3. During her husband’s admission at the Trust from 25 January 2022, Ms J complains Dr B and Dr M misdiagnosed him with post COVID-19 complications (pneumonitis), and they delayed diagnosing and treating his organising pneumonia (with pulsed methylprednisolone).
4. She says her husband’s misdiagnosis and the delay in treatment caused his death.
5. Ms J wants explanations about what should have happened, the Trust to acknowledge its mistakes and the impact they had, and service improvements.
6. On 25 January 2022, Mr J’s GP called an ambulance to take him to hospital. After prescribing him antibiotics for an infection two days earlier, his GP had concerns he was developing sepsis. Paramedics took Mr J to the Trust’s Emergency Department (ED).
7. ED staff admitted him to hospital. They gave Mr J supplemental oxygen, and they started intravenous fluids and antibiotics.
8. After reviewing X-rays and computerised tomography (CT) scans, staff diagnosed Mr J with post COVID-19 complications on 27 January. They decided to start giving him dexamethasone. This is a corticosteroid treatment staff can use to treat a wide range of health conditions, including severe COVID-19 and other serious infections.
9. Staff also sent Mr J’s scans to the interstitial lung disease (ILD) unit at another NHS hospital for advice on his condition. Staff at the ILD unit gave their views about this on 1 February. ILD staff said they wondered if he had organising pneumonia. This is a condition where the small airways (bronchioles) and the air sacs (alveoli) in the lungs become inflamed.
10. As a treatment for this condition, ILD staff suggested starting intravenous methylprednisolone for three days, followed by oral prednisolone. This is another type of corticosteroid. Staff can use it to treat inflammatory disorders.
11. The Trust’s staff decided to continue with Mr J’s dexamethasone treatment. On 11 February, when he completed his course of dexamethasone, staff started methylprednisolone. They switched Mr J to oral prednisolone on 14 February.
12. Sadly, Mr J did not recover from his illness, and he died on 24 February.
17. In her complaint to us, Ms J said Mr J started to feel unwell on 21 January 2022. The events we described in paragraph six followed on from this. She said her husband’s medical records show ED staff confirmed his GP’s diagnosis of sepsis caused by a chest infection.
18. She said Mr J told ED staff he had been unwell for one week. She said she told staff he had been living in isolation for two years and did regular lateral flow tests for COVID19. She added the test staff did for COVID-19 on Mr J’s arrival at the ED showed a negative result.
19. Throughout Mr J’s admission, she added his tests came back negative. She said he did not lose his sense of taste or smell, and his scans did not conclusively show COVID-19.
20. She said Dr B assessed her husband a few days later and amended the history about his symptoms to ‘five weeks dry cough, fevers and malaise’. She added Dr B noted she gave them this information. She said this is not what she told Dr B, and her husband’s symptoms had lasted around one week.
21. She said Dr B then discussed her husband’s inconclusive scan images with Dr M. She complained they diagnosed her husband with post COVID-19 complications (with COVID-19 having started several weeks earlier).
22. She added these doctors failed to test whether COVID-19 antibodies in his body were caused by her husband having the illness or his previous vaccinations. She felt COVID-19 serology tests would have shown which scenario was accurate, and this was a crucial step they missed in diagnosing her husband.
23. She also complained these two doctors did not act on the advice of ILD staff. Rather, they decided to stick with their diagnosis and not provide the treatment ILD staff recommended. She added by the time they accepted the ILD unit’s diagnosis and started the treatment it suggested it was too late for her husband.
24. In its complaint process, the Trust said Mr J came to its ED with breathlessness, a dry cough, low oxygen levels, a reduced appetite, and a reduced sense of taste. Staff noted he was dehydrated, and he had a high temperature. After reviewing the results of his Xray, staff diagnosed pneumonia and possible COVID-19.
25. The Trust said staff arranged a CT scan to investigate further, noting his negative COVID-19 test result. Staff concluded the scan suggested COVID-19 pneumonitis after reviewing it on 27 January. The Trust said staff then started treating him with dexamethasone.
26. The Trust added serology testing for COVID-19 antibodies would not have helped with Mr J’s care.
27. It said a positive result does not tell staff whether any COVID-19 infection is acute or historical. A negative result does not tell staff whether it is too early into a patient’s illness to produce antibodies, or whether they were immunosuppressed and therefore did not produce antibodies. It added a serology test would show antibodies produced from both COVID-19 vaccines and the illness itself.
