Perforated bowel 14. Miss A says the Trust took too long to identify and treat her sister for a perforated bowel following her emergency admission on 16 December 2022.
15. The GMC guidance, section 15(a) states clinicians must provide a good standard of practice and care. If they assess, diagnose or treat patients, they must adequately assess the patient’s conditions, taking account of their history (including the symptoms and psychological, spiritual, social and cultural factors), their views and values; and where necessary, examine the patient.
16. It is important to outline the Trust never formally diagnosed Miss B with a perforated bowel. We have therefore considered whether it appropriately assessed Miss B’s condition during her admission.
17. The records show when Miss B went to the ED on 16 December 2022, she felt unwell, had a high temperature, a raised C-reactive protein (CRP) which is a blood test used to identify signs of infection, and doctors felt that her leg ulcers had become infected. She had a distended abdomen and chronic constipation.
18. The Trust’s working diagnosis at this point was that Miss B’s leg ulcers had become infected, and she had biliary sepsis, which the Trust treated with antibiotics. Our adviser explained based on the presenting condition, this diagnosis and treatment was appropriate in the circumstances and in line with GMC guidance on treating a patient based on their assessment of the patient’s conditions.
19. The Trust carried out an X-ray of Miss B’s abdomen and chest and a rectal examination in a timely manner following her initial presentation. These tests were appropriate and in line with the GMC guidance on examining a patient and our clinical advice supports this view.
20. Miss A says the Trust failed to diagnose her sister had a perforated bowel. The records show one doctor at the Trust raised the possibility she had a perforated bowel, but as we explain above, there was never a formal diagnosis of this condition.
21. Our adviser explains when diagnosing a perforated bowel, there is usually air under the diaphragm, which confirms the diagnosis. Our adviser has reviewed the X-rays and scans carried out Miss B during her admission. They explained there is no evidence from these tests that she had any air present under the diaphragm at any point or any other signs of a bowel perforation. With this in mind, we have not seen evidence to support the view Miss B had a bowel perforation during her admission, and our clinical advice supports this view.
22. On 17 December the treating doctor sought advice from the surgical team, who recommended a CT scan to rule out a bowel perforation, but Miss B was too unwell to have this during her admission due to excessive vomiting. Unfortunately shortly after this discussion with the surgical team, her condition quickly deteriorated and she sadly died.
23. Miss A tells us she was told during the admission that her sister had a perforated bowel. Miss A tells us how concerned she is that the Trust did not diagnose her sister appropriately. We have seen no indication Miss B had a perforated bowel during her admission. Overall, we consider the Trust carried out appropriate investigations into Miss B’s condition following her presentation, in line with the GMC guidance and our clinical advice supports this view. We cannot begin to understand how difficult this time was for Miss A and we hope our findings help to assure her about the care Miss B received.
Enema 24. Miss A says the Trust took too long to complete an enema to relieve her sister’s constipation, and failed to provide appropriate medication for her sister to treat her constipation while she was waiting for this to take place.
25. Our adviser explains in the circumstances, Miss B’s constipation was not straightforward to treat. The clinical records show upon admission to the ED, Miss B had a distended abdomen and was chronically constipated for ‘months’ prior to the admission, this suggests constipation was not a new condition for her.
26. The clinical records outline the abdominal X-ray results from 16 December show she had faecal loading (faeces in the colon), which is not necessarily a sign of constipation and is an expected finding. The Trust also carried out a rectal examination which did not show any signs of constipation. Considering Miss B’s presenting condition, our adviser explains the overall priority for the Trust here would be to treat the potential sepsis, which was treated with antibiotics and fluids.
27. The Trust did give an enema to Miss B on at 8.25pm on 16 December. Our adviser explains there are no set timescales for when a patient should receive an enema to treat constipation, and the Trust acted appropriately here in the time taken. The Trust were treating Miss B’s sepsis initially and had difficulty locating her veins for to provide IV fluid as treatment for sepsis, so had to resort to an IO administration, again this took time to arrange.
28. Our adviser explains the Trust were rightly treating her presenting condition of sepsis as a priority, and there is no evidence of a delay in the circumstances. We can see no indication of any delay in the Trust giving Miss B an enema following her admission and our clinical advice supports this view.
