Complaint about gastroenterology input and ward transfer
15. There are no clinical standards or guidelines that explain what level of specialist gastroenterology support should be provided to a hospital inpatient or when a patient should be transferred to a specialist ward.
16. Our physician adviser explains in cases such as this (where a non-specialist hospital site has an in-reach service to provide specialist services that are available at its other site) it is important to have a local policy or protocol. This would make it clear what level of service is expected, and what the criteria are for transferring patients to specialist wards.
17. We asked the Trust about its gastroenterology service at Hospital A. It could not provide a written policy or procedure but was able to describe the service to us.
18. It explained that at the time, a team of ‘in-reach’ specialist doctors from Hospital B provided a gastroenterology service for patients at Hospital A on weekdays from 9am to 5pm.
19. It said this involved a consultant gastroenterologist doing two ward rounds a week, and reviewing new gastroenterology referrals or people that needed a consultant review. Then, the rest of the time a doctor such as a registrar (the most experienced type of junior doctor) would do ward rounds to review gastroenterology patients.
20. It explained that decisions on whether to transfer a patient were based on whether they were going to need a longer period of gastroenterology care. If the in-reach team felt a patient was suitable, they would make the referral to the specialist ward at the Hospital B.
21. The Trust said Mr G received the same level of care at Hospital A that he would have received had he been transferred to Hospital B straight away. It said the frequency of gastroenterology in-reach input was appropriate.
22. Having examined the records, we consider Mr G did not receive enough consultant gastroenterologist input during his admission to Hospital A.
23. A gastroenterology consultant saw him on Monday 14 March, and then not again until the end of the following week, on Friday 25 March. A consultant provided virtual advice to the medical team who had a query on Monday 21 March.
24. This meant a consultant only saw Mr G once a week. This was not in line with the twice a week consultant ward round the Trust said it would provide. He also only saw a registrar once each week (on 15 and 24 March). The Trust failed to follow its own procedure.
25. Our physician adviser said this level of input was unacceptable for a patient being managed as an outlier with their first presentation of end stage chronic liver disease.
26. Our physician adviser explained it was significant that this was Mr G’s first presentation with chronic liver disease. It was important for him to receive consistent and involved expert care to establish, for the first time, his diagnosis and prognosis.
27. In this case, there were early signs from the time Mr G presented to hospital that his liver failure was end stage. We cannot see from the gastroenterology in-reach records that the Trust thought about this in enough detail or communicated it to Mr G and his family. It appears this is due to a lack of consistent regular oversight from the in-reach team.
28. People with established liver disease and a clear diagnosis or prognosis, or people who have previously been in hospital with liver disease, are less likely to need as much specialist input as someone in Mr G’s case. Its more suitable for patients like them to be managed as an outlier and receive care from the in-reach team.
29. Our physician adviser said that given this was Mr G’s first presentation to hospital with chronic liver disease and it was end stage, it would have been beneficial for him to receive regular care from specialists on a gastroenterology ward sooner than he did.
30. We therefore find the Trust should have thought about transferring Mr G to the specialist gastroenterology ward at Hospital B sooner than it did. It is difficult to say exactly how much sooner, and this further emphasises the need for the Trust to have a clear written policy about this.
31. We found failings in this aspect of the complaint. Later in this report we set out our thinking about the impact of these failings.
Complaint about a drain not being inserted sooner
32. Mrs N says she and her sister had to keep asking for the staff to put a drain in, but this should have been done sooner.
33. Liver cirrhosis leads to a complication called ascites. This is where fluid builds up inside the abdominal cavity.
34. The ascites guidelines say the main way to manage the symptoms of ascites is with diuretics (tablets that help the body remove excess fluid). If there is a large volume of ascites, or diuretics cannot be used, a procedure called large volume paracentesis can be done. This is where a drain is inserted into the abdomen to drain away the excess fluid.
