Concerns about care and treatment – no surgery to repair bowel perforation
17. GMC guidance explains clinicians must ensure any treatment they provide, or decide not to provide, is in the patient’s best clinical interests. They should not give treatment that is not effective or unlikely to benefit the patient. They should take all possible steps to alleviate pain and distress, even if a cure is not possible.
18. Our adviser explained the only way to repair a perforated bowel is to carry out surgery to repair the hole or remove the part of the bowel that is causing the problem. If a patient is not stable enough to undergo or survive surgery, then the clinician should help manage their symptoms with IV antibiotics (this helps the infection) and IV fluids (to maintain hydration).
19. When deciding if a patient is stable enough for surgery, clinicians must consider their current clinical condition, as well as their previous clinical history and co-morbidities.
Mrs E had Alzheimer’s dementia and was bed bound (with pressure sores) prior to her admission. She required carers to attend to her at home three to four times a day.
20. Upon admission, Mrs E had a high heart rate, low blood pressure, low oxygen saturations and a significantly reduced level of consciousness. Her national early warning score (NEWS) varied between 10 and 14. As detailed by NICE guidelines, NEWS score of 7 or more means the patient is in critical condition and is at high risk of deteriorating quickly.
21. Mrs E was also suffering from peritonitis, which was significantly impacting her clinical condition. The NCBI study on intestinal perforation shows patients in this situation, and are stable enough to undergo surgery, only have a 30% chance of surviving the procedure. This shows the risk of dying, in clinically stable patients, is very high. In patients who are not clinically stable, the risk of dying is even higher.
22. It is also important to consider that if a patient did survive the procedure, the risk of post operative complications such as collection of fluid or further infections is significant. Therefore, they are likely to suffer further distress whilst the risk of dying remains high.
23. Our adviser explained Mrs E’s clinical condition upon admission was very poor. Her co-morbidities, along with her high NEWS score, suggested she was in critical condition and likely to deteriorate quickly. She was approaching the end of her life.
24. Because of this, she was very unlikely to survive surgery on her bowel or being put under general anaesthetic. Providing surgery would not have been in her best clinical interest and this treatment was likely to cause her more distress and harm.
25. Although the chances of Mrs E’s bowel perforation healing on its own were low, the benefits of waiting for this would have outweighed any benefits of carrying the surgery to her bowel. As we can see that staff acted in line with GMC guidance when they did not operate on Mrs E’s bowel. We have found no indications of failings here.
26. We recognise Mr A wanted his mother to have the best possible chance of survival, and wanted staff to carry out the surgery, even if this would have led to her passing sooner. However, we would not expect staff to provide treatment that would be ineffective and cause Mrs E more pain and discomfort.
27. We can also see that staff provided Mrs E with IV antibiotics to help her infection and IV fluids for hydration. This treatment helped manage her symptoms and alleviate any pain or distress she was suffering. This was in line with GMC guidance.
Concerns about care and treatment – no treatment for ruptured appendix
28. We have carefully considered the death certificate and Mrs E’s medical record. However, we cannot see any reference here to Mrs E having a ruptured appendix.
29. A ruptured appendix occurs when a patient has severe appendicitis (inflamed appendix) which is severe enough to rupture the appendix. This is like a bowel perforation in that it leads to air, fluid and bacteria to enter the abdomen, which can also cause peritonitis. However, it is different in that the hole is in the appendix.
30. As explained earlier, Mrs E had a perforated bowel. This meant she had a hole in her bowel (either the colon (large intestines) or small intestines) which led to the escape of gas, fluid and bacteria into her abdomen.
31. The hole in Mrs E’s bowel was caused by the lack of blood supply to her bowel, not from appendicitis. Taking this into consideration, we can see no indication that Mrs E had appendicitis which led to a ruptured appendix. For this reason, we have not considered this point further.
Concerns about care and treatment – inappropriate treatment for aspiration pneumonia
32. NCBI study on aspiration pneumonia shows that antibiotics should be used to treat aspiration pneumonia.
33. Mrs E was already on IV antibiotics at the time, and had been for several weeks (due to sepsis and peritonitis). Therefore, staff were already providing her with antibiotic treatment. There was no other treatment staff could have given at this stage to help aspiration pneumonia specifically.
