Discharge on 25 October 2022
18. Mr E is unhappy with the lack of a care plan when surgeons discharged her mother from the Hospital following her hernia operation. He says, after the discharge his brother called the Hospital, and someone advised him there were no consultant review appointments for four months. He says his mother was left without support at home.
19. The Surgical Adviser told us there are no specific national guidelines regarding discharging and reviewing patients who have had hernia surgery of the type Mrs E had. It is a matter of the individual consultant’s clinical judgment about when someone should be discharged following surgery. However, doctors should take Good Medical Practice into account.
20. Good Medical Practice says doctors must provide a good standard of care. This includes carrying out adequate assessments, taking account of the patient’s history and examining them if necessary. Doctors should also arrange timely treatment and appropriate investigations or referrals if needed.
21. The Surgical Adviser said it would be expected that a patient ready for discharge would:
• be comfortable with oral painkillers if necessary • have normal or improving observations • have no active untreated infection • have appropriate support at home • have ‘safety netting’ advice regarding where to seek support if concerned.
22. The clinical records include a discharge summary from 25 October 2022. This shows the plan was for Mrs E to attend an outpatient clinic appointment in eight weeks with the surgeons and for her to continue antibiotics until 28 October. The nursing notes also show the plan was for an outpatient clinic in eight weeks. We can see no reference to appointments being unavailable for four months.
23. Mrs E’s observations on 25 October 2023 were normal. Nurses noted her wound was clean and she felt well with no pain. She was taking medication for her infection. The records also show she was given ‘safety netting’ advice. Mrs E was ‘keen to go home.’
24. An occupational therapist reviewed Mrs E on the morning of 25 October 2022. They noted Mrs E needed two walking frames and arranged for them to be delivered the same day. Physiotherapists had already reviewed Mrs E on the previous day and had no concerns. They noted she lived alone but had a supportive family.
25. The Surgical Adviser said the clinical records showed the criteria referred to above were met. They said a review in eight weeks was an appropriate for timescale Mrs E.
26. We find surgeons provided a good standard of care for Mrs E around the time of her discharge from the Hospital. They followed Good Medical Practice. Clinicians reviewed her home situation, her health and her mobility and considered it was safe to send her home. We recognise Mr E disputes this view. We can see no evidence to suggest Mrs E needed any additional support or that she needed a review at an earlier date.
Hospital attendances in November 2022
27. Mr E says his mother attended the Hospital several times in November 2022 because of problems with her surgical wound. He says even though she attended by ambulance doctors decided she did not need to stay in the Hospital.
28. The doctors who reviewed Mrs E when she attended the Hospital in November 2022 should have followed Good Medical Practice. This would have included taking her history, monitoring her observations and carrying out physical examinations.
29. We can see that Mrs E attended the emergency department at the Hospital twice before she was admitted on 17 November 2022. The first of these was on 8 November. Doctors in the emergency department took Mrs E’s history and referred her to the surgeons on call.
30. A member of the surgical team reviewed Mrs E early on 9 November 2022. They found there was no redness or tenderness, and the wound appeared to be healing well. There was no sign of any infection. The wound was oozing, and clinicians drained some of this. The surgeon noted they had a discussion with a consultant before deciding to send Mrs E home with a course of antibiotics.
31. The clinical records from 13 November 2022 show that a surgeon assessed Mrs E. They noted the wound was ‘discharging a lot.’ The surgeon removed the dressing and noted the wound was ‘gaping’ and discharging fluids. There was no evidence of any dead tissue at that stage, although the area was reddened. The surgeon reviewed photographs and took a wound swab. They advised Mrs E to complete the course of antibiotics and return to the emergency department if the skin started to turn black before the scheduled follow up appointment.
32. A consultant surgeon representing the Trust at one of the complaints meetings accepted that, ideally, a consultant surgeon should have reviewed Mrs E on 9 and 13 November 2022. The consultant surgeon accepted that when a patient reattends after surgery on two occasions this should be escalated to a consultant. They said if there had been a senior review, the surgeon may have admitted Mrs E to the Hospital on 9 November and would probably have done so on 13 November.
