Medical records
17. Mr S complains the medical records are sparse and contain little information.
18. We requested the relevant records from the Trust. The records we received have multiple time periods missing. The Trust has confirmed it has no further records for the time period. The records have been difficult to review as they are incomplete, poor in quality, have minimal medical team documentation or explanations of decisions, lots of physiotherapy and nursing notes of little relevance, and do not contain any formal imaging reports. They also contained information from 2018 that was not requested.
19. Good medical practice, states ‘Documents you make (including clinical records) to formally record your work must be clear, accurate and legible.’
20. It also states, ‘clinical records should include: relevant clinical findings, the decisions made and actions agreed, who is making the decisions and agreeing the actions, the information given to patients, any drugs prescribed or other investigation or treatment, who is making the record and when’.
21. Both our oncology and our physician adviser commented the records did not contain all the required information. In the records we received notes were missing and in the wrong order. We have seen in the records Mr E’s admission was complicated by medical problems such as chest pain and diarrhoea. However, the medical notes are so poor it is difficult to determine if these were managed and treated appropriately and safely.
22. It has not been possible to fully understand the quality of the continuity of care between wards due to the poor records. Reviewing the totality of the records, we have been able to draw conclusions, but we can’t get the exact clear picture of Mr E’s care.
23. We understand how stressful it must be to not know exactly what has taken place while a loved one has been under the care of an NHS Trust. We were sorry to hear of Mr S’ experience.
24. We have found the records are not in line with Good medical practice. This is a failing. We consider the impact of this later in the report.
Cancer diagnosis
25. Mr S complains his father’s cancer was not picked up sooner by the Trust. He complains his father was an inpatient for 11 weeks and therefore the Trust should have picked up on his cancer sooner.
26. NICE guidelines, Suspected cancer: recognition and referral, lists cancer red flags. These include: • Unexplained weight loss (the guidelines recommend offering urgent investigation or a suspected cancer pathway referral) • Anaemia in patients over 60 (the guidelines recommend quantitative faecal immunochemical testing (a test designed to detect hidden blood in the stool)).
27. The Trust said there were no suspicions of bowel cancer. The Trust has said as there were no suspicions of bowel cancer, scans would not have been requested sooner.
28. The Trust said it did not consider Mr E fit for colonoscopy, due to his age. A colonoscopy is a medical procedure performed using a camera mounted on a flexible tube and passed through the anus.
29. It explained colonoscopies are only arranged for very fit people who are likely to be agreeable and able to withstand major surgery, should cancer be found or complication from colonoscopy occur. Therefore, the plan was to arrange an endoscopy (a long, thin tube with a small camera inside, passed into your body through a natural opening such as your mouth) to complete investigations for iron deficiency anaemia, treat the urinary tract infection, and then plan discharge.
30. The records show on 6 October, on admission, Mr E had a blood test which showed haemoglobin of 51 (the normal range for men is 14 to 18) and MCV (mean corpuscular volume, which indicates the average size of red blood cells) of 72.6 (normal range would be 80 to 100). Our physician adviser explained these results indicated chronic ongoing blood loss from somewhere in the body, usually from the gastrointestinal tract.
31. Mr E’s weight was recorded as 63.75kg on 29 October 2019. This is recorded on a Malnutrition Universal Screening Tool (MUST), which states, ‘to be completed on admission and weekly thereafter.’ There are no other weight recordings on this document. On this document it states there has been a weight loss of 5 to 10%. On 5 December 2019 his weight was recorded as 60.4kg, showing a weight loss of 3.35kg between October and December.
32. Mr E’s anaemia diagnosis is well documented throughout the records.
33. Mr E was experiencing consistent weight loss and he had a diagnosis of anaemia. In line with NICE guidelines, Suspected cancer: recognition and referral, these are red flags. Across his long admission in the Trust, Mr E did not appear to be improving. Our physician adviser explained this alongside his other symptoms are cancer red flags.
34. The consultant at the Trust, in a document to us, said, ‘although it was not documented in the entry, I was probably aware of the result of a previous CT scan’ of the chest, abdomen, and pelvis from 12 October 2018. The outcome of this CT scan was that no gross malignancy was demonstrated’.
35. We discussed this with our physician adviser who explained a CT scan over a year old is not sufficient to rely upon given the often progressive nature of cancer.
36. We understand how difficult it is to have a loved one in hospital, and it is natural to have questions about the care they received. At this time, we consider there were clear indications Mr E had red flag symptoms for cancer across the admission. While he was not medically fit for a colonoscopy or cancer treatment, he could have had a CT sooner if the red flags were picked up on. This would likely have led to an earlier cancer diagnosis. We consider this a failing. We consider the impact of this later in our report.
