Stomach examination
14. Miss A says when she attended ED on 24 November 2022 a doctor did not examine her stomach correctly. She says they placed a hand on her stomach without checking for tenderness. She also says they did not question her about her symptoms or take her clinical history.
15. GMC Good Medical Practice (2013) states clinicians must provide a good standard of practice and care. They must adequately assess the patient’s condition taking account of their history and where necessary examine the patient.
16. Miss A arrived at ED on 24 November 2022 and was triaged at approximately 3am. At 7.05am an ED doctor examined her. The records state Miss A had a ‘diffused abdomen’ (pain throughout the abdomen) with gradual onset of pain and ‘dull pain in waves’. The records also show Miss A’s abdomen was soft not tender (SNT) and there was ‘no guarding on palpitation’. Guarding is when the abdominal wall muscles tense to protect inflamed internal organs. This is detected when pressure is applied to the abdomen during examination.
17. Miss A was referred to the on-call medical team. At 9.27am a clinician assessed her. The records state on examination she was alert, talking and seen mobilising. Her abdomen was soft with no guarding, she had tenderness in her lower abdomen which was more on the right side. The clinician also recorded ‘bowel sounds were present’ (a low-pitched gurgling sound which occurs every five to ten seconds).
18. We asked our A&E clinical adviser and general medicine adviser about both stomach examinations at 7.05am and 9.27am. Our advisers confirmed each examination was appropriate and in line with GMC guidelines. The records indicate Trust staff correctly considered her clinical history, symptoms and palpitated (physically examined) Miss A’s stomach. Having done so, both examinations found her abdomen was soft with no guarding or tenderness. This indicates a thorough physical examination of the abdomen was completed and clearly documented in records.
19. We appreciate Miss A’s concern her abdomen was not properly examined, particularly given she was later diagnosed with an appendicitis. We hope to reassure her the records indicate her abdomen was appropriately examined and the findings were clearly documented in her records. These actions are in line with GMC guidelines. We have not identified failings in relation to this aspect of Miss A’s complaint.
Gastroenteritis diagnosis
20. Miss A complains when she attended ED on 24 November 2022 she was misdiagnosed with gastroenteritis when she had an appendicitis. She says this led to her being incorrectly discharged, without appropriate pain relief or treatment. She says had her appendicitis been diagnosed when she attended ED on 24 November 2022 her reproductive organs would not have been at risk. She says she would not have experienced the distress and anxiety of being told these might need to be removed.
21. We do not wish to underestimate how painful and distressing this experience was for Miss A. We recognise being told about the potential complications of her appendicitis would have been very worrying and upsetting for her. We are sorry to hear she has experienced such a difficult time with her health.
22. NICE appendicitis guidance explains it can be challenging for a clinician to confirm a diagnosis of an appendicitis when examining a patient. This is because the symptoms of an appendicitis can be ‘atypical’ (not have all the common characteristics) and ‘vary in severity’. It goes on to explain the common symptoms of an appendicitis. This includes nausea and vomiting, abdominal pain and periumbilical (pain around the belly button) or epigastric pain (pain under the ribs) that worsens and migrates to the right lower quadrant of the stomach over 24 to 48 hours. Finally, this guidance explains if a clinician suspects a patient may have an appendicitis, they should refer them for an ultrasound or CT scan to investigate this further.
23. GMC Good Medical Practice (2013) states clinicians should ‘adequately assess the patient’s condition by considering their clinical history and where necessary examine the patient. It also says clinicians should ‘promptly provide or arrange suitable advice, investigations or treatment’ where necessary.
24. The records show when Miss A arrived at ED she was triaged and had a blood test. An ED doctor assessed her at 7.05am. The ED doctor recorded her symptoms as nausea and vomiting, diarrhoea, abdominal pain which was coming in waves and a raised temperature and heart rate. The ED doctor reached a working diagnosis of infective gastroenteritis.
25. The ED doctor’s plan was for Miss A to be prescribed antibiotics and IV fluids and for urine, stool and blood cultures to be taken. The plan also stated Miss A would have a chest X-ray and ECG and be referred to the on-call medical team for review.