28. The Trust noted the ILD unit later suggested organising pneumonia following its review of Mr J’s scans, and he may need steroid treatment. The Trust said this type of pneumonia is a complication from infections, including COVID-19.
29. The Trust said three respiratory consultants then discussed Mr J’s care with him. As he was improving already on dexamethasone, and there are risks with taking high dose steroids like methylprednisolone, they agreed to continue his current treatment. They decided to try methylprednisolone if his condition worsened, which it later did.
30. Regarding the information Ms J says Dr B recorded from her (about a five-week history of symptoms), the Trust said Dr B noted their understanding on what she told them at the time. It also added these comments made no difference to the treatment they gave Mr J.
31. Following careful consideration of these accounts and the evidence, we found staff acted in line with guidelines in reaching the diagnosis they made. Based on their diagnosis, staff then gave Mr J treatment in line with guidelines.
32. We start, in paragraphs 33 to 88, by explaining our decision about the diagnosis staff made about post COVID-19 complications and the treatment staff started giving Mr J for this. We then address Ms J’s concerns staff did not find and start treatment for organising pneumonia soon enough in paragraphs 89 to 107.
The Trust’s diagnosis of post COVID-19 complications and treatment
33. The BMJ COVID-19 Guidance says staff should have a high level of suspicion for COVID19 in patients who present with a fever and/or acute respiratory illness.
34. In reaching a diagnosis, staff should take a history from the patient to assess the possibility of COVID-19. This includes considering risk factors which mean they are more likely to have been exposed to the illness. For example, whether the patient lives or works in an area with a high risk of COVID-19 transmission.
35. Staff should consider the clinical presentation of a patient. The BMJ COVID-19 Guidance says the most common symptoms of COVID-19 include fever, cough, shortness of breath, and an altered sense of taste/smell. It also lists 15 less common symptoms. It says 90% of COVID-19 patients will present with more than one of the common symptoms.
36. Staff should be mindful some patients may have minimal or no symptoms. However, others may have severe pneumonia or complications like acute respiratory syndrome, septic shock, acute myocardial infarction, venous thromboembolism, or multiorgan failure.
37. Staff cannot use one single symptom alone to accurately diagnose COVID-19. However, the presence of symptoms should raise suspicion which prompts staff to do further testing.
38. Staff should check to see if a patient’s oxygen saturation level is below 94% to identify patients who are seriously ill. They should also do blood tests in patients with severe illness to check for abnormalities. For example, markers in the blood that indicate high levels of inflammation.
39. In patients who present with symptoms of COVID-19, the BMJ COVID-19 Guidance recommends staff perform molecular testing. For example, a polymerase chain reaction (PCR) test to check for the illness. It adds staff should use the test result only as an aid to diagnosis. Staff should be mindful these tests are not always accurate.
40. Staff should consider a positive or negative result in combination with other information on their condition, including the patient’s history and clinical observations. This can include chest imaging (from scans like X-rays and CT scans).
41. The BMJ COVID-19 Guidance says staff should X-ray all patients they suspect have pneumonia. In diagnosing COVID-19, staff should look out for common abnormalities like ground glass opacity and consolidation.
42. Ground glass opacity is the term to describe hazy non-solid lung shadowing which doctors see in a scan. This feature is associated with patients who have infection, inflammation (pneumonitis), or fluid in their lungs.
43. Lung consolidation is when the air in the small airways of the lungs is replaced with fluid, solid, or other material. This can include pus, blood, water, stomach contents, or cells. This is also a sign of infection when staff see it in a scan.
44. In COVID-19, the BMJ COVID-19 Guidance says the distribution of ground glass opacity and consolidation in the lungs is normally bilateral, peripheral, and basal zone predominant. This means, in scan images, doctors see such abnormalities in both lungs, normally away from the centre of the lung and in the lower part the lung.
45. The BMJ COVID-19 Guidance says no single feature from the images can confirm COVID19 and X-rays cannot always diagnose it. The guidance says CT scan images provide more detail. Therefore, staff should consider ordering chest CT scans for hospitalised patients, particularly when molecular testing has been inconclusive, or staff consider the patient may have an alternative diagnosis.