35. Mr G initially could not be treated with diuretics. Blood tests showed he had impaired kidney function, and diuretics would have put too much strain on his kidneys. The gastroenterologists recommended a drain, but concerns about Mr G’s kidneys meant this could not happen straight away. Our physician adviser says the initial delays to treatment due to his kidney impairment were reasonable.
36. Mr G was able to start on diuretics on 16 March. On 17 March the doctors said they would need to see some further blood tests results to assess his kidney function before a decision could be made on the drain. Then, on 18 March they reviewed him and decided a drain was now appropriate, with a plan for ongoing diuretics to try and control ascites.
37. We could not see any signs the drain on 18 March should have been done any sooner, and we consider the Trust acted in line with the ascites guidelines. We understand why this was a worry for Mrs N. To offer further reassurance, we have seen the timing of the drain being inserted did not impact Mr G’s prognosis or the progression of his liver disease.
Complaint that weights were not done when requested
38. Mr G had heart failure. This can cause fluid to build up in the body, which is an additional challenge when someone has ascites.
39. A cardiology consultant reviewed him on 16 March to help the medical team decide whether he could receive diuretics. The outcome was that he could have them but needed to have his kidney function monitored and be weighed daily. This would measure any fluctuations in the excess fluid in his body.
40. The GMC guidance says doctors must arrange suitable advice, investigations, or treatment where necessary. They must also consult colleagues where appropriate. In this context, it would mean ensuring the nursing team are aware of the plan for daily weights, and to monitor the results of these weights and act on them accordingly.
41. From a nursing perspective, the NMC code says nurses must respect the expertise and contributions of colleagues, working with them to preserve the safety of patients. In this context, it would mean taking note of the plan for daily weights, carrying them out, and working with the medical team if there were any issues.
42. We found the Trust did not act in line with the GMC or NMC guidance. Mr G was never weighed, and neither the nursing or medical staff acted on this or questioned it. This was a failing. We consider what impact this had later in the report.
Complaint that enemas were not given
43. People with liver cirrhosis can develop a problem called hepatic encephalopathy. This is a decline in brain function, caused by a build up of toxins in the body that the scarred liver cannot effectively filter out of the blood. Common symptoms are mood changes, confusion, and drowsiness.
44. One way to treat this is to help the body get rid of toxins by having a patient open their bowels more regularly. This can be achieved through the use of oral laxatives or enemas (a treatment where liquid is placed into the bowel to assist with a bowel movement).
45. In Mr G’s case, the doctors decided on 14 March that he should be opening his bowels two to three times a day. To help achieve this, they prescribed regular oral laxatives and also said enemas could be used.
46. The prescription charts are unclear but, based on the Trust’s account, it appears these were initially prescribed on an as and when needed basis, until 19 March when they were prescribed to be given once a day.
47. As we have established that the purpose of enemas is to ensure regular bowel movements, and the plan was for him to have two to three a day, we have looked at whether the staff did enough to achieve this.
48. The NMC code says nurses must respect the expertise and contributions of colleagues, working with them to preserve the safety of patients. They should refer to other practitioners (or escalate matters) when any action or advice is needed. In this case it was the nurses’ responsibility to administer the prescribed medications, monitor Mr G’s bowels, and escalate to the medical team if he was not able to open his bowels often enough.
49. We found staff did not act in line with the NMC code here. Mr G’s stool chart (which recorded his bowel movements) was not completed on 15 March, so we cannot be confident that monitoring was adequate that day.
50. Then, Mr G did not have any bowel movements on 16 or 17 March however no enemas were administered. A doctor requested an enema on 17 March but the records indicate nurses did not give this until 18 March. By this stage, there had been no recorded bowel movements since 14 March.
51. We found there was a failing in care here. On 15 and 16 March nurses should have either given Mr G an enema as prescribed, or escalated to the medical team when there were no bowel movements. They should have given the enema on 17 March when it was requested. The delay until 18 March was not acceptable. We consider the impact of this later.
