Medical treatment
17. Mrs A complains that doctors at the Hospital did not investigate what was happening to her husband. She is particularly concerned about why an MRI scan was delayed, as she believes this could have led to his condition being better managed. She believes her husband had a UTI and bleeds on his brain that were responsible for his death.
18. 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.
19. The Delirium Guideline explains how clinicians should manage delirium. It explains how people with delirium should usually be admitted to hospital for urgent assessment, close monitoring and treatment. It says doctors should treat any reversible causes of delirium and consider using antipsychotic medications (such as quetiapine).
20. The UTI Guideline explains how clinicians should treat lower UTIs in men. It says doctors should admit patients to hospital when they have symptoms such as fever, vomiting or confusion. It sets out the types of antibiotics doctors should prescribe in different scenarios.
21. The LUTS Guideline explains how clinicians should manage older men with lower urinary tract symptoms (LUTS). It refers to how they should treat urinary retention. The treatment should include inserting a catheter and considering a range of options to prevent recurrence.
22. The clinical records show Mr A attended the Hospital on 11 December 2022 with confusion, fever, acute urinary retention (difficulty passing urine) and constipation. A doctor in the emergency department carried out a full examination and arranged routine blood tests. They also arranged an ECG (an electrocardiograph, which is a review of the heart’s rhythm and electrical activity), a CT scan of the head and a chest X-ray. The doctor diagnosed urosepsis, constipation, dehydration and delirium and admitted Mr A to the Hospital.
23. Doctors treated Mr A with intravenous antibiotics, intravenous fluids, laxatives and paracetamol. They inserted a urinary catheter (a tube into the bladder) to relieve the retention. They also made an additional diagnosis of Parkinson’s disease.
24. During his admission there were occasions when Mr A fell. Each time he fell doctors reviewed him and investigated him for any injuries, for example by carrying out X-rays. Mr A’s falls did not lead to any significant injuries.
25. On 28 December 2022 a neurologist reviewed Mr A. They suggested he should have an MRI scan to exclude CJD (Creutzfeldt-Jakob disease – a rare and fatal brain disease). They also recommended he should have a lumbar puncture so they could test his cerebrospinal fluid to see whether there were any signs of brain or spinal cord disease. The lumbar puncture did not highlight any significant problems.
26. By 12 January 2023 Mr A complained of pain around his testicles and doctors diagnosed epididymo-orchitis (an infection in the testicles). Doctors gave him antibiotics for this. Around this time Mr A remained confused. At this point he was on a waiting list for a non-urgent MRI scan. On 23 January doctors treated him for urinary retention by inserting a urinary catheter.
27. Clinicians attempted an MRI scan on 19 and 24 January and 2 February 2023. Unfortunately, Mr A was too agitated to tolerate the procedure. The MRI took place under general anaesthetic on 9 February. The MRI scan showed mild degenerative changes and three microbleeds in Mr A’s brain.
28. The Medical Adviser told us an MRI scan is not an emergency procedure for investigating the decline in brain function. The main investigations for that would be a CT scan and a lumbar puncture. The MRI scan was intended to exclude any other causes for the decline Mr A had been experiencing since October 2022. There was no need for clinicians to arrange this urgently.
29. MRI scans require the patient to lie still for usually between 30 and 60 minutes. This is difficult for many patients and more so for those who are confused or agitated. It was challenging for the team to carry out the MRI scan for Mr A under sedation and these attempts were unsuccessful. They took the decision to use a general anaesthetic. This carries a higher risk of harm and doctors were understandably hesitant to carry out the procedure for Mr A when he was so frail. The Medical Adviser was not critical of this decision because doctors were not expecting to find an abnormality on the MRI. This was proven when the MRI scan did take place and showed no issues that would have led to a change in management.
30. The Neurology Adviser told us the microbleeds were tiny dots on the brain which are relatively common in older people. Microbleeds can arise from various causes, for example due to high blood pressure, or trauma, but they are usually incidental. They were of no clinical significance and did not require treatment. The Neurology Adviser said it was quite right that no action was taken in respect of the microbleeds.
31. Mr A spent the remainder of his admission waiting for a care home placement because his health was stable. On 19 February 2023 he developed pneumonia and doctors treated him with antibiotics. On 6 March he pulled out his urinary catheter and again retained urine until clinicians replaced the catheter. Doctors discharged him from the Hospital just over a week later.
32. The clinical records show Mr A returned to the Hospital on 25 March 2023. In the emergency department doctors found he had pneumonia and gave him intravenous fluids and antibiotics. Mr A was frail, and his organs were not functioning properly. During this admission it became clear he was nearing the end of his life.
33. The Medical Adviser told us Mr A’s confusion appeared to fluctuate throughout the two admissions we have investigated. He had good and bad days. The initial confusion was due to a UTI and this is described as delirium. The Medical Adviser said recovery from delirium is variable and can sometimes take weeks or months. Other illnesses can delay recovery and worsen delirium. As we have said above, Mr A had a range of problems including epididymo-orchitis, UTI, pneumonia and urinary retention. Some of the medication he was taking, such as quetiapine, can also delay recovery from delirium.
