14. Mr O says the Trust failed to diagnose the cause of his wife’s condition despite attending hospital five times with the same symptoms. He also says the Trust failed to provide his wife with the appropriate care and treatment during each attendance. Having reviewed the records we have now seen Mrs O attended the Trust on six separate occasions during this period. We will address each attendance in turn and provide our view on whether there is any evidence of failings in the diagnostic pathway or the care and treatment provided by the Trust on each occasion.
15. The GMC guidance states:
‘You must provide a good standard of practice and care. If you assess, diagnose or treat patients, you must: • adequately assess the patient’s conditions, taking account of their history (including the symptoms); where necessary, examine the patient • promptly provide or arrange suitable advice, investigations or treatment where necessary • refer a patient to another practitioner when this serves the patient’s needs.
In providing clinical care you must: • provide effective treatments based on the best available evidence • consult colleagues where appropriate
Record your work clearly, accurately and legibly. Documents you make (including clinical records) to formally record your work must be clear, accurate and legible. You should make records at the same time as the events you are recording or as soon as possible afterwards.
Clinical records should include: • relevant clinical findings • the decisions made and actions agreed, and who is making the decisions and agreeing the actions • the information given to patients • any drugs prescribed or other investigation or treatment • who is making the record and when.’
Admission to hospital from 16 October to 18 November 2021
16. Mrs O presented at hospital with symptoms consistent with sepsis (a serious condition that happens when the body’s immune system has an extreme response to an infection) and associated acute kidney injury (AKI – an abrupt reduction in kidneys' ability to filter waste products). The NICE sepsis guidance states that in such circumstances the clinician should investigate the source of the infection and take blood samples before providing antimicrobial treatment (such as antibiotic medication).
17. Mrs O was admitted to the Trust’s Intensive Treatment Unit (ITU) upon her admission on 16 October 2021. The records indicate the Trust clinicians performed several investigations including blood tests, a CT scan and a chest X-ray. The records indicate the Trust clinicians considered multiple sources of infection including urosepsis (sepsis resulting from a urinary tract infection), acute cholecystitis (sepsis resulting from an infection in the gallbladder) and pneumonia (an infection of the lungs). The Trust clinicians provided initial treatment with antibiotic medication for Mrs O’s infection and fluids to treat her AKI.
18. Our physician adviser said the Trust clinicians performed the correct standard investigations but the investigations did not identify a definitive source of Mrs O’s infection on this occasion. However the resulting improvement in her condition supports the Trust’s presumed diagnosis of infection of unknown source. Our physician adviser said difficulty identifying the specific cause of an infection is not uncommon in patients who attend with symptoms consistent with sepsis.
19. The records indicate following treatment Mrs O’s condition improved and she was transferred to a ward on 28 October 2021. The Trust clinicians provided physiotherapy and nutritional support to help increase Mrs O’s mobility and fitness so she could be discharged. The records indicate during this period Mrs O developed pain and swelling of her joints and the Trust clinicians provided treatment with a trial of steroid medication for suspected migratory polyarthritis (a type of arthritis where pain spreads from one joint to another).
20. Mrs O was discharged on 18 November 2021 and our physician adviser said the records indicate the care and treatment provided by the Trust had resolved the symptoms which prompted her admission to the point she was well enough to be discharged. The records indicate the Trust clinicians put in place plans for a further follow-up appointment in the Trust’s outpatient clinic.
21. We carefully considered Mr O’s complaint and the supporting information he has provided. We also considered the information in the records, the guidance and the advice we have received. We acknowledge that a definitive diagnosis for the cause of her symptoms of infection and sepsis was not established during this admission. We accept that this is not always possible.
22. We found the Trust clinicians carried out the appropriate investigations in line with the GMC guidance to try and establish the definitive cause of her infection. We found the Trust clinicians provided treatment in line with the sepsis guidance to improve Mrs O’s symptoms and enable her to be discharged from hospital.
Admission to hospital from 10 December to 20 December 2021
23. Mrs O attended with symptoms of abdominal pain which the records indicate the Trust clinicians believed was being caused by diverticulitis (an inflammation or infection of the colon). The Trust clinicians performed blood tests which identified raised inflammatory and infection markers in her blood. The Trust clinicians performed a CT scan in an attempt to confirm the cause of her infection and provided antibiotic treatment.
