18. 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. We have done this and have not found any indications that something has gone wrong.
Issue 1 - several hours waiting outside ED in an ambulance and several hours waiting on trolley bed in a corridor
19. The Royal College of Emergency Medicine, initial assessment of emergency department patients, February 2017 says triaging patients is required to make a detailed assessment in a timely fashion, usually within 15 minutes or less.
20. The Trust sent complaint response letters dated 31 August 2023 and 1 March 2024 to Dr E. It acknowledged that it was not ideal that Mr U was kept waiting in the ambulance and that this reflected the pressure that the hospital was under at the time.
21. It is important to outline the ongoing pressures on emergency departments (EDs) nationally. The current crisis in the NHS has affected ED’s leading to long waits for ambulance patients to be taken into the ED, extended waits for assessment and prolonged stays in the ED whilst waiting for a bed to become available on a ward. This was highlighted in a more recent report, the King’s Fund’s report, ‘What’s going on with A&E waiting times’, 12 July 2024. The factors responsible for the decline in standards of care in the ED include increased attendances to the ED, continuing difficulties in recruitment and retention of ED staff, a lack of available in-patient hospital beds (exit block) and the continuing effects of the COVID pandemic.
22. Our physician adviser said delayed ambulance offload into ED is an NHS-wide issue for which there is no easy solution when the demand on the system is so high.
23. From review of the medical records, we can see Mr U arrived at ED by ambulance on 9 May 2023 at 2.46pm. From review of the ambulance records, we can see that following triage, Mr U remained in the ambulance vehicle because there was no space to move Mr U into ED. Mr U was assessed by an ED triage nurse at 2.55pm. This was within 15 minutes of arrival and in accordance with the Royal College of Emergency Medicine guidance.
24. A triage score is calculated using the Manchester Triage System (Emergency Triage: Manchester Triage Group 3rd Edition 2013) which is universally used across the NHS. The triage nurse assigned a priority of four. The system recommends that patients with a priority of four are seen by a clinician within two hours. From review of the medical records, we can see Mr U was assessed by a clinician just under three hours after triage, at 5.45pm. Although this falls outside national guidance, we have taken into account the extreme pressures on both this ED and across the NHS. We have seen no evidence that this delay had any undue adverse effects on Mr U’s care. The Trust took further observations at 4.35pm (within the two hour timeframe) and at 6.58pm.
25. The medical records show that whilst in the ambulance Mr U was assessed by an ED junior doctor at 5.45pm. Blood tests and X-rays were requested. It appears that Mr U was transferred into the ED at approximately 6.30pm. Further regular observations were recorded whilst Mr U remained in ED over the next 30 hours until he was moved to the Acute Medical Assessment Unit (AMU) on 11 May at 12.05am.
26. An inquest took place on 23 April 2024. It was noted that care in the back of an ambulance and in a corridor were not acceptable, but this did not lead to Mr U’s death.
27. We appreciate it must have been distressing for Dr E knowing her father was waiting in an ambulance and on trolley bed in a corridor. We cannot see any indication that this impacted the care provided and Mr U continued to be assessed in accordance with guidance during this time. We have noted that the Trust and inquest report accept this is not an ideal situation, but this was due to pressure on ED. The Trust are already aware of the issue surrounding these concerns and this is a national problem. We have seen no evidence to indicate the Trust could have done anything differently taking into account the factors it was faced with. We will not consider this further at detailed investigation.
Issue 2 - delays in diagnosing a collapsed lung
28. From review of the medical records, we can see one of the three lobes of Mr U’s right lung was compressed by the fluid around the lung (the pleural effusion). Our physician adviser explained that Mr U’s collapsed lung was not a punctured lung and was not due to the chest wall injury. It was also not a collapse of the whole lung.
29. The lung compressed by the fluid around the lung was not visible on the chest X-ray due to the pneumonia and pleural effusion (fluid around the lungs). From review of the medical records, the CT scan was performed to check for the cause of Mr U’s pain, not to check for lung collapse. The cause of the pain was found to be due to rib fractures on the CT scan. We understand Dr E felt her father’s diagnosis was delayed. The passive compression (collapse) of the lower lobe of the right lung was found as an incidental finding on the CT scan.
30. Our physician adviser said there are no specific guidelines as to how quickly X-rays and scans should be performed in hospital. GMC good medical practice says a doctor must promptly provide or arrange suitable advice, investigations or treatment where necessary.
31. We appreciate it must have been difficult for Dr E not knowing what was wrong with her father and feeling there was a delay in waiting for a diagnosis. Mr U had his chest X-ray on the day of admission and the CT scan within six hours of the request for the scan on day two of his admission. These timings are reasonable and in line with good clinical care and treatment and GMC good medical practice guidance. We have seen no indication of a delay in diagnosis or investigations, we will not consider this further at detailed investigation.
