UTI diagnosis & treatment 17. Mrs A says the Trust failed to diagnose and treat Mr B for a UTI during the admission, despite him being diagnosed by his GP shortly before he was admitted by ambulance.
18. The NICE QS 3 explains clinicians should assess symptoms to determine if a urine sample should be sent for culture and if antibiotics should be prescribed when a urine culture identifies bacteriuria (the presence of bacteria in urine). It explains they do not prescribe antibiotics to treat asymptomatic bacteriuria in men.
19. Prior to his admission, Mr B’s GP started him on oral antibiotics and took a urine sample, which was sent to the hospital for testing.
20. The clinical records show Mr B presented to the hospital following a large volume of rectal bleeding which had reduced his overall blood level in his body by half, he was not displaying any significant signs of sepsis and the blood tests initially showed a normal white cell count of 7.2 (normal range is between 4.0 and 11.0) and only mildly raised C-reactive protein (CRP), which is a sign of infection.
21. At this time the doctors suspected Mr B had a urine infection given the GP’s actions, but had no official diagnosis of this at the time. The doctors therefore arranged a repeat urine test. We are satisfied this course of treatment is in line with the NICE QS 3 which says doctors should use urine test results to determine if there is an infection present which requires antibiotic treatment.
22. Our physician adviser explains antibiotics should be started when the urine analysis confirms an infection and clinical judgement can be used to decide if antibiotics should be used prior to confirmation of a urine infection. At the time of the initial assessment in the ED, doctors had not officially diagnosed a urine infection and in the absence of clear signs of infection or sepsis, our physician adviser considers it was a reasonable decision by the Trust not to continue Mr B on the antibiotics and to focus on the primary treatment related to rectal bleeding.
23. Our physician adviser explains when the results of the urine test were returned, they clearly indicated any infection Mr B had prior to admission, had already been partially treated, and the Trust then decided to restart the antibiotic treatment. This is in line with the NICE QS 3 on treating infection with antibiotics.
24. Overall we are satisfied the Trust appropriately treated Mr B following his presentation and when the results were returned which showed he had an infection, they restarted the antibiotics to treat this. We have therefore seen no indications of a failing in the Trust’s overall treatment here.
Antibiotics 25. Mrs A says the Trust failed to administer Mr B his GP-prescribed antibiotics between 20 and 23 February 2023.
26. The NICE QS 3 explains clinicians should assess a patients’ symptoms to determine if a urine sample should be sent for testing, and if antibiotics should be prescribed when a urine test identifies bacteria. It explains they do not prescribe antibiotics to treat asymptomatic (not showing any symptoms) bacteria in men.
27. As we explain above, prior to the admission, Mr B’s GP had prescribed antibiotics for a urine infection and sent the urine for testing. Our physician adviser explains the decision to continue or stop the antibiotics started by the GP is a clinical decision which the ED team decides upon, based on the patient’s presenting condition. The doctors in the ED did not continue Mr B on these antibiotics initially, as the test results were not available. When the test results came back on 21 February, the antibiotics were restarted. This is in line with the NICE QS 3 and our clinical advice supports this view.
28. Our physician adviser explains due to Mr B’s poor renal function, his kidneys would take longer to efficiently filter the antibiotics out of his system, therefore the Trust only gave half-doses of these antibiotics. Unfortunately Mr B’s condition significantly declined and he was started on end-of-life care, and the Trust therefore did not give another dose of the intended course. This action was appropriate in the circumstances.
29. Overall we can see the Trust initially waited for the results of the urine test to decide whether to restart Mr B on the antibiotics following his admission, when the test results confirmed Mr B had a urine infection, the Trust restarted the antibiotics, this action was appropriate and in line with the NICE QS3 and our clinical advice supports this view. We have seen no indications of a failing in respect of the Trust’s use of antibiotics on Mr B.
End of life care 30. Mrs A says the Trust inappropriately started Mr B on end-of-care on 24 February 2023, despite not sufficiently exploring treatment options for his UTI before this point. The NICE NG31 guidance explains the recommendations supplement the individual clinical judgement that is needed to make decisions about the level of certainty of prognosis. Section 1.1.1 explains if it is thought a patient may be entering the last days of life, clinicians should father and document information on: • the person's physiological, psychological, social and spiritual needs • current clinical signs and symptoms • medical history and the clinical context, including underlying diagnoses • the person's goals and wishes • the views of those important to the person about future care.
31. Section 1.1.4 explains clinicians should avoid undertaking investigations that are unlikely to affect care in the last few days of life unless there is a clinical need to do so.