24. The records from this admission sent to us by the Trust provide very limited evidence to indicate the Trust clinicians acted in line with the GMC guidance when diagnosing the cause of Mrs O’s symptoms on this occasion.
25. The records indicate the Trust believed her infection was due to diverticulitis but the report from the CT scan provides no evidence to support this diagnosis. Our physician adviser said there is no evidence in the records to indicate it was appreciated by the Trust that there was no definitive evidence of diverticulitis on the CT scan or that there may have been a possible alternate diagnosis.
26. We found the Trust missed an opportunity to consider alternative diagnoses in line with the GMC guidance. We found no evidence that any further investigations were carried out after the CT scan to see if there were any other possible diagnoses which may have explained Mrs O’s symptoms.
27. The records state the Trust clinicians also diagnosed Mrs O with palindromic rheumatism during this admission due to her fever and abnormal blood tests results. Rheumatology is a branch of medicine devoted to the diagnosis and management of disorders whose common feature is inflammation in the bones, muscles, joints, and internal organs. Palindromic rheumatism is a form of inflammatory arthritis that causes attacks or flare-ups of joint pain and inflammation that come and go.
28. There is very little evidence in the records to indicate how this diagnosis was reached. There is no evidence in the records of any further blood tests, which we would expect to see in the diagnosis of a rheumatological condition such as palindromic rheumatism. The records provide no information to indicate the Trust arranged the follow up care Mrs O would require from the Trust’s rheumatology department. The records indicate the Trust planned for Mrs O to be referred to the rheumatology department but it seems she was discharged without this being carried out.
29. The NICE RA guidance states:
‘Adults with suspected persistent inflammation affecting more than 1 joint, or the small joints of the hands and feet, are referred to rheumatology services within 3 working days of presenting in primary care’ and that assessment should be ‘in a rheumatology service within 3 weeks of referral’.
30. We acknowledge this guidance is aimed at primary care however we think it is reasonable for the patient to expect similar timely referral within secondary care or appropriate transfer of care to enable this to happen from primary care.
31. The onward referral guidance states:
‘The provider clinician should make an onward outpatient referral to any other service, without the need for referral back to the GP where the patient has an immediate need for investigation or treatment.’
32. The discharge letter issued by the Trust requests Mrs O’s GP make a referral to the rheumatology department, however the discharge letter does not provide sufficient information about Mrs O’s symptoms, the investigations carried out or the progress made during the admission to support the GP in doing so.
33. We acknowledge that the records provided by the Trust for this admission are limited.
The records do indicate the Trust made a working diagnosis (the most likely condition amongst a list of potential diagnoses) of diverticulitis during this admission. However there is no evidence in the report of the CT scan performed at the time to support this diagnosis and no evidence in the records to indicate further diagnoses were considered for Mrs O’s abdominal pain.
34. The records also indicate the Trust made a diagnosis of palindromic rheumatism as a cause for her other symptoms during this admission. However there is no evidence in the records of any rheumatological opinion which would be required to confirm the diagnosis in line with the NICE RA guidance. There is also no evidence in the records of an adequate onward referral for a rheumatology review.
35. We carefully considered Mr O’s complaint and the supporting information he has provided. We also considered the information in the records, the guidance and the advice we have received. We found the Trust did not act in line with the GMC guidance when investigating and diagnosing the cause of Mrs O’s condition during this admission.
36. We acknowledge that Mrs O’s condition improved to the point she was well enough to be discharged. We also acknowledge that further investigations may not have enabled the Trust clinicians to reach a definitive diagnosis of the cause of her recurrent infection at this time. It is clear from the records of her subsequent admissions that it was not possible to establish one unifying underlying diagnosis and we go on to comment on this later in our report. However in light of the lack of evidence to support the diagnosis of diverticulitis we think the Trust missed an opportunity to carry out further investigations during this admission.
