24. Before we decide if we should conduct a detailed investigation of a complaint, we look at whether there are signs the organisation has got something wrong. We do this by comparing what should have happened with what did happen.
25. Before looking at Mr A’s concerns in detail we note that the care in question happened on Christmas Day. This is a time when emergency services will be under particular pressure. While we believe this means we should make some allowances when considering the general experience as a patient, but fundamental standards of safe care should still be maintained.
26. The bar for us to investigate in more detail would be if there are indications established guidance or standards had not been followed. If we see indication, we would then look to see if there is evidence of an impact or injustice flowing from that failing.
Wrongly being placed on a trolley with no bedding 27. As outlined above, Mr A’s records show that a referral was made to the AMU to request a bed but there were not any available due to high pressures on the services on Christmas Day.
28. Our adviser explained A&E departments generally don’t have beds and most are equipped with trolleys for patients to lie on. Therefore, it would not be ideal for Mr A to be placed on a trolley, but this would be what would usually be available in A&E. They also noted that, as it was Christmas Day and the Trust’s resources were under exceptional pressure at the time, hospitals have to prioritise patients by level of need in such situations.
29. Mr A’s medical records indicate that, while he was suffering from a fever, he was fully conscious and able to mobilise. We can establish his level of clinical need from his NEWS scores, a system based on vital sign observations used for establishing the severity of a patient’s illness and how urgent the need for intervention is.
30. Mr A’s score was six (medium) initially when the ambulance arrived at his home. This had lowered to three by the time he was awaiting admission to A&E following the ambulance crew’s initial assistance. Following admission his scores were calculated seven times, and they were not higher than three (moderate) at any point. While not wishing to diminish how worrying and distressing Mr A’s situation was for him at that time, this is reassuring.
31. The Trust confirmed to us that there are a limited number of beds in its A&E but, on that night, these were all occupied by severely ill patients. There was no alternative available despite the A&E staff trying to locate an available bed for Mr A. We were unable to identify a standard relating to bed provision, so we think it is reasonable to give higher priority to patients with more severe acute need.
32. Based on this we cannot say Mr A was wrongly placed on a trolley. We recognise this was not ideal and very uncomfortable for him, especially as he suffers back pain. We do not consider there was any other option at the time, and his discomfort would not have led to any lasting harm. This appears to be the best that the Trust could offer so we do not consider this indicates a failing in care.
A doctor who did a prostate examination did not complete a report
33. Mr A says that due to a lack of proper documentation regarding a prostate examination performed in the emergency department his GP had to perform another two examinations when he became ill again sometime later. He says these were humiliating and avoidable.
34. Mr A’s medical records show the emergency department (ED) doctor documented a prostate examination, stating ‘PR examination: NO tenderness noted over the prostate.’ Our adviser explained that the reason for this examination was to confirm/exclude prostatitis (an infection within the prostate). They said this, or a urinary tract infection (UTI), was the initial suspected cause of his illness and as the treatment regimens would be different for each, it was necessary to perform the examination.
35. Our adviser explained that, in line with NICE CKS on when to suspect acute prostatitis, Mr A’s symptoms could have matched that cause, and an examination of his prostate would therefore be required to check for signs of this.
36. GMC Good Medical Practice requires that doctors should ‘Keep clear, accurate and legible records.’ A lack of tenderness in Mr A’s prostate ruled out a diagnosis of prostatitis at that time and allowed the doctors to diagnose a UTI as the cause of his illness instead. Therefore, what was written in the medication records provided all the key information required to explain why prostatitis was ruled out as a potential diagnosis.
37. A UTI (which was confirmed as the cause of the sepsis later in the sample results) requires a one-week course of antibiotics, which is what Mr A was provided with upon discharge, in addition to the antibiotics given by injection during his admission.
38. Our adviser also noted Mr A’s GP records show his GP was aware of the reason for the examination done in A&E, and why it was done. They explained that the later prostate examinations performed by the GP appear to be necessary as Mr A was suffering urinary symptoms again. Prostatitis would again have been a potential diagnosis and need to be confirmed or ruled out in the event of a reoccurrence of an infection.
39. We note that these later examinations also did not indicate any tenderness. This, along with the results of the urine sample cultures from the A&E, is reassuring. It strongly indicates a UTI, not prostatitis, as the diagnosis on each occasion and that the correct diagnosis was made at the time of Mr A’s admission to hospital.
