14. Before we decide if we should conduct 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 have not seen any indication of failings in the decision to discharge Mr J from the ED on 29 August.
Discharge from Emergency Department
15. Mrs J complains staff did not recognise her husband had a bowel blockage when he attended the Emergency Department (ED) on 29 August 2020, discharging him the same day with a hiatus hernia.
16. We have considered the General Medical Council Good Medical Practice (GMC guidance) to tell us what doctors should do when assessing patients.
17. Paragraph 15 of the GMC guidance says ‘[doctors] 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; 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.’
18. Records show that when Mr J attended the ED on 29 August 2020, he was triaged within five minutes of his arrival. It was noted Mr J had been experiencing epigastric pain (pain in the upper part of the abdomen) since 8pm the night before but had not had any episodes of vomiting or diarrhoea.
19. Mr J had observations that showed a minor raise in his heart rate (NEWS 1) and he was also assessed as having mild pain. NEWS is an abbreviation of National Early Warning Score, which is used to determine the degree of illness of a patient and identify deterioration in their condition. The NICE innovation briefing for NEWS scoring says that an overall NEWS score of 1-4 is low risk.
20. Mr J was then assessed by an ED junior doctor who noted his history of epigastric pain which had come on whilst lifting a heavy object. The pain was associated with feeling clammy and nauseous but there had been no vomiting. The doctor recorded their examination of Mr J, finding that the abdomen was soft with epigastric tenderness. Our ED adviser says a soft abdomen suggests there was no evidence of a significant problem inside the abdomen when Mr J was examined. A series of blood tests, an echo cardiogram (ECG) and chest X-ray were ordered.
21. The doctor documented their differential diagnosis (possible diagnoses from information gained from information gained through examination) of possible acute coronary syndrome (ACS a range of acute heart problems from angina to heart attack), possible pancreatitis (inflammation of the pancreas gland) and possible gastritis (inflammation of the stomach).
22. The ED doctor then recorded that Mr J’s blood results showed a white blood cell count which would indicate either inflammation or infection. The amylase (an enzyme released in pancreatitis) as noted to be normal. The doctor also recorded their interpretation of the chest X-ray as showing a large hiatus hernia.
23. The working diagnosis is recorded as being gastritis and the doctor’s plan was recorded as discharging Mr J if his troponin level (a blood test to identify heart damage in ACS) was normal. Whilst in the ED, staff completed two additional sets of observations on Mr J, both of which were normal (NEWS 0). A further progress note records that the troponin level was normal, and that the doctor had explained the situation to Mr J who was happy with the plan to discharge him home.
24. A final note by the ED doctor states Mr J’s pain was improving, that advice was given for him to see his GP in a week’s time with advice to return if things didn’t improve or worsened. He was discharged with a course of omeprazole (a medication to reduce acid in the stomach).
25. Our ED adviser says the ED doctor’s working diagnosis of gastritis can be justified given the history of abdominal pain, the tenderness over the stomach on examination and the findings of a raised white cell count and hiatus hernia on the chest x ray. In addition, Mr J’s observations remained normal throughout his stay in the ED and his pain was noted to have improved prior to his discharge.
26. Having looked at all the evidence and taken the views of our adviser into account, we consider the care and treatment was in line with the guidance quoted in paragraph REF _Ref164693951 \r \h 17.
27. It is important to note that Mr J was later diagnosed with small bowel obstruction, a condition which the BMJ describes as a medical emergency that requires early diagnosis and intervention. It describes that the condition presents with the combined symptoms of severe abdominal pain, vomiting and bloating.
28. The Trust says that in hindsight it is possible to say that Mr J should have remained in hospital for further investigation due to the CT scan findings the following day when he required emergency surgery. However, in light of what the staff knew on the day, we do not see indications of failings.
29. At the time of Mr J’s assessment in the ED his abdominal pain was described as mild and improving, he had not vomited and there was no complaint of bloating so not consistent with the symptoms described by the BMJ in paragraph 23 as being consistent with a small bowel obstruction.
30. The ED doctor took a thorough history, examined Mr J and arranged for him to have relevant investigations and treatment. We appreciate it was upsetting for Mrs J to witness her husband deteriorate when at home. There was no way of knowing at the time that his condition would develop into a small bowel obstruction and surgery would be required.
