A&E treatment 30 May 2022:
17. Mrs A says A&E staff incorrectly moved her husband to the medical decisions unit (MDU) following a rectal (PR) bleed on 30 May. She says he was already in a bay receiving fluids when they decided to send him to MDU. He then had a further bleed, so MDU staff sent him back to A&E where he was placed in the waiting room and not monitored. She says they had to manage the bleed themselves in the public toilet.
18. The Trust said when clinicians decided to transfer Mr A to MDU, he was stable and there was no active bleeding. It says the team made this decision to try and get Mr A seen more quickly and directly by the medical team. It acknowledged the clinical team should have addressed Mr A’s bleeding when he was sent back to A&E, and Mr and Mrs A should not have had to manage this themselves.
19. The notes show Mr A attended A&E on 30 May and a doctor assessed him at 6:11am. The doctor recorded a relevant history, examined Mr A, organised for him to have investigations, and administered appropriate treatment. Our A&E adviser told us this is in line with paragraph 15 of GMC Good Medical Practice Guidance which states doctors must:
a.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 b.promptly provide or arrange suitable advice, investigations or treatment where necessary c.refer a patient to another practitioner when this serves the patient’s needs.
20. Clinicians then decided to transfer Mr A to the MDU for further assessment by the acute medical team. Our A&E adviser explains decisions relating to the facilities where patients are seen and then moved to, are based on local Trust policy and there are no national guidelines on this. Each Trust organises patient flow in a way that is bespoke to that Trust.
21. Since the date of these events, the Trust’s MDU has expanded and become the Medical Assessment Unit (MAU). The Trust has provided us with its current policy dated April 2023 which sets out the criteria and process for admission to the MAU. The Trust says it cannot locate a finalised copy of an earlier version of this policy that would have been in place in May 2022. There are several ‘exclusion criteria’ listed in the 2023 policy which would mean a transfer from A&E to the MAU was unsuitable. This includes if the patient is unstable for transfer.
22. Our A&E adviser says it appears a senior A&E clinician made the decision to transfer Mr A to the MDU at a time when his condition was stable. His observations were normal, and he was receiving intravenous fluids. Our A&E adviser says there is nothing in the records to suggest Mr A was not fit to transfer to another acute facility within the hospital at this point. We are therefore not critical of this decision.
23. The records show Mr A had another episode of rectal bleeding shortly after arriving on the MDU, and clinicians decided to send him back to A&E.
24. The next entry in the medical records is the A&E doctor’s assessment at 12pm. It appears from Mrs A’s recollection and the Trust’s response; Mr A was left in the A&E waiting room for some time after being sent back from MDU.
25. The Trust explained the A&E department was under considerable pressure at this time and that there was no capacity in A&E to move Mr A straight into a cubicle due to the high volume of patients. Our A&E adviser says Mr A should not have been left in the waiting room without monitoring whilst having a rectal bleed. In recent years A&E’s nationally have been under extreme pressure due to a combination of factors including staffing issues, ever increasing attendances, the continuing effect of the COVID-19 pandemic and the lack of in-patient hospital beds to move patients to.
26. We are not critical of the Trust’s decision to move Mr A to the MDU for further assessment when he was in a stable condition. Clinicians could not have foreseen that Mr A would have another bleed and need to go back to A&E, by which point there were no beds immediately available.
27. Whilst we are mindful of the pressures and the context of the resource difficulties all A&E departments are under, Mr A should not have been left in the waiting room whilst having a PR bleed when he was sent back to A&E. We consider this is a failing.
28. We do not doubt how traumatic and worrying it was for Mr A to have to manage his PR bleed without clinical help. We are very sorry he had to experience this, and Mrs A had to witness and help with this. We understand Mrs A says this experience made her husband delay seeking additional treatment as he did not want to attend A&E again. We can understand why Mr A may have felt that way and that the distress both he and Mrs A experienced would have left them feeling negatively about hospital, but we cannot hold the Trust responsible for his subsequent decision to delay seeking treatment.
29. NHS complaints standards say ‘an effective complaint handling system makes sure staff take a thorough, proportionate, and balanced look into the issues raised in a complaint. It gives people fair and open answers to their questions based on the facts, and takes full accountability for mistakes identified…. wherever possible, staff explain why things went wrong and identify suitable ways to put things right for people. Staff give meaningful and sincere apologies and explanations that openly reflect the impact on the people concerned’.
30. We recognise this experience caused Mr and Mrs A distress and worry. The Trust has acknowledged it should have addressed Mr A’s bleeding when he was sent back to A&E and explained about the resource difficulties it was experiencing. It has apologised for Mr and Mrs A’s experience and said it is sorry for the distress the transfer caused. This is in line with the NHS complaints standards We are pleased to see the Trust has made some service improvements since these events. We do not think it has yet done enough to put this right and make a recommendation at the end of this report.
Admission on 27 June
31. Mrs A says clinicians did not explore any active treatment options for her husband when he was admitted to hospital on 27 June. She says clinicians at another hospital in Birmingham had told them he may be eligible for a liver transplant in the future if his condition improved, but she feels like the Trust just gave up on him.