33. The consultant representing the Trust was not critical of the junior doctors who reviewed Mrs E because there was no requirement for them to escalate care based on her clinical observations at the time. They said the wound needed to be cleaned, but there was no indication this was an urgent matter. In any case, they considered the decision to wait until 17 November 2022 did not affect the outcome for Mrs E because her organs were functioning in the same way at that time.
34. In September 2023 the Trust wrote to Mr E to confirm it had acted following his complaint. It said it held a learning event with junior doctors to advise them they should arrange a consultant review for patients who return following hernia surgery where a mesh is in place.
35. The Emergency Medicine Adviser told us doctors in the emergency department would not normally be responsible for postoperative wound management. They would be expected to refer a patient to the surgical team. This is what happened on 9 November 2022. A doctor noted Mrs E’s history, arranged blood tests and referred her to the on-call surgeons. They followed Good Medical Practice in this respect.
36. The Surgical Adviser told us the records from 9 November 2022 showed Mrs E’s wound was healing nicely. They said necrotising fasciitis could not have been present. This condition develops quickly and was first considered eight days later. There was no need for a consultant surgeon to attend specifically to review the wound.
37. On 9 November 2022 Mrs E’s blood results and levels of CRP (a protein made by the liver. Raised levels of CRP show there is inflammation in the body) were normal. The Surgical Adviser said this was not complex surgery and the correct treatment was antibiotics with a clinic review in around a week.
38. The Surgical Adviser said the records from 13 November 2022 showed appropriate surgical staff reviewed Mrs E. They show Mrs E’s observations were again normal and her blood test results were satisfactory. The surgical team discharged Mrs E with a plan for an early review and ‘safety netting’ advice.
39. We recognise the Trust considers a consultant surgeon should have reviewed Mrs E during her attendances at the Hospital on 9 and 13 November 2022. However, there is no requirement, or any national guidance, for a consultant surgeon to review patients presenting as Mrs E did on those occasions. Clearly, this was a distressing time for Mr E and his family. Based on the evidence we have seen, including clinical advice, we find doctors followed Good Medical Practice.
Intensive or high dependency care
40. Mr E complains about a decision to transfer his mother out of intensive care. He understands this was because there were not enough beds. He believes doctors should have readmitted her to the ITU when her health worsened.
41. The Critical Care Guideline explains the different levels of care hospitals in the UK should deliver. It explains the differences between ward-based care, enhanced care (Level One) and critical care (Level Two and Level Three). The Hospital’s high dependency unit (HDU) is Level Two and the ITU is Level Three.
42. Doctors should also have followed Good Medical Practice, as explained above. Good Medical Practice also says doctors must refer a patient to another practitioner when this serves the patient’s needs.
43. The Trust has explained how it only admits patients who need organ support to the ITU. Mrs E did not need organ support on 4 December 2022, so doctors transferred her to a ward. It said this was also because two emergency patients needed to be admitted to the ITU.
44. The Medical Adviser told us that not all hospitals would step someone down to the HDU from the ITU. Often patients remain in the HDU or the ITU until stable enough to be moved to a standard ward, which is what happened to Mrs E. Patients will normally stay in Level Three care only if they need monitoring and support for two or more organs at an advanced level or need complex care for multiple organ failures.
45. The clinical records for Mrs E’s admission to the Hospital are for the most part detailed. Many different clinicians completed the records at the time of the events. They are consistent in terms of Mrs E’s symptoms, observations and treatment. We are persuaded the clinicians accurately recorded Mrs E’s admission. The exception relates to records about her hydration, which we will refer to later in the report.
46. The Medical Adviser reviewed the clinical records for Mrs E’s admission. They said clinicians removed the relevant invasive monitoring and treatment devices several days before Mrs E left the ITU. These included her central line (a cannula inserted into a large vein for monitoring or to provide medication), arterial line (a smaller cannula inserted into an artery to accurately monitor blood pressure) and tracheostomy (an opening in the neck to assist with breathing). The Medical Adviser said there was an adequate period of time for doctors to ensure her health was stable without those devices in place.