31. There was no indication Mr J had a bowel obstruction on 29 August 2020. Taking all the above into consideration, there were no definite indications that Mr J required admission at the time of his assessment in the ED.
Communication about visiting
32. Mrs J complains the nursing staff on her husband’s ward did not tell her until 13 December that as of 3 December, she had been granted two visits per week. Mrs J says that this caused her distress and upset as she feels as she could have spent more quality time with her husband before he died.
33. In its complaint response letter of 2 February 2021, the Trust and the sister from the ward apologises that Mrs J was not made aware of the visiting allowances when the decision was made on 3 December 2020. It says that staff on the ward have been spoken to, describing the impact that poor communication has on the patient and their families.
34. The Ombudsman’s Principles for Remedy says that ‘the public body responsible should take steps to provide an appropriate and proportionate remedy’.
35. Trust has apologised for not sharing the increased visiting information with Mrs J and has taken action to ensure that this does not happen again by reminding staff of the impact poor communication can have on the patient and their families. Due to the delay in sharing the information, Mrs J missed out on the maximum of two visits with her husband, totalling two hours.
36. We fully appreciate that it is upsetting for Mrs J knowing she could have spent more time with Mr J before he died. We consider the actions taken by the Trust are enough to remedy this part of her complaint as outlined in paragraph 35. The Trust has apologised and taken action to prevent the events being repeated. There is nothing further we would be able to achieve through further consideration of this issue.
Treatment of infection
37. Mrs J says when she visited her husband on 12 December he was confused and showing signs of infection. She informed staff of her concerns. She complains the Trust did not take any action to treat the infection until 17 December causing sepsis to develop.
38. The Trust say staff discussed treatment plans with Mr J. It had discussed carrying out surgery to reverse his stoma and told him if the procedure went well, he could be discharged home in the new year. The Trust also said throughout the admission Mr J was very unwell, although at times he did stabilise, and his blood results showed some small improvement. Despite all treatments, Mr J’s condition quickly and suddenly deteriorated due to his fragile condition and he was not able to survive the infection.
39. To identify infection, our physician adviser says that doctors use a combination of indicators. The indicators are clinical symptoms and signs, physical observations (recorded as NEWS scores as per paragraph REF _Ref169001623 \r \h 19, and blood test markers. Mr J NEWS scores up until 17 December were all less than 4. As referenced in paragraph REF _Ref169001623 \r \h 19, a NEWS score less than 4 means a patient is low risk.
40. In addition to Mr J’s low NEWS score, staff were taking daily bloods from Mr J to monitor any changes. Our physician adviser says that Mr J’s c-reactive protein (CRP) measurements were stable and not significantly raised until 17 December.
41. The BMJ explains that CRP is a non-specific marker of inflammation. It is produced in response to tissue damage (including surgery), infection, inflammation, and cancer. A high CRP is does not confirm an infection.
42. Normal CRP levels are those below 3mg/L. On 12 December Mr J’s CRP level was 24mg/L but his NEWS sore below 4, low risk. Although, the CRP is higher than normal, our physician adviser says that this does not indicate infection. It is likely that Mr J’s CRP was slightly increased due to his surgery in August and the subsequent procedures that followed.
43. Our physician adviser says the clinical reviews undertaken from 12 to 17 December do not document that Mr J had any clinical sign of infection.
44. The fist documentation of possible infection was at 9pm on 17 December when Mr J’s CRP level rose to 54 and his NEWS score rose to medium risk. This is when the Trust started antibiotic treatment for sepsis.
45. There is no indication Mr J had an infection on 12 December. It was not until 17 December when Mr J’s CRP doubled, and his NEWS score increased that Mr J started to show signs of an infection. We have seen at that point the staff acted and started to treat an infection.
46. Mrs J tells us she found her husband to be confused and showing signs of infection on 12 December and this must have been difficult for her to see. We can see Mr J was reviewed on a daily basis and when test results showed changed to his condition, on 17 December, treatment was started.
47. Having looked at all the evidence and taken the views of our adviser into account, we also consider the care and treatment was in line with the guidance quoted in paragraph REF _Ref164693951 \r \h 17.
48. Mrs J has told us how upset she has been over her husband’s death has been and how she has been affected. We extend our sincere condolences to her. We hope this statement clearly explains the reasons why we will not be considering the complaint further.