26. We asked our A&E adviser to explain whether the ED doctor took appropriate steps to assess and reach a working diagnosis of infective gastroenteritis. They confirmed the ED doctor correctly considered Miss A’s clinical history and symptoms in line with GMC guidance. Importantly, her symptoms were also typical of gastroenteritis. NHS Inform gastroenteritis guidance explains the main symptoms are ‘sudden, watery diarrhoea, feeling sick, vomiting and a mild fever’. The records confirm Miss A appears to have had several of these symptoms during her ED assessment.
27. Our A&E adviser continued to explain the ED doctor referred Miss A for ‘suitable investigations’ to diagnose her symptoms in line with GMC guidance. Her blood test result show she had a raised white cell count and raised C-reactive protein (CRP) levels. This is a non-specific indictor of infection or inflammation in the body. It was therefore reasonable for the ED doctor to suspect Miss A had ‘infective gastroenteritis’.
28. We next considered whether the on-call medical team appropriately assessed Miss A at 9.27am. The records show her symptoms changed. The on-call medical team found she had ‘tenderness in the lower abdomen’ which was ‘more on the right side’. This is a common and typical symptom of an appendicitis in line with NICE appendicitis guidance.
29. Our general medicine adviser told us this additional finding, taken in the context of her other symptoms, indicated Trust staff should not have ruled out symptoms of an acute appendicitis. The records show she had a history of two episodes of diarrhoea the previous day with nausea and vomiting. These are also symptoms of an appendicitis as outlined in appendicitis guidance. Miss A was a young patient (aged 31). Our general medicine adviser explained the incidence of appendicitis is known to peak between the ages ten and thirty.
30. As Miss A had symptoms of an appendicitis, she should have been referred to the surgical team for further investigations. This is in line with GMC guidance, which says clinicians have a duty to provide prompt investigations when necessary. Had this occurred, Miss A would have undergone a CT scan or ultrasound. On balance, given her symptoms, we are satisfied this would have confirmed a diagnosis of an appendicitis.
31. The records show Miss A was not referred to the surgical team. Instead, she was discharged home without pain relief for her symptoms. The RCEM pain guidelines explain ‘recognition and alleviation of pain should be a priority when treating the ill and injured. This process should start at triage, be monitored during their time in the ED and continue through to admission or discharge ensuring adequate analgesia is provided at all times, including beyond discharge where appropriate.’
32. We consider Miss A should have been given some pain relief to take home. She had experienced pain during her ED admission. Whilst the pain was controlled during her 9.27am assessment, Miss A had ongoing symptoms. As such, there was a strong possibility of her experiencing further pain on discharge. There is no evidence Miss A was discharged with pain relief. This is not in line with the RCEM pain guidelines which says staff should make sure adequate pain relief is provided ‘beyond discharge’ if appropriate.
33. Miss A also has concerns she should have been given antibiotics on discharge. NICE gastroenteritis guidance explains if a patient is over the age of 16, a clinician should not ‘routinely prescribe antibiotics to adults with gastroenteritis’. We are satisfied this diagnosis was incorrect. However, as the Trust had a working diagnosis of gastroenteritis, we are not critical of the fact she was discharged without antibiotics. In line with NICE guidance, this medication is not routinely prescribed to patients with infective gastroenteritis.
34. In summary, we consider the Trust’s on-call medical team missed the common signs of an appendicitis when it assessed Miss A at 9.27am on 24 November. Had they correctly suspected an appendicitis, Miss A would have been immediately referred for a CT scan or ultrasound to confirm this diagnosis in line with NICE guidelines. This did not happen. Instead, Miss A was incorrectly discharged home and did not have a CT scan until approximately 6.30pm the following day. Had she remained in hospital, it is more likely than not Miss Horwood’s pain would have been monitored and she would have had access to pain medication for her symptoms. The records show she was also incorrectly discharged without pain medication which is not in line with RCEM guidelines. This care falls short of the standard expected and it amounts to a failing. We have considered the impact of this in paragraphs 48 to 61 of this report.