47. The clinical records from 4 December 2022 show Mrs E was able to breathe well and had a strong cough, meaning she could clear her airways. She was confused with delirium which was improving. The Medical Adviser said delirium can take several weeks to settle and staying in the ITU would have made this worse. However, Mrs E was calm and there was no clear reason for her to remain in the ITU. Doctors in the ITU provided a good written and verbal handover.
48. The clinical records show doctors followed the Critical Care Guideline when they transferred Mrs E to a ward from the ITU.
49. The clinical records show both the critical care outreach team (CCOT) and the ITU doctors reviewed Mrs E following her transfer to the ward. The Medical Adviser told us this was good practice. The doctors on the ward also carried out frequent reviews including examining the wound. On 7 December 2022 the ward team noted a deterioration in Mrs E’s condition. They arranged for a CCOT review which established she did not need organ support.
50. A doctor from the ITU reviewed Mrs E during the following night. They noted Mrs E was feverish, but her observations were otherwise reasonable. There was again no indication that she needed support from the HDU or the ITU. They restarted Mrs E’s antibiotics.
51. The Medical Adviser noted Mrs E had limited physiological reserve to withstand all the acute illnesses and surgery she had endured. The Medical Adviser said their impression is that Mrs E would have been very unlikely to survive a second admission to the ITU.
52. The clinical records show doctors also followed the Critical Care Guideline when deciding not to readmit Mrs E to the ITU. They also followed Good Medical Practice by carrying out adequate assessments and referring to specialists in critical care when necessary. We find doctors followed the relevant standards. We hope Mr E is reassured that we have seen no evidence of any failings in this respect.
Feeding tubes
53. Mr E says there was a delay in clinicians reinserting a feeding tube for his mother when she moved to the ward from the ITU. He says clinicians took too long to give his mother mittens to prevent her from removing the tube. He says there were several occasions when the feeding tube was not in place and referred to one occasion when his brother found the tube on the floor.
54. The Nutrition Guideline explains how healthcare professionals should identify and care for adults who are malnourished or at risk of malnutrition. It contains guidance about managing feeding tubes, such as ensuring they are in the correct position before use. It says clinicians need to test some of the stomach comments (known as aspirate) to see whether the tube was in the correct place. If needed, they should check the position using X-ray.
55. The Medical Adviser told us that feeding into a tube that has moved can be fatal. This is because the nutrients could be fed into the lungs. It is very important the feeding tube is in the correct position and clinicians need to check this regularly.
56. The clinical records show Mrs E received nutrition via a feeding tube between 19 and 30 November 2022. There is no reference to any difficulties between those dates. On 30 November Mrs E removed the feeding tube. A doctor replaced it a few minutes later and confirmed its position by X-ray. There were no further problems relating to the feeding tube in the ICU. A physiotherapy record referred to Mrs E wearing mittens on 4 December.
57. On 5 December 2022 a nurse noted that feeding had not resumed as planned. This was because they were unable to obtain any aspirate. On 6 and 7 December nurses recorded that Mrs E’s feeding tube was intact and was providing nutrition for her. This stopped on the afternoon of 8 December because clinicians needed to check the position again.
58. The clinical records from 8 and 9 December 2022 show doctors confirmed the feeding tube could be used because its position had been confirmed by X-ray. But nurses and doctors were unable to obtain aspirate. This mean they could not confirm it was safe to start using the feeding tube. These difficulties continued over the following days. On 11 December Mrs E pulled the tube out again.
59. On 12 December 2022 a dietician reviewed Mrs E and recommended continuing with a feeding tube. They suggested using mittens again to make it more difficult for Mrs E to pull the tube out. The next day an X-ray showed the tube was in the correct place. Mittens were in place on 13 and 14 December. On 16 December Mrs E again removed the feeding tube despite wearing mittens.
