15.Having carefully considered the relevant evidence, we did not see any evidence of significant failures which contributed to Mr C’s deterioration and death.
16.Our adviser described the records for this period as being good and in line with the requirements of Good Medical Practice, which says doctors should record their work clearly, accurately and legibly.
17.Before he went to hospital, Mr C had significant existing health problems. He had alcohol dependency and was a long-term heroin user, as reported on admission. Long-term misuse of alcohol and heroin can both weaken a person’s immune system, making them more vulnerable to serious infections. Two weeks previously, Mr C’s GP had diagnosed him with a chest infection and started him on antibiotics. The post-take ward round, which is the first medical review after admission, noted that for the previous four days, he had been confined to bed and not drinking or eating.
18.There are different levels of critical care, depending on support needs. These are described on the website of the Intensive Care Society. https://ics.ac.uk/resource/levels-of-care.html
19.This explains there are three levels of higher care above normal ward care. Level 1 includes patients who need more detailed observations or interventions. Level 2 is for patients who may need basic support for two or more organ systems and for those ‘stepping down’ from higher levels of care. Level 3 is the highest and includes patients who need advance respiratory support and monitoring and support for two or more organ systems, and those requiring support for multiple organ failure.
20.Our adviser explains the difference between ICU and HDU is the difference between level 3 and level 2 provision of care, particularly in terms of the ratio of nursing staff to patients. Level 3 will be staffed by one nurse per patient, while level 2 will have one nurse per two patients. A patient is not always clearly level 2 or 3 and the question of whether a patient should be in ICU or HDU is not always obvious. The support Mr C needed for most of his stay on ICU and HDU was mainly respiratory, but he also had renal replacement therapy to treat an acute kidney injury for a reasonable period of time.
21.We did not see any evidence in the records that Mr C lacked any necessary support or care as an HDU patient from 27 March. We did not see a record of the medical rationale of why he was transferred from ICU to HDU, but we noted that doctors had moved him to an environment with a window, as they identified his condition was improving and thought it would be better for his mental state. We can reassure Miss C we have seen no indication her brother’s wellbeing was compromised by the change to HDU, and so the decision to move him to a more agreeable environment seems reasonable. Although it has a lower level than ICU, the HDU still provides a high level of care and monitoring.
22.Earlier in the admission, after diagnosing aspergillosis, Trust doctors contacted the National Aspergillosis Centre in Manchester for advice on treatment. The specialists’ advice included the use of antifungal medication, which was noted in the Trust’s first response. Therefore. the Trust’s doctors acted in line with GMP which says ‘In providing clinical care you must:… consult colleagues where appropriate’. This was demonstrated in terms of asking the microbiologists (specialists in bacterial infections) within the Trust for expert advice, who in turn, sought advice from the National Aspergillosis Centre. The role of such specialist centres is not solely to take inpatients, but to help clinicians all over the country by advising them on management of patients with a specific condition that most doctors may not encounter very often.
23.On 17 March, while Mr C was still in ICU, staff contacted the Lane Fox Unit (the Respiratory Service at Guy’s and St Thomas’ Hospital in London, which their website explains is ‘one of the largest services in the UK for home ventilation and weaning people from mechanical ventilation.’) for help extubating from the ventilator. This refers to the removal of the tracheostomy tube.
24.Extubation is a potentially dangerous time for ICU patients because of the effects of long-term sedatives and analgesics, poor nutrition, prolonged intubation and inability to clear secretions. Hospital doctors may contact specialist weaning centres like the Lane Fox for advice or possible transfer. In this case the Lane Fox Unit provided advice and confirmed that Mr C was not a candidate for transfer to their unit at that point. ICU doctors also got advice from within the Trust from a thoracic surgeon.
25.On 28 March, Mr C was reviewed by SALT (speech and language therapist, who can help patients with swallowing difficulties), a psychologist, a physiotherapist, a dietitian, as well as medical reviews and nursing. This shows he had a thorough multidisciplinary assessment before ICU doctors decided to transfer him.
26.Miss C was understandably concerned about the bleed her brother experienced soon after transfer. Aspergillosis has a recognised risk of pulmonary haemorrhage (bleeding). The records show that Mr C’s blood gases were worsening just before the incident, but his haemoglobin was stable. His blood pressure was dropping. Our adviser explains that these were signs before the bleed that something was wrong with his chest. However, they did not indicate that such a serious bleed was developing. Although bleeding was a risk, we do not consider it could have been predicted. The signs were also consistent with a new developing infection, which would have been a more likely cause.
27.When Mr C did have the initial bleeding, a member of nursing staff attempted to suction it immediately and remove any airway blockage. This was the right response.
28.We cannot say with absolute certainty what the cause of the bleed was. A chest X-ray on 28 March showed fibrosis (buildup of scar tissue in the lungs, making breathing increasingly difficult) and cavitation (collection of gas and/or fluid enclosed by a thick wall). These findings fit in with damage of aspergillosis.
29.Aspergillus can cause damage to blood vessels as the infection progresses. If it does not clear up it - which it did not for Mr C’s, despite treatment – then the risk increases. This is probably what happened in Mr C’s case; he had a bleed of such a size as to block the tracheostomy tube and had a hypoxic brain injury (caused by lack of oxygen) because of that blockage. The Trust’s explanation in its response of 16 October 2023 was reasonable. When he did have the bleed, there were no options for surgical treatment.
30.Evidence shows that the Trust staff did what they could for Mr C. He had multiple comorbidities and was deconditioned before admission to hospital. Aspergillosis is very difficult to treat and with Mr C’s long-term health conditions, sadly he was not fit enough to fight it.
31.Following his cardiac arrest, the recognised treatment was generally in line with the Resuscitation Council guidance apart from some issues with controlling temperature and avoiding hyperthermia (overheating) in the first 24 hours. Considering Mr C’s medical condition before the cardiac arrest and the fact his cardiac arrest was prolonged, our adviser did not consider the hyperthermia was a significant factor in the poor outcome and Mr C’s death.
32.Doctors had been trying to wean Mr C off the ventilator. He had not been fully weaned – he still needed some support for his breathing – and after his cardiac arrest, he went back to full ventilation, which would be normal practice after a cardiac arrest of this type.
33.In summary, there was appropriate involvement of clinicians from several disciplines, showing there was an appropriate multidisciplinary approach to managing a difficult to treat fungal infection. Doctors obtained advice from outside the Trust in managing Mr C. We did not find any failures in the care and treatment Mr C received. Sadly, it appears the aspergillosis damaged his lungs to the extent it caused a significant bleed, and consequent cardiac arrest and brain injury due to lack of oxygen.