Treatment on 25 November 2022
35. Miss A said when she re-attended ED on 25 November 2022, she was left without food, pain relief or antibiotics for approximately eight hours.
36. We can appreciate on return to hospital, Miss A would be very anxious and worried about her symptoms. We recognise the additional wait in ED would have been difficult, particularly as she was feeling so unwell. We do not underestimate how distressing this experience was for her.
37. GMC Good Medical Practice (2013) explains clinicians have a duty to put a ‘system in place which protects patients’ and deliver safe, good quality care. It says clinicians should take ‘prompt action’ to ‘meet their needs’ and ‘protect the safety, dignity and comfort of patients’.
38. We recognise it would have been uncomfortable for Miss A to wait in ED without food when she was hungry. The Trust explained in its response when a patient presents at ED with abdominal pain and vomiting, it can ask them not to eat or drink until there is a clear diagnosis and treatment plan. This is because, eating and drinking could potentially impact its ability to deliver care safely. It apologised this was not clearly communicated at the time.
39. It is unfortunate this advice was not clearly explained to Miss A during her ED visit. We are pleased to see the Trust recognised and apologised for its poor communication. Overall, we are satisfied this explanation is appropriate and in line with GMC guidelines. We have not found failings in relation to this matter.
40. The RCEM pain guidance recommends recognition and alleviation of pain should be a priority when treating the ill and injured. This process should start at triage, be monitored during their time in the ED and continue through to admission or discharge ensuring adequate analgesia is always provided.
41. The records show Miss A’s pain score was zero when she was initially triaged at 10.37am. That said, it appears staff did not need to take further steps to provide pain medication at this time.
42. Following this, there is no evidence in the records to show Miss A’s pain was reassessed until 5.34pm by the on-call medical team. At this point Miss A’s medical records state she ‘continued to have abdominal pains’ and ‘the nature of the pain had not changed’. Miss A also told us during our telephone call with her on 19 August 2024 she felt in significant pain whilst in the ED.
43. We see no evidence Miss A’s pain was monitored or she was given pain medication whilst she waited in ED. This is not in line with the above RCEM pain guidance. We have seen evidence to show she was in pain after her initial triage, so Trust staff should have given her ‘adequate analgesia’ to help with this. We consider this is a failing. We have addressed the impact in paragraphs 48 to 61 of our report.
44. Finally, we considered if Miss A should have been given antibiotics when she returned to ED. A retrospective medical record from 5.34pm indicates Miss A had metronidazole and ciprofloxacin (antibiotics) at around 4.25pm and 4.27pm. It appears she was given antibiotics at the same time as being first examined by an ED doctor.
45. Good Medical Practice (2013) says doctors should promptly provide or arrange suitable advice, investigations or treatment where necessary. Our A&E adviser informed us there are no national standards which say when antibiotics should be administered, other than when a patient has sepsis, which is not relevant in this case.
46. GMC prescribing guidelines explain a clinician is ‘responsible for the prescriptions they sign’. This means they ‘must only prescribe drugs’ when they have an ‘adequate knowledge of the patient’s health’.
47. In line with GMC guidelines, it would not have been appropriate to give Miss A antibiotics until a doctor had examined her. This is because, the doctor needed to make sure the antibiotics were suitable to meet her clinical needs. We can see there is no specific timeframe to say when Miss A should have been given antibiotics for her appendicitis. The records indicate she was given her antibiotics promptly (at the first opportunity) once the doctor had completed their assessment. This indicates there was no undue delay in giving her this medication. We do not see failings for this part of the complaint.
Impact
48. We next consider what impact, if any, Miss A experienced because of the failings we have identified in this report.
49. Miss A says the delay in diagnosing her appendicitis did not impact her physical health. She says she had successful surgery on 26 November 2022 and her reproductive organs were not affected. Rather Miss A says, had her appendicitis been diagnosed when she first attended the ED on 24 November 2022, her reproductive organs would not have been at risk, and she would not have experienced the distress and anxiety of being told these might need to be removed.