Issue 3 - no close monitoring of blood pressure, heart rate and oxygen. Her father should have been allocated a dependency bed/area
32. The Royal College of Physicians (RCP), national early warning score (NEWS), 2017 provides a NEWS scoring system and clinical response to the NEWS trigger thresholds. It provides guidance on how frequently physiological observations (NEWS score) should be measured. The RCP guidance states that if the NEWS score is five or more then observations should be measured hourly. Continuous monitoring is only recommended if the NEWS score is seven or more.
33. We have seen copies of NEWS charts relating to Mr U’s time in ED from 9 May to 10 May 2023. There are 17 separate entries from 10.08pm on 9 May 2023 to 11.15pm on 10 May 2023. This equates to the observation measurement every one to two hours. The NEWS scores range from four to six.
34. During triage, the nurse took a series of observations and NEWS score of four was calculated. Our A&E adviser said this score appears to have been calculated automatically and Mr U’s oxygen saturation of 90% were scored as three. Given Mr U’s documented history of COPD, the NEWS SpO2 scale two score for this oxygen saturation is zero and the correct NEWS score should be one in accordance with the NEWS scoring system. The clinical response to the NEWS trigger thresholds recommends that for a NEWS score of between one and four monitoring should take place four to six hourly as a minimum. From review of the medical records, the Trust’s observation charts have a response of two to four hourly observations.
35. We note the ward round at 10.25am on 12 May 2023 documents a NEWS score of four. As we know RCP guidance recommends that observations are repeated four to six hourly if the NEWS score is four. There is a physiotherapy note from 13 May 2023 at 3.42pm which states that Mr U’s oxygen saturations were in range on 28% oxygen and that he was ‘chatting’ with his family. This suggests that he was physiological stable at this point. The NEWS charts document scores of two to four from 11 May 2023 up until the cardiac arrest in the early hours of the 14 May 2023. The last observation was taken on 13 May 2023 at 9.41pm, a score was recorded as two and an observation check to be carried out in six hours. The cardiac arrest was noted at 1.32am and CPR started at 1.33am. The observations were measured and recorded four hourly prior to the cardiac arrest which was in line with RCP guidance.
36. We understand Dr E felt her father should have been monitored more frequently and it must have been upsetting finding out her father had a cardiac arrest. The RCP guidance states that high dependency care is only required for patients with a NEWS score of seven or more. The NEWS charts document scores of two to four from 11 May 2023 up until the cardiac arrest in the early hours of the 14 May 2023. The observations were measured and recorded four hourly during this time which was in line with RCP guidance. We have seen no evidence to suggest Mr U’s blood pressure, heart rate and oxygen were not monitored. The NEWS scores confirm that Mr U did not require continuous monitoring or transfer to a high dependency area. We have seen no indication that we need to consider this further at detailed investigation.
Issue 4- lack of care and staff
37. GMC good medical practice says a doctor must promptly provide or arrange suitable advice, investigations or treatment where necessary.
38. Mr U was first reviewed by a consultant physician in ED on 10 May 2023 at 7.50pm. The consultant noted that he was in severe pain. The investigation results were reviewed. A diagnosis of chest wall trauma (injury), pneumonia and an accidental fall was made. The plan was to give treatment with pain relief, oxygen, antibiotics, and to undertake further investigations including a CT scan of the thorax (chest and lungs).
39. A CT scan was undertaken and the result was reviewed at 12.43am on 11 May 2023. The scan reported scapula fracture, fracture of two left ribs and one right rib, a right pleural effusion (fluid around the lung) and collapse of the lower lobe of the right lung. The Trust’s doctor who reviewed the scan result sought advice on the findings from the orthopaedic and thoracic surgery teams. This assessment and treatment plan were in line with GMC good medical practice.
40. NICE guideline pneumonia (community- acquired): antimicrobial prescribing NG138, 16 September 2019 refers to the choices of antibiotic to treat the patient. The Trust used a combination of two antibiotics (coamoxiclav and doxycycline) both of which are recommended in the NICE guidance.
41. We understand it must have been a very stressful and upsetting time for Mr U’s family when he was admitted to hospital and when they found out Mr U had a cardiac arrest. From the information provided, it appears that the medical professionals involved in Mr U’s care assessed and treated him in line with GMC, RCP and NICE guidance as outlined in this statement. We appreciate the additional strain on a Mr U’s family during this time. From review of the medical records relating to the complaint parts we have discussed above, there are no indications of any lack of care or lack of staff. We have seen no indication that we need to consider this further at detailed investigation.
42. We have decided not to consider this complaint further at detailed investigation. We have not seen an indication that anything went wrong in the care provided. Our decision is not made without recognition of the distressing events.
43. We are sorry to hear about the events that led to Dr E’s complaint. We understand this has been an upsetting time. We are sorry to hear about Mr U’s death. We appreciate it must have been difficult witnessing her father in hospital.
44. We do log all the complaints we receive. This means, if we receive a similar complaint about the same organisation or see a pattern from a number of complaints, we may raise this with the organisation in future. We will log this complaint, so we have a record of it if we do receive any similar complaints. We hope this reassures Dr E that she did the right thing by bringing her complaint to us.