Care and Treatment
21. Mrs T raises concerns about the care and treatment provided to Mr T upon his admission to hospital. She is concerned that the Trust did not take Mr T’s previous medical history of peptic ulcers into account when reviewing his presentation and symptoms, and therefore did not carry out a gastroscopy to investigate the cause of his illness when it should have done.
22. In response to the complaint, the Trust has explained that Mr T’s medical history, previous hospital attendances, and presenting symptoms were taken into consideration at the point of triage in A&E and throughout his admission. It explained that the decision not to investigate with an emergency endoscopy was a clinical one made over the weekend of 17 September. The admitting team concluded that his blood cells breaking down were the cause of the low blood count.
23. The Trust considers there were no apparent features of active bleeding, and therefore no clinical indication to perform an endoscopy at the time Mr T was admitted based on the available criteria. Further to this, the Trust considers any bleeding prior to Mr T’s death was a consequence of liver failure, and an endoscopy earlier in his admission before he was reviewed by the gastroenterology consultant, would have sadly made no difference to the ultimate outcome.
24. We have carefully considered this part of the complaint with our adviser. We first considered if there were indications within the records that the medical teams took Mr T’s medical history into account when he was admitted into hospital.
25. During our review of the records with our adviser, we have identified several entries which clearly and fully document Mr T’s medical history, including his history of ulcers, upon his admission to hospital. We consider this is in line with the GMC’s Good Medical Practice guidance which says:
“15 - You must provide a good standard of practice and care. If you assess, diagnose, or treat patients, you 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)”
26. We then considered if there were any indications that the gastroenterology team missed any signs or symptoms of a gastrointestinal (GI) bleed, and whether there were any indications a gastroscopy was required prior to Mr T’s death.
27. We will again refer to the GMC’s Good Medical Practice guidance, which says:
“15 - You must provide a good standard of practice and care. If you assess, diagnose, or treat patients, you must:
• Promptly provide or arrange suitable advice, investigations, or treatment where necessary • Refer a patient to another practitioner when this serves the patient’s needs”
28. Our review of the records suggests there were no indications an endoscopy was required, as this is only useful in situations where there is proven GI blood loss. We can see from the records that there were no signs of GI bleeding, prior to the hematemesis on the night of Mr T’s death.
29. Signs of GI bleeding can include black stools, bright red blood in vomit, cramps in the abdomen, tiredness, paleness, and shortness of breath. We can see the clinicians assessed Mr T thoroughly, noting that he had not had any episodes of vomiting, and had not passed any black stools. Mr T reported abdomen pain, and the notes suggest the cause of this was thought to be distension due to the ascites. This is supported by entries which state Mr T reported his abdomen pain had decreased following a drain of the fluid, and that he felt more comfortable. We consider there are indications the assessments throughout Mr T’s admission excluded GI bleeding as a possible cause of his low haemoglobin levels in line with the GMC’s Good Medical Practice guidance.
30. Additionally, we can see that the clinicians had established an alternative cause for the anaemia which was haemolysis (red cell destruction) following discussion and input from the haematology team. Our adviser explained that this can occur on a background of severe alcohol related liver disease.
31. Our adviser also observed that Mr T had a very severe liver failure, and his alcoholic hepatitis was severe upon admission. The cause of death in someone with underlying cirrhosis and alcoholic hepatitis is usually multi-organ failure.
32. Sadly, this is what was happening to Mr T. The records show us his renal function became very notably impaired by 20 September which indicates a significant deterioration. The vomiting blood which occurred on his final hospital day was a sign that multi-organ failure was now very advanced.
33. We understand that the only time Mr T had evidence of bleeding was when he suffered the vomiting episode, and at this point, he would not have been able to safely have an endoscopy. Therefore, it would not have been appropriate to offer this as a diagnostic test. Our adviser told us that because the bleeding was caused by multi-organ failure, even if an endoscopy had taken place, it would sadly not have changed the outcome of this case.
34. Overall, based on the evidence we have reviewed, we have not identified any indications of a service failure in the care and treatment provided to Mr T. There are indications that the team treating Mr T acted in line with the GMC’s Good Medical Practice guidance, and therefore, we will not be taking any further action on this part of the complaint.
