Attendance in January and February 2022
16. Mr A complains the Trust did not arrange a CT scan for his mother in January or February. He says he and his family told the medical team she had suffered a stroke in 2018. He believes the mix-up of his mother’s records may have impacted their knowledge of her medical history.
17. Mr A said the Trust responded to his complaint in April 2022 to say CT scans expose patients to radiation and so need to be used with caution. However, days after this response, doctors arranged a CT scan for his mother. Mr A questions what had changed.
18. The GMC’s Good Medical Practice says doctors who assess, diagnose or treat patients must, ‘adequately assess the patient’s conditions, taking account of their history’, and where necessary, ‘examine the patient’. They should also, ‘promptly provide or arrange suitable advice, investigations or treatment where necessary’.
19. The NHS website explains the symptoms of a UTI include needing to pass urine more often, including during the night, and needing to pass urine with more urgency than usual. Symptoms can also include a burning sensation while urinating and having a temperature.
20. Doctors arranged tests for Mrs B when they admitted her in January. She had a temperature of 37.9°C which is slightly above a normal temperature of 37°C. Mrs B’s blood test results showed she had a slightly elevated C-Reactive Protein (CRP) level. A higher CRP level indicates either inflammation or infection.
21. Mrs B also had a positive urine dipstick test. This tests the pH of the urine which is affected by substances present in the urine. A positive test means a UTI is likely. Mrs B also had new urinary incontinence and urinary urgency (a sudden and intense need to pass urine).
22. Our adviser explained all these results and observations indicate Mrs B had a UTI. We can see the symptoms she presented with meet those listed on the NHS website about UTI’s. Doctors also assessed Mrs B as having delirium, this is a sudden onset of confusion. Our adviser has said confusion is a common symptom of a UTI in older people.
23. The medical team treated Mrs B with antibiotics. The records show her symptoms improved as a result. Our adviser has said the team appropriately managed Mrs B for the symptoms she presented with.
24. On review of the evidence and advice we have received, we consider the Trust assessed and treated Mrs B in-line with the GMC guidance referred to above during her admission in January and February.
25. In terms of whether the medical team should have arranged a CT scan of Mrs B’s head, our adviser has referred to the clinical article, ‘Delirium in Hospitalized Older Adults’. This says scans of the brain are indicated for patients who have had a head trauma or where there is a new focal neurological finding. This is a weakness in one part of the body.
26. Our adviser has said the records do not indicate Mrs B was showing signs of a focal neurological deficit.
27. Mrs B had a bleed on her brain (a type of stroke) in 2018 after she had a fall and banged her head. The bleed she suffered at the time was due to the fall. We have seen reference to this throughout the notes from 2022 when doctors documented Mrs B’s medical history.
28. We note Mrs B had not suffered a fall or trauma to her head in January 2022. Our adviser has said Mrs B’s history of a bleed on her brain in 2018 was not relevant to the care and treatment she required in January 2022.
29. Our adviser has also explained confusion is not a typical symptom for a stroke, unless there is no other clear reason for this. That was not the case here because Mrs B’s symptoms all indicated a UTI.
30. Having considered the advice and the clinical article, we are satisfied there was no indication the medical team should have arranged a head CT scan for Mrs B in January 2022.
31. Turning to Mrs B’s attendance in April 2022, the records show she was admitted following a period of unresponsiveness. The medical team documented she had been having recurring syncope’s (a loss of consciousness) and falls.
32. A doctor requested a CT scan of Mrs B’s head, alongside other tests. Our adviser explained the CT scan was likely to check for any bleeding on Mrs B’s brain in case she had hit her head due to her falls.
33. The CT scan showed Mrs B had previous strokes, but no new ones. Our adviser has said it is not possible to say when the previous ones happened. However, as set out above, it is our view there was no indication in January or February she had a stroke.
34. The reason for Mrs B’s admission in April was different than in January. We have seen clinical justification for why the CT scan was done in April.
35. Mr A has told us his mother sadly deteriorated from January 2022, and has questioned if this was due to her not getting the treatment she needed. We are sorry to hear of his concern and understand this has caused him significant distress.
36. In terms of whether the mix-up of records could have affected his mother’s care, we asked our adviser to review the overall plan for her care. They have said there are no significant differences across the documented plans in January and February and there is consistency across the records.
37. Our adviser also commented a person’s medical history does not always have a bearing on the treatment they receive during an admission. Doctors treat a person for the condition and symptoms they are admitted for and this treatment is unlikely to significantly change no matter their medical history.
38. We are sorry to hear Mrs B declined following her admission. While we have not seen that anything went wrong, we hope it is helpful to share our adviser’s comments. They have said that when a person is older, frail and have other health issues, they can take longer to recover from an illness. It can also be the case they sadly do not fully recover at all.
39. In summary, we consider the care and treatment Mrs B received in January and February 2022 was in-line with the GMC’s Good Medical Practice. We hope we have been able to provide some answers and reassurance for Mr A on what happened.
Discharge letter
40. Mr A has told us that due to the mix-up in his mother’s records with another patient, he thinks the Trust did not send her discharge information to her care home or GP. He has specific concern that in February, the Trust instructed Mrs B’s GP to refer her to memory services for a dementia assessment but this did not happen.
41. One-year after his mother’s death, the care home of the ‘other Mrs B’ called Mr A’s family. He says this demonstrates the Trust had sent his mother’s information to the wrong place as it was the only way the other care home would have their contact details.
42. Our Principles say public bodies must handle and process information ‘properly and appropriately’.
43. In its complaint response, the Trust said it was unable to say with certainty if it had correctly shared Mrs B’s discharge letter with her care home. We can see Mrs B’s discharge information in her medical record but it is not possible for us to say if the Trust correctly shared this with Mrs B’s GP or care home.
44. Mr A’s family contacted his mother’s GP practice two weeks after her discharge in February and this prompted the practice manager to review the discharge information. Mr A has shared their correspondence with us. It is not clear from this communication if the GP practice received the discharge information before the family’s contact prompted them to review this.
45. We cannot determine exactly what information the Trust sent incorrectly and when. However, it appears the mix-up of records meant Mrs B’s information was not shared correctly.
46. This standard of service does not meet with our Principles and indicates a failing. We have therefore considered the possible impact of this.
47. As noted above, Mr A’s family contacted his mother’s GP practice in February. The practice manager checked his mother’s discharge information and quoted from this in their correspondence. This correctly matches the information in Mrs B’s records. We are therefore satisfied they saw the correct information.
48. The practice manager initially understood the Trust had already referred Mrs B to a memory clinic but agreed to chase this up. After contacting the memory clinic, the practice manager learned a referral had not been made and so they actioned this in March.
49. Mr A says his mother did not have a dementia assessment before she died. Our adviser explained if a person has been in hospital with delirium, this would need to resolve before a clinic would carry out a dementia assessment. This is because confusion that delirium can cause would make a dementia assessment inaccurate.
50. Our adviser explained it can take a person a few months to recover fully from delirium and so a clinic would not have wanted to assess Mrs B straight away following her discharge.
51. We have also seen from the GP practice correspondence they had contacted Mrs B’s consultant and they agreed she had dementia, they just did not know the specific type. This is what the memory clinic would determine.
52. Our adviser has also said that even if the clinic had diagnosed Mrs B with dementia, there is no treatment to cure this and the focus would be on how to live a healthy life with this condition. We can already see her medical team agreed she had dementia and so would have been providing care in consideration of this.
53. In summary, we consider what happened did not negatively impact Mrs B. This means we will not take this concern any further. We hope the explanation for our decision will go in some way to bringing some resolution for Mr A.