether a patient should have their bedrails raised, staff should carry out a bed rails risk assessment.
48. Part 1.3 of the Trust’s bed rails guidance says any risk assessment must consider: • ‘Principles of autonomy • Respect of patient’s safety and dignity • Individualised care • Continuous assessment.’
49. This guidance also says any assessment for or against the use of bed rails must be clearly documented in the medical records.
50. Government guidance provides further detail around physical and cognitive factors which should be considered when completing such assessments. For example, it says patients with communication problems, confusion, agitation or delirium must be carefully assessed to understand whether bedrails are appropriate.
51. Mrs L appears to have fallen from her bed on 13 June at 07.30am after ‘reaching out of the bed for an item on chair.’
52. We cannot see the 10 June bed rails risk assessment the Trust refers to. The records show staff carried out a bed rails risk assessment when Mrs L was admitted on 9 June. However, this bed rails risk assessment only records the date and time it took place. It does not provide any consideration of the four points listed in paragraph 48 above or the physical and cognitive factors set out in government guidance at paragraph 50 above.
53. Based on the information available to us, the Trust’s 9 June bed rails risk assessment is not in line with its bed rails guidance or government guidance. This is because it does not appear to have considered Mrs L’s circumstances, including her physical and cognitive state before deciding what action to take with her bedrails. We see this as a failing.
54. While we have found a failing, we are unable to say, even on balance of probabilities, that it caused Mrs L’s fall.
55. Even if staff had assessed Mrs L in line with guidance on 9 June and decided she needed raised bedrails, we cannot robustly say this would have eliminated the possibility of her falling from bed on 13 June.
56. This is because it appears Mrs L was reaching out of bed for something on a nearby chair. We acknowledge bed rails may have made this more difficult and could perhaps have dissuaded her to take such action. But, on balance and following careful thought, we are not persuaded the presence of bed rails under these circumstances is likely to have prevented Mrs L from reaching out of bed or her subsequent fall.
57. We do not see the Trust’s failure to carry out an appropriate bed rails risk assessment on 9 June, or its apparent decision not to raise them, caused Mrs L’s fall.
58. We recognise our decision in this part of our report will be particularly disappointing to Miss L and her family. We hope, however, that we have clearly set out our thinking on how we reached our decision.
Delay in catheter care referral 59. Miss L says her mother had a urethral catheter fitted and was discharged on 24 June without district nurse support in place. She also says she was given no information about how to maintain this equipment. Miss L says this caused her and her family considerable distress as they had to research how a catheter worked to safely operate it.
60. A urethral catheter works by inserting a flexible tube into the canal that carries the urine out of the bladder. This allows the bladder to safely drain into a collection bag.
61. The Trust says it made a referral to district nurses at the time of Mrs L’s discharge but there had been ‘some confusion’ around whether this was sent for ‘wound care and/or catheter care’. The Trust acknowledged its mistake and provided an apology.
62. RCN guidance says district nurses are expected to assess a catheterised patient once they are back in the community. District nurse input is important as they would be expected to assess any hygiene requirements the patient may have and review their fluid intake.
63. Good fluid intake will allow the catheter to work correctly by flushing any urine. Poor intake could, for example, lead to a build-up of debris which could hinder the catheter’s ability to drain. It is also important for district nurses to assess whether the patient is in any discomfort.
64. RCN guidance says patients and their carers should be educated about catheter care to ensure they have a reasonable understanding of this equipment.
65. We can see Miss L called the Trust on 26 June. She pointed out it had not made a catheter care referral to district nurses and instead made an incorrect referral for wound care. While staff appear to have made another referral to district nurses to correct the mistake, this ultimately did not help Mrs L as she was admitted to hospital again the next day.
66. Based on what we have seen so far, Mrs L appears to have been discharged on 24 June without district nurse support. Alongside this, Miss L did not receive any education in catheter care. We consider this a failing as it is not in line with RCN guidance. While the lack of district nurse support does not appear to have had a clinical impact upon Mrs L, we see it likely had an emotional impact upon Miss L who was caring for her at the time.
67. We will consider the emotional impact caused to Miss L later in our report where we will also consider what remedy will put it right.
Visiting 68. Miss L says her mother suffered from severe panic, distress and anxiety during her hospital stay. She says she asked the Trust daily if a family member could be with Mrs L to calm her, but this was not always allowed.
69. Miss L acknowledges the COVID-19 pandemic meant the Trust had to manage visiting carefully but says its visitation policy allowed for additional visiting where a patient is distressed.
70. The Trust says it allowed for additional visits when Mrs L’s condition deteriorated, as set out in its visitation policy. It also acknowledges additional visits could be granted where a patient is suffering ‘severe anxiety’ and there may have been occasions when it did not allow visits when it should have. The Trust apologised for any added distress caused to Miss L and her family.
71. The Trust’s visitation policy recognises the need to suspend normal hospital visiting due to the COVID-19 pandemic and the risk posed to both patients and staff. Under section 4.1 ‘Exceptional Circumstances’, it sets out specific criteria for additional visiting. For example, it says patients who are ‘end of life’ and ‘at risk of distress’ can be considered as exceptional.
72. The records indicate staff were in regular discussion with family members about visiting Mrs L. For example, on 27 June we can see Mrs L was anxious, so her son was allowed to visit and settle her.
73. On 29 June we can see a nurse called Mrs L’s husband to inform him family members had been granted two one hour visits a week. We can also see when Mrs L was sadly nearing the end of her life on 7 July, multiple family members were allowed to stay for a time and two of those family members were allowed to stay overnight.
74. We recognise there are also some entries in the records where family members were denied visiting, but overall, it appears clinical staff were mindful of the arrangements which had been put in place and when Mrs L’s condition deteriorated exceptions were made to allow multiple family members to be present, which is in line with its visitation policy.
75. We acknowledge this must have been a very difficult time for Miss L and her family and the limited visiting will only have added to their worry and distress. While we appreciate our decision may be disappointing, we hope we have provided some reassurance around the Trust’s handling of family visits.
Impact upon Miss L 76. We identified a failing in the Trust’s failure to arrange appropriate district nurse support for Mrs L before she was discharged on 24 June. Mrs L was catheterised, so district nurse support was important to ensure her catheter continued to operate correctly. It also appears the Trust did not educate Miss L around the function of the catheter.
77. We can see Mrs L and her family were left for around three days without support before she was taken to hospital again on 27 June. Miss L says the lack of support was very upsetting and distressing for her and her family.
78. Miss L says she had to do her own research as she had no idea how this equipment worked and was worried about her mother’s wellbeing. She says she resorted to calling local pharmacies to seek advice. Miss L also says her mother’s catheter leaked a couple of times, so she had to buy pads to try to keep her bedding dry.
79. We recognise this three-day period likely caused considerable upset and distress to Miss L at an already difficult time.
80. While the Trust acknowledged its mistake and offered apology, further remedy is needed to fully put right what went wrong. Our recommendations are set out in the next section of our report.