40. We appreciate that Mr A may have thought a more detailed report of the examination was needed and this may have rendered later ones unnecessary. The evidence indicates the ED doctor did a report, this was documented properly, and had no influence on the need for repeated examinations later.
Fluid intake and output was not monitored 41. Mr A was given a total of two litres of fluids over the course of his 15-hour admission to hospital. This was provided to help rehydrate him following his recent illness. We note he was able to mobilise and use the toilet if he needed to, and he did not need to be catheterised. There is no medical note that identifies a clinical reason for monitoring his fluid input or output.
42. We were unable to identify any specific requirement in NICE NG51 about all patients with suspected sepsis requiring mandatory fluid balance monitoring. The guidance states:
‘Alert a consultant to attend in person if an adult, child or young person aged 12 years or over with suspected sepsis and any high risk criteria fails to respond within 1 hour of initial antibiotic and/or intravenous fluid resuscitation. Failure to respond is indicated by any of: • systolic blood pressure persistently below 90 mmHg • reduced level of consciousness despite resuscitation • respiratory rate over 25 breaths per minute or a new need for mechanical ventilation • lactate not reduced by more than 20% of initial value within 1 hour.’
43. Based on this we looked for these signs in Mr A’s clinical observations from his admission, which may suggest his condition did not get better. Mr A’s observations indicate his clinical condition improved steadily over this time following treatment with antibiotics and fluids. As this shows Mr A responded to treatment and no escalation to a consultant was required, it is reasonable to conclude that there was no indication he required close monitoring of his fluid balance.
44. We are unable to identify any risk of harm due to over, or under, hydration. There is no reference in the NICE guidance above to fluid balance monitoring being necessary for a patient with sepsis. Mr A is correct that his fluid balance was not monitored.
45. There is no indication in the records or the guidance that this was needed. We understand how a lack of such monitoring will have been concerning to Mr A if he had expected it. We hope that we have provided some reassurance on this point.
Sepsis was not treated in a timely way in line with national guidance 46. As outlined in the events described above, Mr A entered the ED department at approximately 10.46pm and almost immediately a sepsis screen was done with tests ordered to check for signs of sepsis.
47. Blood gases were taken at 11.22pm and reported at 11.12pm identifying high lactate. This is a flag for sepsis and the first clinical sign the Trust had to act upon. Doctors prescribed antibiotics at 11.15pm and given via injection at 11.20pm. Also, the nurses started IV fluids at 11.20pm.
48. NICE NG51 guidance states antibiotics and fluids should be given ‘within 1 hour of meeting a high-risk criterion in an acute hospital setting’. Therefore, the hour in Mr A’s case would start from when medical team identified high lactate at 11.12pm.
49. Our adviser also provided some reassurance the medical records show that Mr A was in the early stages of developing sepsis. While at serious risk of becoming very unwell, they said the records indicate he was treated and responded well before the condition progressed to anything more serious.
50. Specifically, the adviser explained there was only one flag for sepsis upon admission and an absence of clinical signs associated with severe sepsis described in NICE NG51 guidance. We also note the seven sets of clinical observations recorded over the course of Mr A’s stay, along with the medical notes, show his condition stabilised and steadily improved.
51. Mr A received treatment of antibiotics and fluids within eight minutes of sepsis signs being detected, and well within an hour of arrival in the ED. The evidence indicates the medical team treated him in a timely way, and in line with national guidance.
An incorrect IV drip, which was not high enough or with a pump, was used for his antibiotics 52. Mr A’s medical records show that an IV drip of one litre of saline fluids to rehydrate him following admission started at 11.20pm and this finished at 12.14am. We note another litre of IV fluids completed later in his admission before he was allowed to go home.
53. This indicates the prescription was completed. Mr A received the full prescribed fluid therapy, and so the drip was not ineffective. Mr A explains that his IV stand was not high enough and he was instructed to lower his arm so the gravity feed of his IV fluids would be effective. We recognise was partly due to him having adjusted his position on his trolley. This must have contributed to his frustration, discomfort and upset.
54. The Trust explains pumps are not always used to deliver IV fluids. It accepts there was not a suitably tall drip stand available at that point and apologised for this. The Trust explains this was due to service pressures at the time, and it has since acquired new equipment to increase the availability of taller drip stands. Nonetheless this does not appear to have prevented adequate delivery of the fluid treatment.
