Failure to treat Mr Y’s blocked common bile duct in February 2023
16. Miss X complains that the Trust failed to treat her grandfather's blocked bile duct in February 2023. Instead they gave him a follow up appointment in March and then another in May 2023. Miss X believes the delay in treating the blockage resulted in the perforation which affected her grandfather’s outcome and he may not have died.
17. Our surgeon adviser explained that when Mr Y was admitted in February 2023 he was investigated and managed appropriately in line with the NICE guidance relating to the diagnosis and management of gallstone disease. He had a CT scan of his abdomen and pelvis and a MRCP scan. His results were discussed in the cancer multidisciplinary team (MDT). This is a team of health professionals who will work together to plan the treatment that is best for the patient. The Trust diagnosed Mr Y with a common bile duct stone which was partially blocking the duct and the records also show it had caused acute pancreatitis. This is where the pancreas becomes inflamed over a short period of time.
18. The outcome from the MDT meeting recorded the following, “Outcome: CT reviewed – evidence of acute pancreatitis. No evidence of cancer recurrence. MRI showed stone in CBD, biliary dilatation. As patient cannot have ERCP because of total gastrectomy [stomach removal], will need cholecystectomy & ECBD [exploration of common bile duct] once he has recovered from his pancreatitis.”
19. ERCP (endoscopic retrograde cholangiopancreatography) is a procedure to diagnose and treat problems in the liver, gallbladder, bile ducts, and pancreas. A cholecystectomy is surgery to remove the gallbladder.
20. Our surgeon adviser said it was appropriate to allow the pancreatitis to settle before considering treatment to remove the common bile duct stone. The reason for this is that in the circumstance of a total stomach removal, the more straightforward treatment of ERCP is not possible and the surgical options would not be recommended in the presence of acute pancreatitis due to the higher mortality and morbidity risk.
21. If the CBD blockage had worsened on this admission, the correct treatment would be to have a radiological procedure where a drain is placed through the liver into the CBD to allow it to drain externally into a bag-this then allows the patient to get better and then plan interval treatment to remove the blockage.
22. However, in Mr Y’s case our surgeon adviser said there were signs of improvement (liver function tests improved) and he was then appropriately discharged home with a plan for outpatient follow-up in March 2023.
23. Mr Y was followed up in outpatients on 20 March 2023. There is a detailed letter from the consultant surgeon to Mr Y’s GP (with a copy to Mr Y) which records Mr Y’s symptoms at that time. The letter indicates he seemed to be asymptomatic from the CBD stone at that time and he had symptoms of poor appetite and metallic taste in his mouth with reflux like symptoms. The doctor planned a barium meal and follow through test was planned to check for any local gastric cancer recurrence/blockage.
24. After that, the plan was for a joint operation between the liver surgeon and the gastrointestinal surgeon, to remove the gallbladder and the CBD stone. During this time, it was recognised that Mr Y’s nutrition needed to be optimised and he had gastroscopy tests done to insert a naso-jejunal feeding tube. This tube goes through the nose and into the small intestine, which allows liquid feed to be pumped directly into the small intestine without the patient having to swallow any food.
25. The evidence indicates the Trust had an appropriate plan in place to treat Mr Y and measures were taken to optimise his nutrition prior to surgery. Our surgeon adviser said earlier surgery was not indicated in February 2023 and would have exposed Mr Y to a higher risk than planning interval surgery when he was in a more optimum condition e.g. his nutrition and pancreatitis had improved. Our surgeon adviser said there were no easy options in this case. It was sad and unfortunate that Mr Y subsequently presented with advanced cancer and a perforated gallbladder.
26. In the circumstances, taking into account the available evidence and the clinical advice we find there were no failings in the management of Mr Y’s care and treatment following his admission in February 2023. We therefore do not uphold this part of the complaint.
Operation on 24 May 2023
27. Miss X has questioned if there was any the benefit of the operation being done on 24 May 2023 or was it an unnecessary procedure which left her grandfather in pain. She says her grandfather died in pain and without dignity which added to the trauma of his loss. Miss X and her family met with the consultant surgeon who had operated on her grandfather and they discussed his care and treatment.
28. Our surgeon adviser said it is always a difficult decision on whether to operate in this situation. Immediately prior to the operation, there was no evidence of advanced cancer. The MDT discussion from February 2023 did not see any cancer spread. Furthermore a letter to Mr Y from a consultant haematologist dated 17 March 2023 said that a recent OGD and CT scan suggested there was no recurrence of his cancer. An OGD is a procedure which involves looking at the upper part of the gut which includes the oesophagus (food pipe), stomach and the first part of the small bowel (duodenum) with a narrow flexible tube called a gastroscope.
29. Our surgeon adviser said when the decision to operate was made, the surgical team had a patient who was known to have a perforated gallbladder and a CBD stone. They added in theory an emergency operation would cure this problem. However, sadly this was not the case due to the spread of cancer.
30. In the circumstances, we find there is no evidence of failings on the part of the Trust in carrying out the operation. Therefore, we do not uphold this part of the complaint.
Communication from staff regarding Mr Y’s condition
31. Miss X says the family called the Trust between 7.30-8am on 25 May and were told Mr Y was recovering after his operation. However, when they arrived between 2.30-3pm they found him in pain, vomiting blood and apologising that he was going to die.
32. The clinical records indicate that Mr Y was reviewed by the surgeon at 8.52am and was initially stable after the operation. A physiotherapist then reviewed him at 10.30am and recorded Mr Y declined physiotherapy due to fatigue and pain. There is then a untimed pain team review when it is recorded Mr Y was complaining of nausea, vomiting and chest pain. A doctor then reviewed him at 5.43pm and recorded chest pain and vomiting.
33. Our surgeon adviser said the records indicate that there was further deterioration on at 8.05pm. At this stage Mr Y had a fast heart rate (140/min) and a low blood pressure (91/79). The plan was for a repeat CT scan to see if there was any reversal cause for the deterioration on that evening. Unfortunately, the CT scan showed bowel ischemia (lack of blood flow) and that there were no options apart from keeping Mr Y comfortable.
34. We recognise that it must have been very upsetting when the family arrived to find Mr Y’s condition had deteriorated and he was in distress especially if they had been told over the phone that he was recovering. However, there is no evidence that the nursing staff had misinformed the family when they called between 7.30-8am as the records indicate he was stable at that point.
35. In summary, the clinical notes describe a situation where Mr Y was initially stable and recovering from the surgery. At the time of the physiotherapy review at 10.30am he was still stable although feeling some pain. His condition then seemed to have worsened at the time of the untimed review and subsequent review at 5.43pm. He then had an acute deterioration on the evening of the 25 May. He then sadly died a few hours later. Our surgeon adviser said the cause of this deterioration is likely to have been due to a reduce blood flow to the gut which made Mr Y unwell and then despite the best medical treatment his condition became unsalvageable.
36. In the circumstances, we find is that there is no evidence of failings on the part of the Trust regarding communication about Mr Y’s condition. Therefore, we do not uphold this part of the complaint.
Conclusion
37. In summary, having considered the available evidence we find there were no failings on the part of Trust. Therefore, we do not uphold the complaint. We recognise that Miss X and her family have been greatly impacted by the loss of Mr Y and we are sorry about that. We hope our investigation has provided assurances to them regarding his care and treatment and that we have considered the complaint thoroughly.