60. The records frequently note Mrs E’s confusion, and it would have been difficult for clinicians to ensure she followed their commands. The Medical Adviser told us that clinicians need to take account of the Mental Capacity Act. This outlines when they should use restraint, which includes using mittens to prevent someone removing tubes. The Act is clear that clinicians should use the least restrictive means of addressing a problem. So, it was appropriate that clinicians tried other means before using mittens. In any case mittens do not always prevent patients removing equipment, as happened in Mrs E’s case.
61. We can see there were good reasons why it took time for clinicians to reinsert feeding tubes when Mrs E pulled them out. We also cannot be critical about the use of mittens. We appreciate Mr E feels strongly that clinicians could have done more to support his mother in this respect. This is not what we have seen. We find they followed the Nutrition Guideline.
Dehydration
62. Mr E says doctors failed to manage his mother’s dehydration. He says his mother’s mouth was painful and dry.
63. The CQC Guidance Regulation 14 ‘Meeting nutritional and hydration needs’ explains how people who use health services should have adequate nutrition and hydration to sustain life and good health. It says nutrition and hydration needs should be regularly reviewed during the course of care and treatment. Water must be available and accessible to people at all times.
64. The Medical Adviser told us clinicians managed Mrs E’s hydration status very poorly. The Medical Adviser noted there were gaps in the clinical records which meant there were occasions when Mrs E’s fluid intake and output were unknown.
65. Levels of urea (a waste product from the body found in urine) rise when someone is dehydrated, and high levels of sodium would suggest marked dehydration. The clinical records show Mrs E’s urea levels were consistently above the normal range from 4 December 2022 onwards. Her sodium levels were above the normal range from 9 December onwards. By 6 December she was clearly dehydrated and needed fluids. The following day a doctor noted she was ‘clinically dry.’
66. The clinical records refer to occasions when Mrs E pulled out her intravenous fluid drip and Mr E also referred to such incidents. He recalled seeing the drip being left disconnected for lengthy periods of time. The records also refer to Mrs E having food and fluids on occasions when the quantity was not recorded elsewhere. Dieticians and speech and language therapists (SALT) noted how difficult it was to estimate fluid intake because of incomplete records.
67. The Medical Adviser said the average person needs between two and three litres of fluid each day to prevent dehydration. However, if someone is already dehydrated this amount needs to be higher. The records that are available show Mrs E was losing fluid day by day, which made her dehydration worse. Following her transfer from the ITU the records suggest Mrs E did not take more than one litre of fluids on any day. Notes from surgical reviews did not refer to any clinical examination of Mrs E’s hydration. There is no consistent documentation of reviews of fluid balance or blood test results.
68. We recognise Mrs E’s delirium made it difficult to give her the hydration she needed. But we consider clinicians failed to ensure Mrs E’s hydration was being maintained and she was not given enough fluid to correct her dehydration. Clinicians should have been giving Mrs E regular intravenous fluids by 6 December 2022. There is no evidence they consistently did so. This was below the requirements set out in the CQC Guidance.
69. We asked the Medical Adviser to explain the impact of dehydration on Mrs E. They said Mrs E’s general condition was weak and she had a limited ability fight illness. She had undergone a significant operation and a stay in the ITU. Her abdominal wound was always going to be at serious risk of becoming infected and would have taken weeks to months to heal and may not have healed at all. The Medical Adviser said he estimated Mrs E had a less than 25 per cent chance of surviving to be discharged from the Hospital even if there had been no concerns about her hydration. Her dehydration would, therefore, have played only a small role in her deterioration.
70. We do not consider dehydration was a major contributor to Mrs E’s death. However, the mismanagement of her hydration would have led to her experiencing discomfort and distress and is likely to have prolonged her delirium. We can also see how it has been distressing for Mr E to witness his mother’s distress.
71. We find doctors did not follow the CQC Guidance relating to Mrs E’s hydration. We cannot say this had any significant effect on her declining health. But we can see how it led to avoidable pain and distress for Mrs E and how these issues led to distress for her family.
Delirium
72. Mr E believes doctors should have done more to address his mother’s delirium. He described how distressing it was for him and his family to see how agitated his mother was when they visited her.