Discharge
37. Mr S complains on the day of his father’s discharge from the Trust on 10 November 2019, he was severely dehydrated and should not have been discharged.
38. The Trust apologised for getting this wrong and for discharging the patient too early. The Trust said nurses and observation suggested Mr E was medically fit and safe to leave hospital, and that his X-rays and blood tests were normal with no signs of active urine infection. It acknowledged that in some cases turning points can be missed.
39. When discharging a patient from hospital the ultimate medical responsibility for the discharge of a patient lies with the consultant in charge of the patient’s care.
40. The Trust has provided us with a set of records. These are very limited and do not contain CT scan reports. Many of the documents, such as fluid balance charts, are only partly completed. Some of the notes record a weight but it is not clear on what date this measurement was taken, and so it is difficult to accurately track weight loss.
41. The records show Mr E was experiencing gastrointestinal problems which may have affected his overall hydration levels. Stool charts show diarrhoea from 20 October until the 2 November, then once daily until 8 November, then no further charted bowel motions.
42. Fluid balance charts in the records show Mr E’s oral intake was very poor. On 6 November, only 500mls of fluid was drunk, and only 100mls of fluid was drunk on 7 November.
43. It is difficult to understand from the records if the fluid intake is accurate or if the poor fluid intake is a reflection of the poor record keeping. The records show there is likely to have been dehydration occurring due to the poor fluid intake. We interpret the records as accurate, as records should be maintained accurately and correctly in line Good Medical Practice. This guidance states ‘You must make sure that formal records of your work (including patients’ records) are clear, accurate, contemporaneous and legible.’
44. We have seen the food charts in the records are inconsistently and poorly filled in, with no food charted on 9 November 2019. It is therefore difficult to understand Mr E’s food intake prior to his discharge.
45. In the notes on 5 December it shows Mr E’s creatinine (a chemical compound left over from energy-producing processes in muscles; healthy kidneys filter creatinine out of the blood) had risen to 105. Increased levels of creatinine can be caused by dehydration. The records show a plan for a blood test to be carried out the next day, but no further blood results are documented after this prior to discharge.
46. Our physician adviser explained it is likely Mr E was significantly dehydrated on the day of discharge. It is likely this had come about over the previous few days, and it could have been picked up by the clinical team in the days prior to him leaving. This would be an indication he was not fit for discharge.
47. Mr E returned to the Trust with acute kidney injury and severe lactic acidosis (a buildup of lactic acid in the bloodstream. Excess lactic acid is generally cleared by health kidneys and liver). Mr E’s lactate levels were 7.8 compared to the normal range between one and two. Our physician adviser explained this generally demonstrates poor circulation (although it has many causes, this is the most common).
48. There is no evidence in the records to suggest any communication with the family to explain why Mr E was seen as fit for discharge.
49. The General Medical Council ‘Good Medical Practice’ guidance state ‘in providing clinical care you must: a adequately assess a patient’s condition(s), taking account of their history, including i. symptoms ii. relevant psychological, spiritual, social, economic, and cultural factors iii. the patient’s views, needs, and values.’ There is no overall clinical assessment in the records prior to his discharge. This is not in line with the above guidance.
50. Our physician adviser explained it is likely that Mr E was significantly dehydrated on the day of discharge and that this had come about over the previous few days, and it could have been picked up by the clinical team in the days prior to him leaving.
51. We recognise how worrying it must have been for the family when Mr E had to be readmitted to the Trust so shortly after being discharged. From what we have seen, we believe there is a failing in the Trust’s decision to discharge Mr E in the condition he was in. From what we have seen Mr E was severely dehydrated and this would indicate he was unfit to discharge. We consider the impact of this later in the report.
Diagnosis and treatment plan
52. Mr S complains he did not receive any information regarding his father’s condition, his diagnosis, or his treatment plan.
53. The Trust acknowledges there was poor communication regarding investigation and outcomes. The Trust said it would share the complaint with the teams for learning.
54. NICE Clinical Guidelines 138 states NHS staff should:
‘clarify with the patient at the first point of contact whether and how they would like their partner, family members and/or carers to be involved in key decisions about the management of their condition.
if the patient cannot indicate their agreement to share information, ensure that family members and / or carers are kept involved and appropriately informed, but be mindful of any potentially sensitive issues and the duty of confidentiality.’
55. Additionally, Good medical practice states, ‘you must be considerate to those close to the patient and be sensitive and responsive in giving them information and support.’