46. The guidance says the most common CT scan findings in patients with COVID-19 include ground glass opacity either in isolation or co-existing with other findings like consolidation, interlobular septal thickening, or crazy paving pattern. Interlobular septa are thin connective tissues in the lungs. Crazy paving refers to a pattern doctors may see in a scan. They see irregular lines over the top of lung shadowing. These lines indicate acute lung infection.
47. The guidance says clinicians will most commonly see these findings bilaterally, peripherally, or posteriorly (towards the back) distributed in the lungs. Also, they are normally dominant in the lower lobes (parts) of the lungs. However, more extensive distribution is common in older patients and those with more severe disease.
48. We saw staff diagnosed Mr J with post COVID-19 complications in line with the BMJ COVID-19 Guidance.
49. His care records show staff took a history from him about his condition when he arrived in hospital.
50. Staff noted his GP had started him on antibiotics for a chest infection two days earlier. However, the antibiotics had not improved his condition, his GP suspected sepsis with his infection being the cause, and they arranged for him to come to hospital. Prior to this, staff noted he had been living at home with family, and none of his family reported being unwell.
51. Staff observed symptoms he presented with and obtained a history about them. Staff noted he reported feeling unwell for around one week. This included having a cough which produced bloodstained sputum. He experienced fatigue and breathlessness which had got progressively worse. He reported feeling hot at times too.
52. Staff also noted the paramedics who brought him to hospital found he had oxygen saturation levels below 90% when they first saw him. Paramedics gave him supplemental oxygen to improve these levels.
53. Staff recorded his National Early Warning Scores (NEWS) at 11. NEWS assess a patient’s breathing rate, oxygen saturation level, blood pressure, heart rate, level of consciousness, and temperature. Staff give each parameter a score between zero and three. A score of zero means the parameter is normal. Higher scores indicate the patient is more unwell.
54. Staff add up scores for each parameter to give a total score. They should add two to this score if they need to give a patient supplemental oxygen. A higher overall score means the patient is more unwell and at higher risk of deterioration.
55. Our physician said NEWS above five raise the possibility a patient has sepsis. Our physician added, through the electrocardiogram staff performed, they saw Mr J had a fast irregular heart rate (atrial fibrillation), and this was a new condition for him.
56. We saw all this prompted staff to suspect Mr J had sepsis and atrial fibrillation caused by a respiratory infection. They also noted COVID-19 as a possible cause for this. To investigate COVID-19 further, staff planned blood tests, a COVID-19 test, and a chest X-ray.
57. The BMJ COVID-19 Guidance says staff should have suspected COVID-19 and planned these further tests.
58. Mr J presented with more than one of the common symptoms of COVID-19. He also presented with some of the less common ones. This includes sputum production and fatigue. His NEWS and low oxygen saturation levels evidenced serious illness and complications associated with the condition.
59. Mr J’s care records show staff did the tests they planned.
60. Our physician noted the test results did not confirm COVID-19. However, his X-ray showed bilateral patchy air space in his chest. This meant, in both of Mr J’s lungs, he had patches of air. A normal lung is filled with air throughout, rather than in patches. Patchy air space can indicate inflammation in the lung or fluid pressing on it.
61. Our physician said this finding, alongside his symptoms, suggested an infection like COVID-19. However, the result meant staff could not exclude a bacterial infection or a pulmonary embolus (a blockage caused by a blood clot in one of the pulmonary arteries in the lung). Therefore, they arranged a CT pulmonary angiogram (CTPA).
62. As Mr J presented with COVID-19 symptoms, but the tests staff did were inconclusive and they thought another condition may have explained the serious illness he had, the BMJ COVID19 Guidance recommends CT imaging.
63. Our physician said his CTPA ruled out a blood clot in his lungs. However, it showed bilateral ground glass lung change.
64. As we explained in paragraph 46 and 47, the BMJ COVID-19 Guidance says bilateral ground glass shadowing is the most common finding in with patients with illness associated with COVID-19.
65. Our physician said the evidence staff gathered through their investigations supported the diagnosis they reached on 27 January when they reviewed it all.
66. While Mr J’s COVID-19 test gave a negative result, they said staff cannot rule out COVID-19 related complications purely on this result. The BMJ COVID-19 Guidance says these tests can give false negative results up to 29% of the time. Our physician said the symptoms Mr J presented with, and the results of his scans were in keeping with the diagnosis staff made.
67. We saw staff initially noted Mr J’s symptoms had lasted around a week. Dr B noted on 28 January they spoke to Ms J and recorded she told them his symptoms had lasted five weeks.