Complaint about lack of nutrition monitoring and support
52. The NICE guidance says all hospital inpatients should be screened for malnutrition on admission to hospital, and again weekly. Part 1 of the Trust’s policy says this too, and that the Trust screens patients with the widely used Malnutrition Universal Screening Tool (MUST).
53. Therefore, whilst at Hospital A staff should have completed a MUST for Mr G on 12 March, and repeated it a week later on 19 March. We have seen no screening took place.
54. In its complaint response the Trust accepted it did not do a MUST for Mr G when he was admitted, but said it did one on 24 March. However, there is no evidence of a MUST in Mr G’s records from his time in Hospital A. This was a failing, and a missed opportunity to identify if Mr G was at risk of malnutrition
55. People at risk of malnutrition need additional support and monitoring. Part 2 of the Trust’s policy says the level of support depends on the patient’s MUST score.
56. We cannot exactly say what Mr G’s MUST score would have been had the Trust screened him because information about his weight, height, and eating patterns before admission was not gathered. However, based on the information in the records about Mr G’s presentation and comorbidities, our nurse adviser says he was at least at medium risk, or potentially high risk, of malnutrition.
57. According to part 2 of the Trust’s policy, this risk of malnutrition meant staff should have been completing daily charts recording what Mr Brook was eating. He would have also needed a referral to dietician for further assessment and consideration of supplements.
58. We can see food charts were in place, but staff did not complete them properly. Some days the food charts were only partly filled in, and on other days they were left blank.
59. Mr G was not referred to the dietician and received no supplements. Had he been referred to a dietician he may have been prescribed a special diet for people with liver disease. Our physician adviser explains people with liver disease complications may benefit from a no added salt diet to help reduce ascites, or a high protein diet to reduce the symptoms of hepatic encephalopathy.
60. Therefore, we consider as a result of the initial failing to properly screen Mr G’s malnutrition risk, the Trust also further failed to provide appropriate nutrition support. We consider the impact of this, and the other failings in his care, next.
Impact of the failings
61. We identified the following failings: • Mr G did not receive enough gastroenterology in-reach input • Doctors should have considered moving him to the specialist ward sooner • Staff did not follow the plan to do daily weights • Enemas were not given when prescribed and the lack of bowel movements was not escalated to the doctors • Staff did not carry out nutritional screening or arrange appropriate nutritional support
62. Mrs N is concerned these failings impacted her father’s chances of recovery and contributed to his death. We can reassure her this is not the case.
63. Our physician adviser told us the severity of Mr G’s liver disease sadly meant there was nothing that could have been done to reverse his liver damage or avoid its unfortunate progression. However, the failings did lead to some missed opportunities.
64. More gastroenterology input or an earlier transfer to Hospital B would have likely meant there was a clearer view about Mr G’s prognosis earlier on and his family would have better understood things.
65. Not doing daily weights meant there was a missed opportunity to measure how much his weight fluctuated due to accumulation of fluid and inform the diuretic treatment plan. Because we do not know his weight, we cannot say how much the plan would have changed.
66. Not giving Mr G regular enemas caused a missed opportunity to potentially ease his hepatic encephalopathy symptoms. It is difficult for us to say how much, as we cannot determine from the records whether his hepatic encephalopathy symptoms improved after 18 March when he was able to open his bowels more regularly.
67. The lack of nutritional monitoring and support meant there was a potential missed opportunity to give Mr G nutritional interventions which could have eased his ascites or hepatic encephalopathy symptoms.
68. We will never know to what extent Mr G’s symptoms, and therefore quality of life, could have been improved if not for the failings. This will be an ongoing source of uncertainty for Mrs N. This will compound the worry and distress she has already suffered as a result of witnessing the failings in her father’s care.
69. Mrs N tells us she spent her father’s admission worrying about his care and could not spend quality time with him. The failings also affected her bereavement and made it harder to grieve. She been left feeling guilty and wondering whether she could have done anything differently during her father’s time in Hospital A to get him the care he needed.
70. We were sorry to hear how Mrs N was impacted. We decided the Trust should act to put things right for her.