56. The records show very little documentation of discussions with the family between 6 October and 10 November. We do not know whether this is because of the poor records or because discussions with the family did not take place.
57. There is one nursing entry on 10 October 2019 which states a discussion took place with Mr S regarding his father’s general health. This nursing entry details information Mr S shared with the Trust. No information appears to have been given to him regarding his father’s diagnosis or treatment plan during this conversation.
58. The records show on 13 December the senior house officer (SHO) spoke with Mr S on the phone. He raised some questions that she could not answer and the SHO suggested he come in earlier to speak with the team on the ward round.
59. On 16 December the records state, ‘detailed medical treatment and plans explained to son and daughter in law. No concerns raised’. No further information or detail is given in the records. It is not possible to tell how much information was given, or whether Mr S understood the diagnosis or treatment plan.
60. It is not possible to identify from the records what conversations took place and what was discussed. Mr S has explained they were not given information regarding his father’s care and treatment plan.
61. We understand how worrying it is when a loved one is in hospital and you are unclear about their condition or their treatment plan. There is no evidence to suggest communication was in line with NICE clinical guidelines or Good medical practice. We have found a failing in relation to this point. We consider the impact of this later in our report.
Complaint handling
62. Mr S complains the complaint handling was poor. He has explained he never received an explanation or response to the concerns he has raised. He explained he had a meeting in September 2021, but he did not feel this meeting answered his concerns satisfactorily.
63. NHS Complaint Standards set out organisations should:
Give fair and accountable responses that: • set out what happened and whether mistakes were made • fairly reflect the experiences of everyone involved • clearly set out how the organisation is accountable • give colleagues the confidence and freedom to offer fair remedies to put things right • take action to make sure any learning is identified and used to improve services.
64. The Trust told us the complaint went directly to a resolution meeting and there is a letter dated 24 September 2021, enclosing a table of meeting minutes and an action plan following the meeting.
65. In accordance with the NHS complains standards, fair and accountable responses should be provided. This can be in the form of minutes to a complaint resolution meeting and an action plan, which was provided.
66. We can see concerns raised were addressed during the complaint meeting which took place on 17 September 2021. Minutes were supplied in the form of a table of information which set out what was discussed, what action was agreed, what action will be taken, and a deadline. We understand Mr S’ concern that a formal complaint response was not issued in the form of a letter. We have found the complaint was responded to appropriately in line with NHS complaint standards.
67. We understand how difficult it can be to raise a complaint, and how frustrating it feels when you do not feel your complaint has been taken seriously, been fully considered and you feel you have not received a substantive response.
68. We understand Mr S felt there were still outstanding issues. We have seen the complaint handling in this case was in line with NHS Complaint Standards.
Impact
69. We have identified the following failings:
• The Trust did not identify red flag symptoms for cancer • Inappropriate discharge on 10 November 2019 • Poor record keeping • A lack of information given to the family
70. Mr S says his father was let down by the Trust. The poor records meant that there was no continuity of care between the wards, and he felt this affected his father’s care. He does not know why his father was discharged when he was, and he felt his father did not get the care he deserved. He is frustrated by what happened and this has been upsetting for the family.
71. We understand how important it is for family members to have questions answered about a loved one’s care. We have seen the records for Mr E’s care were poor. This means that Mr S cannot get a clear picture of his father’s care and will cause him to question further whether there was continuity of care between wards and if care could have been different for his father. This is likely to add distress and frustration at what already is a difficult time.
72. We have seen Mr E was not well on the day he was discharged from the Trust. We acknowledge it would be upsetting for Mr S to have his father discharged when he was unwell and then be readmitted again a few hours later. Given Mr E was only discharged for a short number of hours we cannot say overall it impacted his prognosis. However, being diagnosed with dehydration on readmission which was likely there before discharge would further compound feelings that the Trust had let Mr E down.
73. Our oncologist adviser explained that Mr E’s premature discharge from the Trust is not likely to have had an impact on his cancer. They explained that he was a frail, elderly gentleman who was not fit enough to undergo investigations or treatment for cancer if diagnosed. Therefore, the timing of his hospital discharge would bear no impact on his specific prognosis from either a diagnosed but untreated or undiagnosed cancer.
74. Being informed of prognosis and diagnosis is important for patients and their family. Had Mr E been diagnosed sooner the family would have had time to better understand his diagnosis and the care he was receiving. We understand to learn his father had cancer would have been upsetting for Mr S and cause him to ask questions why it was not diagnosed earlier. It likely would compound his feelings that his father was let down by the Trust.
75. We understand why Mr S feels father did not get the care he deserved. We can link the failings to the claimed impacts of frustration, upset, distress, and feeling let down.