Transferred Mr J from DM Hospital to BA Hospital on 18 July 2019 when he was too unwell to be moved and whilst he still required significant care and treatment for his discitis and spinal infection
11. The GMC guidance states clinicians:
‘must provide a good standard of practice and care. If you assess, diagnose or treat patients, you must:
• adequately assess the patient’s conditions
• promptly provide or arrange suitable advice, investigations or treatment where necessary
In providing clinical care you must:
• provide effective treatments based on the best available evidence.’
12. Mr J was admitted to DM hospital on 27 June 2019 suffering with left sided back pain. The Trust performed an initial CT scan which identified discitis. The Trust started treatment with intravenous antibiotics on 12 July 2019 and planned the treatment to continue for the next six weeks. The records indicate Mr J had retained secretions (a build-up of excess phlegm) and a further CT scan on 18 July 2019 identified a collapsed left lung. The Trust deemed Mr J fit enough to be transferred to BA hospital to continue his antibiotic treatment and recovery.
13. Our adviser said there is no evidence in the records to indicate Mr J was too unwell to be transferred on 18 July 2019. His symptoms and conditions at this time would not indicate that a transfer to a different hospital would be inappropriate and the records of his observations in the days leading up to the transfer were unremarkable. There are no reports in the records of Mr J suffering with fever or high temperature and his national early warning score (a system used for scoring physiological measurements routinely recorded at a patient’s bedside) indicated he was deemed to be at low risk of an imminent deterioration in his condition at this time.
14. The records indicate Mr J’s CRP (C-reactive protein, a protein found in the blood which increases in response to inflammation in the body) level was rising prior to the transfer. However our adviser said his recorded CRP level immediately before the transfer (77 on 16 July 2019) is not of a level which would prevent transfer to a different hospital. Our adviser said many patients with CRP of that level would be safely treated as an outpatient.
15. Our adviser said as Mr J was being transferred for continuation of his care and treatment, to a hospital environment with acute care available, it was reasonable to continue with the transfer.
16. We carefully considered Ms K’s complaint and the supporting information she has provided. We also considered the information in the records, the guidance and the advice we have received. We acknowledge Ms K’s concerns about the transfer to BA Hospital in light of the deterioration her father suffered after the transfer was carried out.
17. We found the Trust acted in accordance with the GMC guidance when assessing Mr J’s condition and deciding to transfer him to a different hospital to continue his treatment. The decision to transfer him can be supported by the information in the records during the days leading up to the transfer.
18. We found no evidence to indicate Mr J was too unwell to be moved or that the Trust’s decision to transfer him to a different hospital was inappropriate. We found no evidence to indicate Mr J needed to remain in DM Hospital at this time to continue his treatment.
Failed to provide the treatment he needed for his significant conditions following his transfer to BA Hospital
19. Following his transfer to BA Hospital the Trust continued Mr J’s antibiotic treatment for discitis and spinal infection. The records indicate he was not seen by a doctor over the weekend of Saturday 20 and Sunday 21 July 2019. However the Trust did carry out urinalysis (a test that checks urine for blood cells, proteins and other substances which may indicate signs of infection or other health conditions) on 20 July 2019. The test was positive for nitrites (a sign of bacteria) and leukocytes (white blood cells) in Mr J’s urine.
20. Our adviser said these findings indicate a probable urinary tract infection (UTI) and the NICE UTI guidance recommends treatment with urinary antibiotics in such circumstances if a patient has symptoms. However there is no record of the Trust taking any additional action or prescribing and treating Mr J with urinary antibiotics at this time in the information provided to us by the Trust.
21. The records indicate the Trust reviewed Mr J on 22 July 2019 and reported him to be very sleepy, cold and clammy to touch and he was found to have discharge from his penis. A sample of this discharge was sent for tests and the Trust reviewed him again later that day and reported him to be drowsy, unwell, cold and clammy.
22. The Trust diagnosed ‘acute urinary retention’ and recorded Mr J to be ‘acutely drowsy secondary to infection’. The records indicate the Trust promptly provided treatment with intravenous piperacillin with tazobactam (antibiotic medication that can act against a wide range of bacteria, usually used when the specific bacteria causing an infection is unknown). The records indicate the Trust transferred Mr J back to the emergency department at DM Hospital on 22 July 2019.
23. Our adviser said the information in the records provided to us by the Trust indicate the initial signs of infection in Mr J over the weekend of 20 and 21 July 2019 were not acknowledged or acted upon by the Trust. His urinalysis suggested a UTI but there is no evidence to indicate any action was taken by the Trust. When Mr J was subsequently reviewed on 22 July 2019 his condition had worsened considerably requiring transfer to the emergency department at DM Hospital.
24. Our adviser said the evidence in the records provided to us by the Trust indicates there was a potential opportunity for the Trust to recognise the early signs of deterioration during the weekend of 20 to 21 July 2019. Our adviser said it is possible earlier recognition of the initial signs of deterioration may have led the Trust to review Mr J’s treatment plan and provide additional treatment in BA Hospital or transfer him back to DM Hospital sooner for additional treatment.
25. Our adviser said the records confirm the results from the tests of the discharge sample taken on 22 July 2019 identified Klebsiella pneumoniae, a bacterial infection which in this case was resistant to most commonly used antibiotic medication and which would have required specific treatment with meropenem (an intravenous antibiotic usually used to treat severe infections of the skin, stomach and bacterial meningitis).
26. Our adviser said the results of such a test would usually take several days for the laboratory to complete and for the results to be returned to the doctors. The records indicate the results of Mr J’s sample test were only available to the Trust on 27 July 2019, after Mr J had died. Our adviser said in light of this finding it is possible, even if the Trust had recognised the early signs of his deterioration sooner and arranged further treatment or earlier transfer back to DM Hospital, it may not have changed Mr J’s outcome due to the resistant nature of the bacteria.
27. We carefully considered Ms K’s complaint and the supporting information she has provided. We also considered the information in the records, the guidance and the advice we have received. We acknowledge Ms K’s concerns about the care and treatment provided to her father by the Trust in BA Hospital her account of the distressing nature of the deterioration her father suffered during his time there.
28. We found the Trust failed to identify and act on the initial signs of deterioration in Mr J’s condition over the weekend of 20 to 21 July 2019. This is not in keeping with the GMC guidance and led to a missed opportunity for the Trust to consider additional treatment or transfer Mr J back to DM Hospital sooner.
29. We cannot say that this failing has led to the injustice claimed by Ms K. There is insufficient evidence to indicate that if it was not for this missed opportunity Mr J’s condition wouldn’t have deteriorated at this time. There is insufficient evidence to indicate this missed opportunity directly caused Mr J’s death. Mr J was extremely unwell at this time, had significant comorbidities (existing chronic health conditions) and was suffering with a severe infection of unknown origin.
30. However we acknowledge that as a result of the missed opportunity to identify the early signs of deterioration sooner, Ms K is left with uncertainty about the possible impact earlier intervention may have had on her father’s condition.