68. This happened after staff diagnosed post COVID-19 complications. Also, our physician could not see this did or should have influenced the diagnosis staff reached because Mr J’s symptoms and scan results supported the diagnosis they made.
69. Regarding a serology test, Mr J’s records show staff did one on 25 January. This showed a positive result for COVID-19 antibodies.
70. The BMJ COVID-19 Guidance says staff can do a serology test. That said, staff cannot use the result as a standalone test to diagnose an acute COVID-19 infection.
71. Staff can use these tests to support the diagnosis of the illness. They can be useful when a patient’s molecular tests are negative for COVID-19, and in diagnosing patients with late presentation or prolonged symptoms.
72. However, serology tests have limitations. The results do not indicate the presence or absence of current or previous COVID-19 infections with certainty. The test may detect antibodies the body has developed to fight a different type of infection. If a patient is vaccinated, this may cause a false positive result. The test does not differentiate an acute infection from the antibodies generated following a previous infection or vaccination.
73. Our physician said the serology test would not have made the distinction Ms J says it would (in paragraph 22). Given the limitations of the test, especially given Mr J had received vaccinations, our physician did not see staff failed to act in line with the BMJ COVID-19 Guidance by not referring to the serology test when diagnosing him.
74. Our physician did not see this affected his diagnosis. They added his scan findings and symptoms supported the diagnosis staff reached.
75. Having considered the evidence and advice, we saw staff did the assessments and investigations the BMJ COVID-19 Guidance says they should. After going through this process, staff reached a diagnosis our physician said their assessments and investigations supported. On this basis, we found no failing in staff diagnosing Mr J with post COVID-19 complications.
76. The BMJ COVID-19 Guidance sets out what treatment staff should give a patient to manage severe COVID-19 disease. This guidance says a patient has severe disease when they have clinical signs of pneumonia plus at least one of the following:
• a respiratory rate of more than 30 breaths per minute • severe respiratory distress • oxygen saturation levels of below 90% on room air.
77. As we explained in paragraph 63, Mr J’s CTPA showed ground glass lung changes (a sign of pneumonitis). His oxygen saturation levels were below 90% on room air when paramedics brought him to hospital. When he first arrived in the Trust’s ED, staff noted he had a respiratory rate of 35 breaths per minute.
78. As a patient matching the severe COVID-19 disease criteria, the BMJ COVID19 Guidance says staff should provide the following treatments:
• supplemental oxygen • intravenous fluids • antibiotics (where staff have clinical suspicion of a secondary bacterial infection contributing to pneumonia type symptoms) • corticosteroids (normally dexamethasone, or an alternative like hydrocortisone or prednisolone if staff cannot use dexamethasone or it is unavailable).
79. Mr J’s care records show, prior to diagnosing post COVID-19 complications, staff had already started the first three treatments listed above. They then added dexamethasone to his treatments and gave him his first dose at 8.09am on 28 January.
80. Therefore, having considered the above, we found staff gave Mr J the treatments they should have based on the diagnosis they reached.
81. We also appreciate Ms J told us, if her husband did have COVID-19, she has concerns about staff not using remdesivir as part of her husband’s COVID-19 treatment.
82. She said staff must provide this drug within ten days of a patient’s symptoms starting. Therefore, the timing of when staff considered her husband’s symptoms started was important. She said the alteration Dr B made to her husband’s medical history made him ineligible for this drug, and it wrongly excluded him from having this treatment.
83. The BMJ COVID-19 Guidance acknowledges remdesivir is approved for use by doctors in the UK. Staff can consider using it, but this is not mandatory.
84. Our physician said, and we saw this reflected in the BMJ COVID-19 Guidance, there is uncertainty about remdesivir’s effectiveness. There are conflicting recommendations from different health bodies around the world on whether to use it.
85. The guidance also referenced clinical trials. The results did not show remdesivir improves the eventual outcomes for patients, including reducing deaths related to COVID-19. For these reasons, the BMJ COVID-19 Guidance did not recommend staff use remdesivir.
86. On this basis, we found no failing in staff not giving Mr J remdesivir.
87. We appreciate Ms J is concerned about the way staff diagnosed her husband. We recognise she considers the diagnosis staff made is a key factor in his death.
88. We hope our findings assure her we carefully considered her concerns. We also hope they help assure her about the diagnosis staff made, that they made it in line with guidelines, and then gave her husband the treatment these guidelines recommend.