34. As detailed above, GMC guidance explain clinicians must take all possible steps to alleviate pain and distress. At this stage, Mrs E was on end-of-life care and her condition had deteriorated again.
35. Staff gave her hyoscine (to reduce saliva production hence avoiding the further build up of fluid in the airways), midazolam (a sedative to manage anxiety) and morphine (for pain relief). These treatments were not given to cure her but to help alleviate her symptoms.
36. Staff’s actions in managing aspiration pneumonia and the symptoms of this were in line with NCBI study on aspiration pneumonia and GMC guidance. We have found no indications of failings in the care staff provided here.
Concerns about communication
37. GMC guidance on communication explains doctors must give patients and their families the information they want or need in a way they can understand. This includes information about:
• The condition(s), likely progression, and any uncertainties about diagnosis and prognosis • The options for treating or managing the condition(s), including the option to take no action • The potential benefits, risks of harm, uncertainties about, and likelihood of success for each option
38. NMC guidance on communication also explain nurses must communicate effectively, ensuring patients and their families understand the information that they need to provide.
39. As explained in the background section, doctors spoke to Mr A on 16 and 17 May. They told him about his mother’s diagnosis and the limited options for treatment. They told Mr A his mother could not be cured, she was approaching the end of her life, and would unlikely survive this admission. Mr A recognised this at the time. We consider this was in line with GMC guidance on communication.
40. After Mrs E received IV fluids and antibiotics, her condition began to stabilise and staff began discussions with Mr A about discharging her to a hospice or a care home so she could receive end of life care in the community setting. As Mr A wanted Mrs E to be discharged home, staff initiated the ‘Fast Track’ pathway which is a pathway for patients needing end of life care quickly.
41. Although during these conversations staff did not reiterate that Mrs E was approaching the end of her life, we can see they did not change the care plan or tell Mr A that Mrs E’s would likely survive past this event. Staff had initially given Mr A this information in detail. We would not have expected them to reiterate this again.
42. The doctors and nurses involved in Mrs E’s care were open and honest about her condition during this period. They clearly explained Mrs E’s condition had stabilised so she could be discharged to a hospice or care home for end-of-life care. They had already informed him that Mrs E’s condition was likely uncurable. This was in line with NMC and GMC guidance on communication.
43. Sadly, on 5 June, Mrs E’s condition began to deteriorate again and she suffered from aspiration pneumonia. Doctors and nurses attempted to call Mr A to update him on Mrs E’s condition but there was no answer.
44. Later that day Mrs E’s condition became worse and her NEWS score increased to 11. Nurses called Mr A again and told him that his mother was approaching the end of her life and he should come to visit her. The notes in the records say that Mr A explained expected this and the family were planning to visit that day.
45. Mrs E’s NEWS score remained between 11 and 13. Nurses called Mr A again on 6 June and explained his mother was approaching the end of life and her condition was critical. Sadly, Mrs E died shortly after.
46. Our adviser explained staff communicated well with Mr A about Mrs E’s clinical condition. There were several instances in her admission where her condition and prognosis were discussed thoroughly with her family. Staff also managed Mr A’s expectations on Mrs E’s likely prognosis. Their actions work in line with GMC and NMC guidance on communication.
47. We understand Mr A and his family are upset with the Trust’s communication. We hope the explanations here reassure him that the Trust’s communication was appropriate.
Concerns about lack of curtains in room
48. The Trust recognise there were no curtains in Mrs E’s room. It explains it is very sorry for this and assures Mr A the room now has curtains.
49. Our NHS Complaints Standards explain where something has gone wrong, the Trust should take steps to help put matters right. It should also take steps to ensure the failing does not reoccur.
50. We can see that the Trust has already taken steps to put matters right by apologising to Mr A for the event that occurred. It has also ensured the failing does not reoccur by already putting curtains in the room. These actions work in line with our NHS Complaints Standards.
51. We recognise that not having curtains in her room would have caused Mrs E distress during her admission. We are very sorry this happened. The Trust has put this right, we have decided not to consider this point further.