29. We have also considered whether there is any indication the Trust failed to treat Miss B’s constipation appropriately during the admission in the time between her admission and the Trust administering an enema. Miss A says the Trust should have prescribed laxatives to her sister sooner, and she was told the Trust had no stock of laxatives within the ED. We know the Trust gave Miss B an enema during the admission, which our adviser explains is the most effective method of treating constipation.
30. The enema was given on the day of admission and was a more appropriate and much faster method of treating constipation for immediate relief. The use of laxatives would not have been sufficient in the circumstances as they take between 12 and 24 hours to take effect, meaning Miss B would have been constipated for much longer if they did not give her an enema when they did. Miss A told us how concerned she was that her sister did not receive appropriate care for constipation, this must have been very worrying for her when she was already unwell.
31. Overall, we have seen the Trust appropriately treated Miss B for constipation and this was done in a timely manner, and our clinical advice supports this view. We will therefore not be considering this point of complaint further.
Pain relief 32. Miss A says the Trust provided insufficient pain relief to her sister during the admission.
33. When Miss B was first admitted to the ED, the doctors had concerns she had overdosed on heroin. Heroin is a type of morphine, which is a strong pain killer. The clinical records show the Trust gave Miss B naloxone the reversing agent for heroin and had to wait for this to take effect.
34. Our adviser explains it would also not have been appropriate to give any strong pain relief to Miss B during her presentation to the ED due to the concerns regarding opiate toxicity. Miss B was also suffering with constipation, and further pain relief would have made the constipation worse. The Trust therefore needed to be careful not to administer too much pain relief to Miss B at this time.
35. The records do not show that Miss B reported to be in any pain during the admission. Following her transfer to a ward, the Trust completed a review of her at 8.49pm, the records state she was settled and comfortable, this suggests she was not in any pain at this time.
36. On 17 December at 6.51am the doctor examined her abdomen which was soft and tender to touch. The pain score from this examination was zero, which means Miss B was not reporting any pain at this time.
37. At 11.46am she was reviewed again and did not report any pain, the pain score is again recorded as zero. The records state Miss B was agitated at this time, which could be an indicator that she was in pain, and the doctor prescribed IV paracetamol, which our adviser explains is a good pain killer in the circumstances. The concern at this time about giving a stronger pain killer would be that any stronger pain relief would have resulted in Miss B experiencing worsened constipation, and she was not reporting any pain in any event. The decision to give IV paracetamol was in line with the GMC guidance on good medical practice on appropriately reviewing a patient’s condition, and our clinical advice supports this view.
38. During the next two hours Miss B’s condition deteriorated further, she had an ITU review at 2pm and the decision was made that she was sadly not likely to survive, again there was no evidence that Miss B was in any significant pain at this time.
39. Overall we can see no documented evidence that Miss B was experiencing significant pain during her admission. She had pain scores of zero and the doctors gave IV paracetamol, which was appropriate in the circumstances given the potential she had experienced heroin toxicity and had constipation.
40. In our work we have carefully considered Miss A’s account and what the Trust recorded about Miss B’s pain levels. Miss A explained to us how her sister was screaming in pain throughout her time at the hospital, this must have been very difficult for Miss A to see her sister in pain. We do not doubt Miss A’s account of her sister’s symptoms of pain at this time or her recollection of the care and treatment she received. We acknowledge she was with her sister in the ED and her recollection of events is evidence of what happened.
41. We looked in the records to see if there was any evidence to help us reach a view here. We can see the records indicate Miss B was comfortable and had pain scores of zero, this suggests she was not in any pain at the times she was reviewed by the clinical teams. We cannot see evidence in the records that she reported to anyone else she was in pain.
42. When investigating this point we paid particular attention to what Miss A told us and looked to see if there was any evidence in the medical records which we could use to support her account. We have been unable to identify any records or any other supporting information which would allow us to challenge or criticise the information provided by the Trust. We appreciate how disappointing this will be for Miss A.
43. It is important that any findings we make and any failings we identify are supported in the evidence available to us and we have to acknowledge where there is a lack of evidence to support a complaint. For this reason, although we do not dispute what Miss A has said, we have not seen any evidence which would allow us to uphold this point of complaint.
44. Overall we have seen no indications of a failing in respect of the pain relief provided to Miss B during her admission, and our clinical advice supports this view. We will therefore not be considering this point of complaint further. We again extend our sincere condolences to Miss A for the death of her sister, we hope our findings provide her with some reassurances over the care and treatment provided by the Trust.