Organising pneumonia
89. We found no delay in staff diagnosing and treating organising pneumonia.
90. As we explained above, staff diagnosed Mr J with post COVID-19 complications in line with guidelines and they started the recommended treatments for this condition.
91. That said, his care records show the staff overseeing his care also sought advice from ILD unit staff about his condition. ILD unit staff reviewed his records, including images from the scans he had. On 1 February, they gave their views on his condition.
92. ILD staff said they were not convinced Mr J had COVID-19. They wondered whether he had organising pneumonia. They suggested starting intravenous methylprednisolone for three days, followed by oral prednisolone.
93. The staff looking after Mr J noted what staff at the ILD unit said. In his care records, they then recorded organising pneumonia as a potential differential diagnosis secondary to the main condition they already diagnosed.
94. Staff also considered whether they should change his treatment following the ILD unit’s advice. They decided to complete his course of dexamethasone. They noted his respiratory symptoms had improved since starting dexamethasone. However, if his condition worsened later, they could consider whether they should start him on methylprednisolone.
95. The Organising Pneumonia Guidance explains CT scan findings showing bilateral ground glass opacities with air bronchograms, which are usually located in peripheral parts of the lungs, indicate organising pneumonia. When doctors see air bronchograms in CT scans, this is a sign of lung consolidation linked to an infection or pneumonia.
96. Our physician said, while Mr J’s CT scan showed ground glass lung changes, this was not located peripherally, and the scan did not show air bronchograms. Therefore, his scan did not show firm evidence to support a diagnosis of organising pneumonia. Also, ILD staff did not make a definitive diagnosis of this condition either. In the ILD unit’s review of his case, staff said they ‘wondered’ whether this could be the diagnosis.
97. Having considered this evidence and advice, we did not find staff delayed or missed making a diagnosis of organising pneumonia. The clinical evidence did not show all the features the Organising Pneumonia Guidance sets out which suggests the presence of this condition. Therefore, we saw no failing in staff deciding to stick with the existing diagnosis they had in place and continue Mr J’s treatment for it.
98. We also note the Organising Pneumonia Guidance says the main treatment staff should use for this condition is corticosteroids.
99. Our physician said staff were already giving Mr J dexamethasone for his COVID-19 illness. This is a strong corticosteroid. From his care records, they saw staff considered whether to use a higher dose of steroids following the ILD’s advice. That is, in the form of methylprednisolone.
100. When making decisions on providing drugs or treatment, section 16 in Good Medical Practice says clinicians must:
• prescribe drugs or treatment only when the drugs or treatment serves the patient’s needs • provide effective treatments based on the best available evidence • take all possible steps to alleviate pain and distress.
101. Our physician said staff weighed up the benefits and risks of using methylprednisolone. In Mr J’s care records staff noted his condition was already improving on dexamethasone. Therefore, the risks of starting a new treatment when this one was working outweighed the benefits.
102. Our physician said this is the kind of consideration they would expect to see. They added starting a stronger steroid carried a greater risk of making Mr J more vulnerable to infections, and the factors they saw staff considered supported the judgment they reached.
103. Mr J’s care records also show staff continued to monitor his condition and review his treatments. After improvement in his condition, our physician said it deteriorated later, and staff commenced the stronger steroids on this basis on 11 February.
104. Having reviewed the evidence and advice, we saw staff reached a decision on what treatment served Mr J’s needs having considered relevant evidence on his condition. This included the advice from the ILD unit. Staff then considered whether they needed to change his treatment and reached a decision about this in line with Good Medical Practice.
105. We also note, throughout the period, the other guidelines we referred to say the corticosteroids staff gave Mr J were suitable treatments for both the primary and possible differential diagnosis staff had in place. Therefore, we found no failing in the treatments staff gave him.
106. Sadly, these treatments did not prevent Mr J’s death. We do not underestimate how difficult this has been for Ms J.
107. We hope we clearly explained our findings. We also hope they help provide Ms J some assurance about her husband’s care, and they help to bring her closure regarding his death.
1. We recognise Ms J has been through a very difficult time. The Trust admitted her husband, Mr J, to its hospital. Sadly, around four weeks later, he died.
2. We carefully considered Ms J’s concerns about his care. Having done so, we found staff diagnosed and treated Mr J in line with guidelines. For this reason, we decided to not uphold Ms J’s complaint.