73. The Delirium Guideline explains how healthcare professionals should diagnose and treat delirium. It says clinicians should try and identify and manage the underlying causes of delirium. It says they should provide a supportive environment for the patient. This would include involving relatives in helping to give reassurance. If the delirium is persistent doctors should consider prescribing relevant medication.
74. The Medical Adviser said it was inevitable that Mrs E would develop delirium because of her lengthy admission to Hospital and her stay in the ITU. The clinical records show clear evidence that doctors and nurses recognised this. Doctors tried to address the causes, although this could have included dehydration, and we have already seen above this was not managed properly. They also involved the family in Mrs E’s care.
75. Doctors considered the benefits and risks of medication when other measures failed. They noted the delirium would have affected other clinical assessments and treatments. The records suggest there were appropriate attempts to manage Mrs E’s delirium, aside from the issues linked to fluids that we have already mentioned.
76. We appreciate how distressing it must have been for Mr E and his family to witness his mother’s delirium. We have seen no evidence to suggest doctors fell below the requirements set out in the Delirium Guideline. We find no failings in this respect.
Treatment of sepsis and necrotising fasciitis
77. Mr E believes doctors did not treat his mother appropriately for sepsis and necrotising fasciitis towards the end of her life.
78. The Sepsis Guideline explains how healthcare professionals should recognise, diagnose and treat suspected sepsis. It explains the factors that increase the risk of sepsis, which includes people who have had surgery in the past six weeks. It says when they suspect someone has sepsis, they should treat this with intravenous fluids and antibiotics. Doctors should also attempt to find the source of the infection and take samples to ensure they can prescribe the most effective antibiotics.
79. The Medical Adviser told us Mrs E had a VAC (vacuum dressing) on her surgical wound to help it to heal. The clinical records show nurses regularly reviewed and changed the VAC as required and provided care to the surrounding skin. Surgeons reviewed the wound progress and noted it was healing. This would have been a lengthy process taking weeks or months.
80. By 9 December 2022 Mrs E developed a fast heart rate. Doctors reviewed her appropriately and arranged investigations such as testing tissue samples, a chest X-ray and a CT scan. The Medical Adviser said these were all appropriate actions. The records show doctors suspected Mrs E had sepsis by this stage. She was already taking antibiotics and intravenous fluids.
81. Over the following days Mrs E’s condition stabilised. Doctors monitored her CRP levels (this a type of protein which is used to monitor levels of inflammation in the body). Usually, someone with sepsis would have a high CRP level. This was not the case for Mrs E whose CRP levels were static for most of the time after she left the ITU. This would not have been a cause for concern.
82. Mrs E’s observations were also noted. While she had a high temperature at times this generally settled. Doctors responded to these incidents appropriately by taking samples to detect the presence of bacteria in the blood. They involved microbiologists to ensure they gave Mrs E the most effective antibiotics. The Medical Adviser said she had a lingering infection that the antibiotics treated, at least partly. Her condition did not suggest she had necrotising fasciitis.
83. The Medical Adviser noted Mrs E’s post-mortem report identified that she died from necrotising fasciitis on the basis of the discoloration of her abdominal muscles. The Medical Adviser did not consider this likely. Typically, necrotising fasciitis is a rapidly spreading infection associate with a significant inflammatory response and sepsis. However, doctors had treated her with several antibiotics which would have reduced these issues to some extent. This means the appearance and behaviour of the infection may have been different to usual.
84. On 16 December 2022 a nurse noted Mrs E making a coughing and gurgling sound. The nurse tried to suction the airway and put Mrs E onto her right side. The Medical Adviser said this was just before Mrs E’s cardiac arrest. It suggests there could have been aspiration (inhalation of stomach contents into the lungs) which can cause low oxygen. It is also possible that her heart may have started to beat too slowly or to pause, as happened in the ITU before her first cardiac arrest.
85. The Medical Adviser said there could have been an element of infection. However, they said it was much more likely that aspiration or issues with the heart would cause such a sudden deterioration.
86. We find the doctors treated Mrs E’s suspected sepsis in line with the Sepsis Guideline. Based on the clinical advice we have received we do not consider there is evidence that Mrs E had necrotising fasciitis.