32. The Trust said dialysis (a procedure to filter blood when the kidneys fail) was not an option for Mr A due to his clinical condition, low blood pressure and co-morbidities. It said due to Mr A having multi-organ failure, an intensive treatment unit (ITU) admission would not have reversed this or changed what happened.
33. The notes show Mr A was admitted to hospital on 27 June with kidney failure, ascites and fluid overload. Fluid overload is when there is too much fluid in the body, and it can cause damage to organs. Clinicians treated this with volume replacement to restore the necessary fluids to the body (human albumin and terlipressin). Doctors arranged for Mr A to have a kidney ultrasound and a CT pulmonary angiogram to investigate the cause of his obstructed urine flow and breathlessness. A pulmonary angiogram checks the blood vessels supplying the lungs.
34. The European Association for the study of the liver (EASL) guidelines say ‘if there is kidney failure its cause should be identified and managed accordingly… volume expansion should be given to patients with fluid loss or in the setting of spontaneous bacterial peritonitis (SBP). Excessive volume expansion should be avoided. Patients meeting the criteria of AKI-HRS (hepatorenal syndrome) should be treated with terlipressin and albumin or nore-epinephrine, if terlipressin is not available’.
35. Our hepatology adviser told us the Trust’s treatment of Mr A’s kidney failure associated with liver disease was in line with the EASL guidelines. Clinicians treated his fluid overload appropriately with albumin and terlipressin and the acute renal failure team reviewed Mr A promptly and considered all treatment options. Dialysis to treat the kidney failure was not possible due to Mr A’s low blood pressure. Our hepatology adviser explained drugs to support blood pressure on dialysis can only be administered in an intensive care environment. Mr A was not suitable for intensive care escalation as he had an extremely poor prognosis from his liver failure with no potential option of liver transplantation in view of his clinical deterioration.
36. We understand a consultant from the liver transplant team at a different hospital in Birmingham had reviewed Mr A on 9 June 2022, when he was much better than when he arrived at hospital on 27 June. The consultant from Birmingham said in their clinic letter that Mr A would not survive liver transplantation at that time due to poor exercise tolerance, malnutrition, and frailty. The plan was to review him in six weeks’ time to see if he has made any nutritional improvements. Sadly, by 27 June, we can see Mr A’s condition had deteriorated further.
37. We appreciate this was an incredibly difficult and distressing time for Mrs A and their family. Very sadly, by the time Mr A was admitted to hospital, he was very unwell. From the evidence we have reviewed, we consider the Trust carried out appropriate investigations and considered treatment options in line with guidelines. We cannot see something went wrong here.
DNACPR:
38. Mrs A says clinicians discussed implementing a DNACPR, when her husband was alone and not supported by family.
39. The Trust said the consultant spoke with Mr A on 1 July to explain he was extremely unwell and there was a strong chance he would not recover. The Trust said it was sorry Mrs A was not present when this discussion took place, but the consultant confirmed Mr A had capacity to make decisions for himself and chose to have the conversation about his resuscitation straight away. It said it endeavours to involve family in these discussions, but it is, ultimately, the choice of the patient.
40. A DNACPR means if the patient’s heart or breathing stops the healthcare team will not try to restart it.
41. GMC guidance on treatment and care towards the end of life says:
131. If a patient is admitted to hospital acutely unwell or becomes clinically unstable in their home or other place of care, and they are at foreseeable risk of cardiac or respiratory arrest, a judgement about the likely success of CPR in restarting breathing and circulation and its benefits, burdens and risks should be made as early as possible.
132. As with other treatments, decisions made in advance about whether CPR should be attempted must be based on the circumstances of the individual patient and take into account their wishes and preferences. It should also involve discussions with members of the healthcare team as well as (with the patient’s agreement) those close to the patient.
133. If a patient lacks capacity to make a decision about future CPR, you must consult those close to the patient as part of the decision-making process.
42. The notes show clinicians updated Mrs A throughout her husband’s admission from 27 June onwards. Mrs A said she did not want her husband to be put on a ‘do not resuscitate’ notice on 29 June. When the treating medical team had excluded any reversible causes of Mr A’s clinical deterioration and had obtained opinions from other specialities, they made a clinical decision that in view of his continued deterioration despite treatment, further escalation of care would sadly be futile. The clinical prognosis and options were discussed with Mr A at 10:15am on 1 July, and he agreed with the opinion. Following this decision clinicians informed Mr A’s family. It is not clear from the notes whether the clinician gave Mr A the option of having family present when the DNACPR was discussed, although the Trust has stated this was the case.
43. Our hepatology adviser told us Mr A’s DNACPR was applied in line with GMC guidance, and it was appropriate based on Mr A’s poor prognosis, comorbidities, and rapid clinical deterioration despite treatment. Mr A had capacity to take part in the conversations regarding the DNACPR on 1 July 2022, and it was his choice to have the discussion right away.
44. We are very sorry to hear about Mrs A’s concerns about the implementation of the DNACPR. Given Mrs A’s concerns expressed on the 29 of June, it may have been preferable if the family had been present for the discussion of the treatment escalation plan and DNACPR, so they were aware what was happening. Overall, we can see the Trust acted in line with GMC guidance when discussing/ implementing the DNACPR, and we do not consider there is a failing here.