50. Miss A had a CT scan of the abdomen and pelvis at approximately 6.30pm on 25 November 2022. This showed she had ‘acute appendicitis with focal inflammation of the neighbouring fallopian tube and broad ligament on the right side’. Miss A underwent surgery to remove her appendix at 10.52am on 26 November 2022. She was subsequently discharged from hospital two days later on 28 November 2022.
51. On balance, our surgical adviser told us had Miss A undergone a CT scan on 24 November, it is likely the results would have been similar to the results seen on 25 November. The CT scan of 25 November showed Miss A had an acute appendicitis which had not perforated (burst). Her blood tests of 24 November showed she had inflammation. These test results indicate her condition had most likely not changed or deteriorated between 24 and 25 November.
52. Miss A signed a consent form for surgery on 26 November. The form indicates there was risk to her right fallopian tube and ovary. We realise this was worrying for Miss A particularly as she told us she was hoping to conceive.
53. Our surgical adviser explained some patients have a primary inflammation of the reproductive organs. This makes the appendix look inflamed if it is lying next to these tissues. Other patients can have an inflamed appendix which makes the reproductive organs look inflamed. Often radiological imaging will not be able to distinguish with absolute certainty the origin of the infection or inflammation.
54. As Miss A’s CT scan findings were likely to be the same on 24 November, we are satisfied she would still have been advised her reproductive organs could be at risk had her surgery taken place one day earlier. We are satisfied the Trust’s delay in diagnosing Miss A with appendicitis did not cause her unnecessary worry about being told of the risks of surgery.
55. Miss A also told us she was in pain after she was discharged home on 24 November and she experienced pain on 25 November whilst waiting in ED.
56. Miss A told us her partner arranged a prescription of Co-Codamol from her GP. She says she took between four and six tablets overnight because of the pain. In her original complaint to the Trust, she describes ‘waking up in severe pain’ in the morning. The records show on 25 November, Miss A had ‘abdominal pain’ which had not changed and was coming in waves. The records show she was not monitored or given pain relief from 10.37am up until she was assessed at 5.34pm. On balance, we consider she was in severe and unnecessary pain for approximately 24 hours. This is an injustice to Miss A.
57. Miss A told us she has also suffered long term anxiety because of her poor care. She says she experienced heightened anxiety since November 2022. She told us she now contacts health services more frequently and checks her blood pressure and pulse regularly, which she did not do before. Miss A told us she does not have a formal diagnosis of health anxiety and has not raised these matters with her GP or other health services.
58. We have considered this matter carefully. In the absence of a formal diagnosis of health anxiety we cannot say if any increase in the frequency with which Miss A may have contacted health services since November 2022 is linked to the Trust’s poor care. We are sorry to hear Miss A feels anxious about her health and compelled to seek medical treatment for symptoms more frequently now. On the balance of probabilities, we cannot say Miss A’s decision to contact health services is because of the Trust’s actions.
59. Miss A told us she has felt distressed and anxious for a period of around one year because of the delay in diagnosis. We carefully considered whether a longer period of anxiety and distress can be attributed to the Trust’s actions.
60. Miss A has told us she has a pre-existing diagnosis of PTSD, anxiety, and depression. We are very sympathetic to Miss A’s position and appreciate she was worried about her ability to conceive when she had surgery. Miss A’s surgery was successfully carried out on 26 November 2022. We would have expected staff to communicate with her about the outcome of her surgery when she was discharged and to address concerns she may have had with her then. We see no further concerns about the outcome of her surgery were raised at this stage.
61. Following surgery, the Trust says Miss A had an ultrasound of her organs a few days later which were normal. Miss A also told us she had a private scan in October 2023 which confirmed her reproductive organs had not been impacted by the surgery. We consider a degree of worry following surgery would be natural and understandable and the scans undertaken should have provided some reassurance her reproductive organs had not been damaged. We have concluded on balance we cannot be satisfied any prolonged period of stress and anxiety Miss A experienced following her surgery is directly attributable to the Trust’s delay of approximately one day in reaching the diagnosis of appendicitis.