32. The clinical records show how, before deciding Mr B was approaching his end-of-life, the Trust initially explored on 23 February the option of him receiving intensive care support to try and stabilise his acute deterioration. The ITU team decided it would not be appropriate to transfer Mr B and that ward ward-based level of care was more suitable. The Trust also completed a DNACPR order at this time. Our physician adviser explains there was no failing in relation to the Trust’s decision to start Mr B on end-of-life care. This is because the Trust deemed it likely Mr B would sadly die, even with all possible treatment options available at the time.
33. Based on the assessments of Mr B’s overall condition, the Trust then decided it was important and would be in Mr B’s best interests to start him on end-of-life care and to make him as comfortable as possible. This decision was communicated with Mr B’s family. This is in line with the NICE NG31 guidance on exploring the current clinical signs and symptoms to reach a decision about whether a patient is at the end-of-life stage, and our clinical advice supports this view. We have seen no indications of a failing here in the Trust’s decision to start Mr B on end-of-life care.
Oral hygiene 34. Mrs A says the Trust provided insufficient oral hygiene and care to Mr B between 24 and 28 February 2023. The Trust explains that it completed a daily mouth assessment on Mr B and he was initially deemed low risk (lips pink and moist, tongue clean, gums not inflamed). From 24 February he became high-risk (swollen or bleeding lips, tongue sore) and mouthcare was provided daily. The Trust says the clinical records indicate that a family member was also present on the ward, supporting Mr B with regular mouthcare.
35. The HEE guidance explains good oral health is important for patient safety and dignity and is an essential element of compassionate care.
36. We know on 24 February at 3.28pm the Trust started Mr B on end-of-life care and therefore placed him on comfort observations, which includes mouthcare. These observations focus on the patient’s comfort and dignity rather than their clinical status.
37. Our nursing adviser explains the completion of these comfort observations is inconsistent between 24 and 26 February 2023. The comfort observations show on 24 February at both 3.28pm and 6pm, Mr B had a slightly sore mouth. There is no record of the Trust inputting any further mouthcare observations on 25 February, or for the majority of 26 February until 7.33pm, when it is recorded Mr B did not have a sore/dry mouth. After this the Trust then regularly input the mouthcare observations until his sad death on 28 February.
38. Importantly here we can see the Trust completed regular comfort charts on Mr B every two to four hours between 24 and 28 February 2023, which includes a section for personal care. The written clinical records during this period also indicate the Trust provided Mr B with oral hygiene and mouthcare, as well as support to the family, who also provided mouthcare during this time. This is in line with the HEE guidance on providing oral health to a patient.
39. While we can see the completion of the comfort observations was inconsistent, we cannot say this is serious enough to amount to maladministration, as importantly we have seen the Trust did provide Mr B with regular oral hygiene between 24 and 28 February 2023. With this in mind, we have seen no indication of a failing in respect of the Trust’s overall oral healthcare provided to Mr B, and our clinical advice supports this view.
Lack of updates 40. Mrs A says the Trust failed to provide sufficient updates to her about Mr B’s condition for the duration of his admission.
41. The GMC guidance on good communication explains clinicians must be considerate and compassionate to those close to a patient and be sensitive and responsive in giving them support and information. Similarly the NICE NG31 guidance explains clinicians should provide accurate information to those important to a patient about their prognosis.
42. The clinical records show on 21 February the Trust spoke to Mr B’s daughter about his condition, it also recorded Mrs A as his next-of-kin, had her contact details and she confirmed she can be contacted at any point. On 22 February there was a conversation with the family about Mr B experiencing ongoing rectal bleeding throughout the admission and had no clear signs of infection, the doctors also explained it was planning a flexible sigmoidoscopy on him.
43. On 23 February the Trust had three further conversations documented with Mr B’s family in which it explained the seriousness of Mr B’s illness, explained he was unlikely to survive the admission and then finally discussed its ongoing treatment plan. On 26 February the Trust spoke to the family again during a ward round to again explain it is unlikely he would survive the admission. We are satisfied the Trust’s communication is in line with the GMC guidance on providing good communication and NICE guidance about providing accurate information on a patient’s prognosis. Our clinical advice supports this view.
44. We know Mrs A disagrees with this and feels the Trust failed to provide updates about Mr B’s condition. We do not doubt Mrs A’s recollection of the updates she received. When investigating this point we paid particular attention to what Mrs 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 Mrs A. 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 Mrs A has said, we have not seen any evidence to support the view that the Trust did not provide sufficient updates to Mrs A about her brother’s condition.
45. Overall we can see how throughout Mr B’s admission, the doctors provided regular updates to his family and spoke to them about his overall condition and its planned treatment including his overall prognosis when he was receiving end of life care. We have seen no indications of a failing in the Trust’s overall communication.