55. Mr A was also concerned that an ineffective drip hindered him getting sepsis treatment. The records and advice we obtained, establish his antibiotics were administered by injection.
56. IV treatment was provided to aid Mr A’s rehydration, in line with the NICE NG51 guidance. He had already received antibiotics to tackle the sepsis and UTI. Effective sepsis treatment for his infection was therefore not dependent on the efficiency of the IV drip, but we recognise he would not have known that at the time.
57. As such, Mr A’s antibiotic treatment was not affected by the IV drip, which was a separate treatment. Also, while not ideally delivered, his IV drip treatment was not incorrect or ineffective and consistent with recognised guidance on how to treat sepsis. We have not seen serious concern with this area of Mr A’s care and treatment.
He was not offered sufficient food and drink during his admission 58. The Trust records indicate nursing staff offered food and drink to Mr A periodically during his time in the ED. The medical records are consistent with the account provided in its responses. Mr A disputes this account and says he was left feeling hungry.
59. We recognise that, ideally, patients will have a more comfortable admission with food and drink offered. We recognise that Mr A was unhappy with the food offered to him. We also recognise it was Christmas day evening and resources were clearly very stretched in the emergency department.
60. Our adviser says they see no indications of any ill effect on Mr A from a lack of food. They explain that Mr A’s admission was short, some 15 hours, and the time would not be sufficient to cause harm in the event he ate nothing. Mr A was provided with two litres of IV fluids so this would provide sufficient hydration for that period in the event he drank nothing.
61. We are unable to form a view on this point due to insufficient evidence. Staff’s priority, rightly, was to ensure Mr A’s sepsis and UTI was addressed. This included rehydrating him with fluids, which the evidence supports was done. We are reassured that, in the event food and drink offerings were not satisfactory, there would be little chance of any adverse clinical impact.
He was not given sufficient pain relief for his back pain 62. Mr A took one gram of paracetamol at 8.30pm before boarding the ambulance according to the service’s records. We have no information on how long before this point he had taken his last dose of his own medications. He was provided gabapentin at 5.12am the day after, paracetamol at 9.20am, and he was then discharged at 1.02pm.
63. The notes taken in the A&E record Mr A’s regular regimen of medication included up to seven 300mg doses of gabapentin per day. Our adviser noted is a very high dose which indicates Mr A was possibly used to needing a lot of pain relief. They also noted that what he received during his admission would be less than that but staff would not necessarily be aware of this in a fast moving busy environment.
64. However, our adviser noted Mr A did not appear to be reporting pain. They advised that if there is evidence of a patient reporting pain and staff not responding to that, this may indicate something has gone wrong, but we have not seen evidence of this here. If the pain levels recorded show a zero, this also indicates staff believed he was not in pain.
65. We note the Trust’s responses apologise if staff did not realise Mr A needed more pain relief and this would have been provided if they did.
66. Mr A’s records show regular pain scores were recorded. There are seven sets of observations following admission, all of which show a pain score of zero out of 10. This suggests that staff understood Mr A was not reporting pain, or that he was asking for more pain relief.
67. Mr A disputes this account, and says he was left suffering with his chronic back pain flaring due to being left in discomfort on a trolley. We recognise that this must have been difficult to experience.
68. There is clearly a difference in accounts here and we have contradictory evidence on what happened. In this case, it would not be possible for us to prove, or disprove, either viewpoint with the evidence available. We do not doubt that Mr A was in pain, but we cannot say there are indications staff knew this and refused him pain relief. For this reason, we cannot reach a view on what happened here.
He was not properly assessed and investigated before being discharged home.
69. Mr A’s key concern is that his illness was not properly treated before he was allowed home, and this later led to a series of health problems that caused his health to ‘fall off a cliff’. Mr A has told us his general health has of late been worse and his A&E admission occurred around the start of this.
70. Our adviser said the prostate examination and subsequent urine culture results provide a balance of evidence to establish Mr A did not have prostatitis, he did have a UTI, and the UTI infection was a strain of E. coli which was sensitive to the antibiotic Mr A was treated with. His tests results for COVID-19 and any blood born infections were also negative which indicates no presence of any infection beyond the UTI.