37. We think the Trust also missed an opportunity to refer Mrs O to the rheumatology department to confirm the diagnosis of palindromic rheumatism or possibly rule out a rheumatological cause of her recurrent infection on this occasion. We think the Trust missed an opportunity to take further action to ensure Mrs O received the appropriate onward referral when she was discharged.
Attendance at the ED on 20 January 2022
38. Mrs O presented at the ED with symptoms of left sided back pain and breathlessness. The ED doctor recorded a recent medical history of severe pain in her left flank and ongoing breathlessness dating back to her previous admission to hospital in December 2021.
39. The records indicate the ED doctor examined Mrs O and documented a working diagnosis of possible kidney stone and provided Mrs O with pain relief medication in accordance with the NICE kidney stones guidance. The records indicate the ED doctor then requested a series of investigations including blood tests, a urine dipstick test and a CT scan of Mrs O’s kidneys and bladder.
40. The CT scan was performed the following morning and identified a stone in her left kidney. No further complications of the stone were identified and the ED doctor discharged Mrs O with a plan to attend a follow-up appointment at the Trust’s urology outpatient clinic.
41. Our ED adviser said the records support the view the initial assessment and the subsequent action taken by the ED doctor during this attendance was in line with the GMC guidance and the NICE kidney stones guidance. The ED doctor recorded Mrs O’s recent medical history and recorded a detailed examination of her condition before organising relevant investigations and administering the required treatment.
42. We carefully considered Mr O’s complaint and the supporting information he has provided. We also considered the information in the records, the guidance and the advice we have received. We found no evidence to indicate the Trust clinicians missed an opportunity to identify the cause of Mrs O’s condition or provide appropriate treatment during this attendance at the ED.
Admission to hospital from 12 February to 4 March 2022
43. Mrs O presented at hospital with symptoms of abdominal pain, breathlessness, diarrhoea and vomiting and due to her combination of symptoms the Trust clinicians referred her to its neurology department. The Trust performed an MRI scan which did not identify any neurological abnormalities to explain her symptoms.
44. Mrs O tested positive for C. Difficile infection (an infection of the large intestine caused by bacteria) and the Trust clinicians treated her with antibiotic medication. The records indicate Mrs O suffered a drop in her haemoglobin levels (the protein in red blood cells that carries oxygen throughout the body) and the Trust clinicians treated this with a blood transfusion.
45. Our physician adviser said the records indicate the Trust felt Mrs O’s underlying condition was rheumatological in nature (resulting from inflammation in her bones, muscles, joints and internal organs) and it arranged a series of blood tests to investigate this further. Following a review of her blood test results and a discussion with the clinical team, the Trust’s rheumatology department decided Mrs O’s condition was not rheumatological in nature and recommended further investigation into other possible causes.
46. Due to her breathlessness the Trust clinicians referred Mrs O to its respiratory department and performed a CT scan of her chest which identified findings indicative of usual interstitial pneumonia (UIP - a form of lung disease characterised by progressive scarring of both lungs). After reviewing Mrs O’s condition and investigation results the Trust respiratory department recommended she undergo outpatient lung function tests and further tests to assess her immune system functions.
47. The Trust discharged Mrs O to await an outpatient PET scan (a more detailed scan which produces 3-dimensional images of areas inside the body) and a follow up appointment in the specialist interstitial lung disease outpatient department at a neighbouring Trust in a further attempt to identify a unifying cause for her ongoing condition.
48. Our physician adviser said the records indicate during this admission the Trust clinicians carried out a thorough and extensive investigation of all of Mrs O’s symptoms dating back to her first admission in October 2021 to try and establish the cause of her condition. Our physician adviser said upon discharge the Trust clinicians arranged appropriate further investigations on an outpatient basis, in line with the advice provided by the Trust’s rheumatology and respiratory departments.
49. Our physician adviser said there is no evidence to indicate there is anything further the Trust clinicians could have done during this admission to find an underlying diagnosis for Mrs O’s recurrent infection or to treat her symptoms. The records support the view that appropriate advice was sought from the relevant specialist departments and the treatment provided was consistent with the symptoms she was suffering with at this time. Once she was well enough to leave hospital the Trust arranged further investigations for her as an outpatient. This is consistent with the standards set out in the GMC guidance.