35. We hope our review provides Mrs T with some reassurance about the care Mr T received. It remains that this was a considerably sad set of circumstances, and whilst we have not found any indications of service failure, this does not take away from the significant impact this has had on Mrs T and her family.
Complaint handling
36. Mrs T has raised concerns about the Trust’s response to her complaint. She tells us that despite the Trust arranging a meeting for her, the clinicians who attended were poorly prepared, were unfamiliar with the questions she had raised, and did not provide her with satisfactory answers. She also feels the written response did not address her outstanding concerns.
37. We have reviewed a copy of the Trust’s written response dated 6 June 2023 and a copy of the transcript of the meeting, held on 16 March 2023. Present at the meeting was a consultant, a matron, and a registered nurse, who each cared for Mr T during his admission.
38. The NHS complaint standards say that organisations should look for ways to resolve complains at the earliest opportunity. Staff should give a clear, balanced account of what happened based on established facts.
39. We consider all three clinicians appear to have spoken from their experience in caring for Mr T and when responding to Mrs T’s questions they have explained why certain decisions were made and why things happened the way they did. We consider this is in line with the NHS complaint standards as they have provided fair and open answers to the questions, based on their experience.
40. We take the same view for the written response, as the Trust has provided clear responses to the questions based on the information in the records, and the accounts from the staff involved in Mr T’s care. We recognise Mrs T may not agree with the response provided, but from an objective standpoint, the questions have been answered.
41. Despite this, we do consider there was a shortcoming in the complaint handling with regards to one of the questions Mrs T posed. Mrs T had asked a question about the medical examiner’s role and some conflicting information she had received about the cause of death.
42. We can see from the transcript that the clinicians answered this question within the limits of their knowledge. However, we consider it would have been beneficial for the Trust to either invite the medical examiner to the meeting to discuss Mrs T’s concerns, or to obtain a statement from them to answer Mrs T’s question with certainty. We understand why the response from the Trust left Mrs T without reassurances about the information she had received.
43. We discussed this with the Trust, and it has acknowledged it could have been more prepared for the meeting. It also acknowledged the distress this likely caused to Mrs T.
44. The Trust has developed an action plan to address this shortcoming, explaining that it will seek input and offer the attendance of the medical examiner to complaints meetings if it is needed in the future. If the medical examiner is unable to attend, the Trust will assure the family and provide feedback in readiness of a meeting to ensure it can respond to all of the concerns raised.
45. We are confident this will provide a better service to families raising complaints, and for this reason, we consider this indicates the Trust has acted in line with the NHS Complaint Standards in order to promote a learning culture to improve the service it provides.
46. We also identified a shortcoming in complaint handling in relation to the delays in providing Mrs T with a written response following the meeting on 16 March 2023. Mrs T received a recording of the meeting promptly but did not receive the response letter addressing her outstanding concerns until almost three months later, on 6 June 2023. We recognise how frustrating this must have been for Mrs T, and that she was not kept updated through this time.
47. The Trust’s complaints and concerns guidance (June 2020) states that it is required to deal with complaints efficiently and provide a timely response (point 3.5). The NHS complaint standards (summary of expectations) say that organisations should respond to complaints at the earliest opportunity and meet expected timescales. They should give clear timescales for how long it will take to look into the issues. Staff should discuss timescales with everyone involved in the complaint and agree how people will be kept informed and involved.
48. We discussed this with the Trust to understand the reasons for the delays. It explained that time was required to transcribe the audio from the meeting and has provided sincere apologies for the length of the delay in this case.
49. The Trust has provided us with assurances that it is committed to ensuring such incidents do not happen in the future. It has explained that after reflecting on the way it handled Mrs T’s case, it has highlighted areas where it can improve and work to enhance its communication processes.
50. Similar to the previous point, the Trust has developed an action plan to address this shortcoming. The Trust has said it will continuously monitor the effectiveness of these measures to ensure they are properly implemented and make further improvements as necessary. It also commented that Mrs T’s feedback has been invaluable in enhancing the care and communication practices with families during difficult times.
51. We are assured the Trust has acted in line with the NHS Complaint Standards and has taken proportionate action to put things right in this case. For this reason, we will not be taking any further action on this part of the complaint. We hope the changes made by the Trust provide Mrs T with some reassurance that the service will improve and that by raising her concerns, she has contributed to this greatly.