71. Based on the above, we consider Mr A was properly assessed, investigated, and treated, before a doctor cleared him to be discharged home. Our adviser says was unable to identify any benefit to keeping him in hospital as he was clinically well enough to leave.
72. This seems particularly the case since, due to the time of year and the pressures on resources at that time, there was no bed available. Mr A would have gained no medical advantage from staying in hospital but would have suffered more discomfort.
73. GMC good medical practice required that doctors ‘refer a patient to another suitably qualified practitioner when this serves their needs.’ The Trust appears to have met this standard by informing Mr A’s GP of his admission upon his discharge home form A&E.
74. Additionally, NHS England 'Hospital discharge and community support guidance' – Annex D, provides specific criteria to guide decision on whether a patient should be kept in hospital or not.
75. This states: ‘If the answer to each question is ‘no’, active consideration for discharge to a less acute setting must be made: • requiring ITU or HDU care?
• requiring oxygen therapy/NIV?
• requiring intravenous fluids?
• NEWS2 greater than 3? (clinical judgement required in persons with atrial fibrillation and/or chronic respiratory disease) • diminished level of consciousness where recovery realistic?
• acute functional impairment in excess of home or community care provision?
• last hours of life?
• requiring intravenous medication > b.d. (including analgesia)?
• undergone lower limb surgery within 48 hours?
• undergone thorax-abdominal/pelvic surgery with 72 hours?
• within 24 hours of an invasive procedure? (with attendant risk of acute life- threatening deterioration)
76. At the point of discharge, Mr A did not meet any of these criteria and so, in line with the guidance, he was discharged to a less acute setting.
77. While we have not seen that anything went wrong in how he was assessed and treated, Mr A may find it helpful to learn that we asked our adviser to review Mr A’s GP records to see if there was any evidence to suggest it was inappropriate for him to be discharged back to the care of his GP. They considered whether there are indications his health issues recorded over the subsequent year suggest he was discharged too early.
78. Our adviser noted that some of Mr A’s later health problems were pre-existing conditions, such as degenerative changes in his back and knee leading to a gradual loss of mobility and fitness, and some bladder difficulties that had been developing in the weeks prior to his admission. Some new conditions appear to centre on ear and nose problems such as inner ear and sinus infections, mouth ulcers and a discoloured tongue.
79. Our adviser said these are not associated strongly with post sepsis complications, and there appear to be other more feasible causes for these illnesses documented in the GP records.
80. Our adviser said post-sepsis syndrome health complaints, as outlined in ‘Recovery after Sepsis & Post Sepsis Syndrome’ by The UK Sepsis Trust, are wide and may be physical, psychological and/or cognitive. These problems can affect around 40% of sepsis sufferers and are common, including repeated infections from the original site.
81. However, they said they are more likely in cases where sepsis has been severe or life-threatening and associated with significant effects on the body, which would have meant Mr A was unable to leave hospital in such a short time had he suffered those. As Mr A appears to have suffered a mild or early bout of sepsis, they said it is unlikely, on balance of probability, that his later health issues are linked to that illness.
82. We hope this advice is reassuring for Mr A. The available evidence indicates he was properly assessed and investigated before being discharged home at the appropriate point back to the care of his GP.
In summary 83. We that the detailed analysis of Mr A’s admission set out above provides reassurance that he received the right care for his UTI and sepsis.
84. Mr A says he suffered avoidable suffering and distress. While any trip to A&E is likely to be distressing, from the account he has shared with us, he did experience more discomfort than we would normally expect in such a trip to A&E. However, this was not a normal scenario. It was Christmas day and there were clearly exceptional pressures on staff and services. We do not consider the discomfort he has told us about indicates a significant service failure and the Trust has acknowledged and apologised for this aspect of his experience.
85. The key duty of the Trust was to ensure Mr A was treated for his illness as a priority. The evidence indicates he was treated effectively, and he got better. This would not rule out later illnesses. The Sepsis Trust guidance outlines, repeat infection of the same kind can be a common occurrence. Suffering a UTI later is not suggestive of inadequate treatment for prior infections.
86. We understand how Mr A may have been concerned that poor care led to him suffering worsening health problems later. While we have not seen indications of failings of this kind. His care was provided in line with recognised national standards, and the available evidence does not indicate any failings happened. For this reason, we have decided we should not consider the complaint further.