50. We carefully considered Mr O’s complaint and the supporting information he has provided. We acknowledge how distressing this period was for him and his wife. We also considered the information in the records, the guidance and the advice we have received. We found no evidence to indicate the Trust clinicians missed an opportunity to identify the cause of Mrs O’s recurrent infection or provide appropriate treatment during this admission.
Attendance at the ED on 14 March 2022
51. Mrs O presented at the ED with symptoms of breathlessness and it is noted in the records by both the triage nurse and ED doctor that she had recently been discharged from hospital with a diagnosis of UIP. It is also noted that she had a follow-up appointment planned in the specialist interstitial lung disease outpatient department at a neighbouring Trust.
52. The records indicate the ED doctor examined Mrs O in line with the GMC guidance and recorded a detailed medical history of her recent attendances to hospital, the symptoms she had been suffering with and the treatment provided up to this point. The records indicate the ED doctor then requested a series of investigations including blood tests and a chest X-ray and discussed Mrs O’s case with the Trust’s ED consultant. The ED doctor documented a working diagnosis of chest infection with a background of UIP.
53. Our ED adviser said the working diagnosis of chest infection is consistent with the information in the records about Mrs O’s presenting condition which included worsening breathlessness, mildly raised levels of white blood cells (produced in response to inflammation or infection) and CRP (C-reactive protein - a substance released into the blood with infection or inflammation). Our ED adviser said the chest X-ray supports this view as it identified signs of superadded infection (a second infection that occurs during or immediately after an existing infection).
54. The records support the view the initial assessment and the subsequent action taken by the ED doctor during this attendance was in line with the GMC guidance. The ED doctor recorded Mrs O’s recent medical history and a detailed examination of her condition before organising relevant investigations and administering the required antibiotic treatment to help with the symptoms of her chest infection.
55. Our ED adviser said the records support the decision to discharge Mrs O as her blood test results did not provide any evidence of significant abnormalities and her national early warning score (a system used for scoring physiological measurements routinely recorded at a patient’s bedside) indicated she was deemed to be at low risk of an imminent deterioration in her condition at this time.
56. In addition to this it was known by the Trust clinicians that Mrs O was due to attend a follow-up appointment in the specialist interstitial lung disease outpatient department at a neighbouring Trust for further investigation of her respiratory symptoms.
57. We carefully considered Mr O’s complaint and the supporting information he has provided. We also considered the information in the records, the guidance and the advice we have received. We found no evidence the Trust missed an opportunity to identify the cause of Mrs O’s recurrent infection or provide appropriate treatment during this attendance at the ED.
Admission to hospital from 23 March to 3 April 2022
58. Mrs O presented at hospital with symptoms consistent with sepsis including abdominal pain, fever, shortness of breath and diarrhoea. The records indicate the Trust clinicians carried out initial investigations which identified low blood pressure and significantly raised inflammatory and infection markers in her blood test results. The Trust performed a CT scan of her abdomen which identified colitis (inflammation of the large intestine).
59. The Trust diagnosed Mrs O with intra-abdominal sepsis and provided treatment with intravenous fluids, supplementary oxygen and antibiotic medication. Sadly Mrs O’s condition deteriorated and she was admitted to the Trust’s ITU on 2 April where she suffered a cardiac arrest. The Trust clinicians’ attempts to resuscitate her were unsuccessful and Mrs O died on 3 April 2022.
60. The records support the view the initial investigations carried out by the Trust clinicians and the initial treatment put in place was in line with the GMC guidance. The Trust recorded Mrs O’s recent medical history and a detailed examination of her condition before organising relevant investigations and starting the required treatment to help with her symptoms. The diagnosis can be supported by the evidence in the records we have seen and the initial treatment with intravenous fluids, supplementary oxygen and antibiotic medication is consistent with the NICE sepsis guidance.
61. However our physician adviser said the records provided to us by the Trust are insufficient to allow us to accurately assess whether the pathway of treatment followed after the diagnosis of intra-abdominal sepsis was made and initial treatment started was appropriate. The records include only one stool sample, which we think is inadequate given the diagnosis of intra-abdominal sepsis.