34. The Medical Adviser said Mr A’s mental health appeared to be worsening. This was linked to his Parkinson’s disease and dementia. By that point doctors considered his confusion was due to these conditions rather than delirium. We will refer to the diagnosis of dementia later in this report.
35. The clinical records show Mr A had antibiotics for most of the time he was in the Hospital. Antibiotics are the recommended treatment as set out in the UTI Guideline. There were episodes of urinary retention and pain around his bladder. But there is nothing to suggest he developed UTIs that doctors failed to identify. The Medical Adviser said it needs to be borne in mind that urinary tract symptoms are extremely common in older men and can develop for a number of reasons that are not always due to an infection. These can include past infections, benign prostate enlargement, urinary catheters, certain medicines and dehydration.
36. The evidence in the clinical records shows doctors provided the close monitoring and treatment Mr A needed for delirium. They tried to treat all the problems he developed during his admissions to the Hospital, including urinary problems. The Medical Adviser told us each of these treatments was appropriate. Doctors followed the Delirium Guideline, the UTI Guideline and the LUTS Guideline. The Medical Adviser said it appeared the main reason for Mr A’s declining health was his underlying dementia. The UTIs and microbleeds on his brain were not responsible for his death.
37. We recognise Mrs A is particularly concerned about the time it took to arrange the MRI scan for her husband. This is clearly a source of distress for her. Our view is the MRI scan was not an emergency investigation and would not have led to any changes in how doctors treated Mr A. There were understandable reasons why it took several weeks for the scan to take place.
38. We find the doctors treating Mr A followed the relevant standards when treating him during the admissions we have investigated. They carried out adequate assessments and examinations. They also gave Mr A appropriate treatment and arranged the investigations he needed. Doctors provided a good standard of care in line with Good Medical Practice.
Lewy body dementia
39. Mrs A says the diagnosis of dementia was ‘based on supposition.’ She says her husband had no signs of dementia and does not believe it could have developed so quickly. She told us that shortly before he attended the community hospital in November 2022 her husband had performed at a local pub playing his guitar, which he could not have done if he had dementia. She recalled dementia was first mentioned during an admission in October 2022.
40. Doctors should have followed Good Medical Practice, as explained above, in terms of carrying out adequate assessments and arranging appropriate investigations when needed.
41. The Dementia Guideline covers diagnosing and managing dementia. It explains how doctors should test for dementia when it is suspected. It says they should carry out physical examinations, blood tests and cognitive testing. It advises using one of various scoring tools for cognitive testing.
42. On 24 December 2022 a Parkinson’s disease specialist reviewed Mr A. They suggested he had Parkinson’s plus syndrome (this is a group of neurodegenerative diseases featuring the classical features of Parkinson’s disease, such as tremor, rigidity and postural instability along with additional features). This included a DaTSCAN for Parkinson’s, which is not often carried out in UK hospitals because of the cost. This scan indicated Mr A had Parkinson’s disease. Doctors also suggested possible Lewy body dementia. The mental health team regularly reviewed Mr A during his admission and prescribed medication for agitation and dementia.
43. By the time doctors readmitted Mr A to the Hospital on 25 March 2023 doctors were firmly of the view that he had Lewy body dementia, which was contributing to his delirium.
44. The clinical records show doctors carried out all appropriate tests and investigations in line with the Dementia Guideline. Doctors also used a scoring tool for cognitive testing which strongly indicated he had dementia.
45. The Neurology Adviser said Mr A had Lewy body dementia. This is a less common type of dementia than conditions such as Alzheimer’s disease. In the more common types, dementia develops when a protein starts to accumulate in the brain. There is now medication that can slow down the rate of dementia to a limited extent. This is not the case with Lewy body dementia. In this case the protein accumulations are known as Lewy bodies and there is no treatment for the condition. Lewy body dementia is often associated with Parkinson’s disease.
46. The Neurology Adviser said there is no specific test for confirming Lewy body dementia. The diagnosis is usually made from clinical opinion. It is not appropriate to take a biopsy from the brain and usually the diagnosis can only be proven after the person affected has died.
47. We appreciate how shocking it must have been for Mrs A when doctors told her that her husband had dementia. These conditions usually develop over several years. We can see from the clinical records that doctors already suspected Mr A had Parkinson’s disease before the admissions we have investigated. There were also episodes of confusion and agitation and some references to possible dementia.
48. We have only reviewed the records relating to Mr A’s admissions from December 2022 onwards and so we cannot know whether he had signs indicating dementia when he saw other doctors before then. The Neurology Adviser said the clinical records they have seen leave no doubt Mr A had Lewy body dementia.
49. We find doctors followed Good Medical Practice and the Dementia Guideline when investigating Mr A’s suspected dementia.
Conclusion
50. We appreciate Mrs A has strong views that doctors failed her husband towards the end of his life. This is not what we have seen. We consider doctors followed the relevant standards. We hope Mrs A is reassured we have seen no evidence to suggest doctors could have done anything differently to give her husband a better chance of survival.
51. We do not uphold Mrs A’s complaint.