62. The records indicate steroid medications were prescribed for 24 hours then stopped but there is no clear reason for either action. The records indicate there was a plan for a gastroenterology review due to her colitis, however there is no evidence of this happening or an explanation for why it didn’t. Similarly the records indicate there was a plan for a rheumatology review but again no evidence of this happening or an explanation for why it didn’t.
63. There is no evidence in the records of discussions with the Trust’s surgical team, which we would have expected given the CT scan findings of colitis in a patient being treated for intra-abdominal sepsis. There is also no evidence in the records of discussions with the Trust’s microbiology team to ensure appropriate antibiotic prescription in light of Mrs O’s recent C.Difficle infection.
64. The records indicate the Trust clinicians planned for a blood film (a microscopic examination of blood cells to evaluate their appearance, number, and function) to investigate potential blood disorders and rule out leukaemia as a possible underlying diagnosis. However no result is provided for this test and it is therefore unknown whether it was completed.
65. The NHS Records Management Code of Practice states:
‘Regulation 17 of the Health and Social Care Act 2008 requires that health and care providers must securely maintain accurate, complete and detailed records for patients or service users’.
66. Regulation 17 of the Health and Social Care Act 2008 states:
‘Providers must securely maintain accurate, complete and detailed records in respect of each person using the service.’
67. We have contacted the Trust several times to make it aware of the inadequacies in the records and the gaps in the information it has provided. We have given the Trust several opportunities to review the records it holds and provide us with the additional records we have asked for but following several attempts it has been unable to provide us with the complete medical record.
68. Our physician adviser said it is possible Mrs O’s admissions may have been due to separate acute episodes of illness which resulted in her becoming immunocompromised (where the immune system has been reduced as result of an illness) to the point she became very frail and unable to recover from the cumulative effects of the infections. It is also possible for there to have been one unifying underlying diagnosis for her condition throughout this period, however we have not seen any evidence a clear unifying underlying diagnosis was missed by the Trust.
69. The evidence indicates Mrs O was very frail on her final admission to hospital. We acknowledge the records do not provide sufficient evidence of a thorough review of her condition from the gastroenterology, rheumatology and surgical teams as we would expect. However our physician adviser said the complexity of Mrs O’s condition, her immunocompromised state and repeated acute infections would have made additional treatment unfeasible at that time.
70. The post-mortem report states that Mrs O had a medical history of:
• Interstitial Lung Disease (awaiting formal diagnosis) • Ischaemic Heart Disease with stent in 2011 • Polyarthropathy (pain and inflammation in joints) • Diverticular Disease • Recurrent admissions with sepsis and diarrhoea.
71. The post-mortem report also confirms her cause of death as fibrinous pericarditis, an inflammatory heart condition.
72. Having considered all of the evidence available it seems although during these admissions she was suffering recurrent infections, Mrs O had numerous significant health conditions. She experienced a relatively rapid deterioration and died as a result of fibrinous pericarditis. It is clear the Trust faced significant challenges during this period in establishing a unifying diagnosis for the cause of her recurrent infections, if indeed there was one.
73. It seems the complexity of her condition and her immunocompromised state with repeated acute infections made diagnosing the cause of her infections and treating her general condition extremely difficult for the Trust. We found no evidence to indicate a clear underlying, unifying diagnosis for her recurrent infections was missed by the Trust during these admissions or that it missed an opportunity to provide additional treatment that may have prevented her death. On balance of probabilities, given the cause of death confirmed by the post-mortem, it is our provisional view that Mrs O’s death could not have been prevented.
74. We carefully considered Mr O’s complaint and the supporting information he has provided. We also considered the information in the records, the guidance and the advice we have received. We acknowledge that further investigations may not have enabled the Trust clinicians to reach a definitive diagnosis of the cause of her recurrent infections. However we could not see that the Trust clinicians acted in line with the GMC guidance when investigating Mrs O’s condition during this admission.
75. We acknowledge that we are unable to resolve the doubt Mr O has about the underlying cause of his wife’s recurrent infections and that this doubt will remain for him.