Missed opportunities to investigate and diagnose Mrs Y’s lymphoma 18. Mrs X has complained about the care and treatment Mrs Y received relating to the investigation and diagnosis of her lymphoma. The Trust said in its SI report there was no evidence of Mrs Y’s lymphoma on any of the imaging including ultrasound, MRCP and CT carried out in January and February 2021.
19. Our radiologist adviser has reviewed the imaging and confirmed that the reports of the imaging as set out in the SI report are an accurate representation of the imaging. Our radiologist adviser confirmed there is no evidence of lymphoma. The imaging reports meet the required standards as stipulated by the above Royal College of Radiologists (Standards for interpretation and reporting of imaging investigations, Second edition).
20. Mrs X complained the Trust did not investigate Mrs Y’s elevated LDH levels and believes this was a missed opportunity to diagnose Mrs Y’s lymphoma sooner.
21. Mrs Y attended the Trust's ED on 20 January 2021 with a one-week history of headache, nausea, fatigue, loss of appetite and breathlessness. It is noted that her LDH result was 1285 which is considered abnormal. The Trust’s SI panel considered the elevated LDH required further investigation. However, Mrs Y was discharged with no further action.
22. Our physician adviser explained that LDH has very little, if any, role in the diagnosis of cancer. This is because it is not specific or sensitive enough and so cannot be recommended as a specific marker in cancer diagnosis. Our physician adviser explained during COVID, LDH was tested more frequently than previously because it was thought to have some benefit in diagnosing the progression of COVID 19 pneumonia and the severity of the disease (Usefulness LDH COVID-19 pneumonia). When Mrs Y had the test in January it was requested in the context of her having suspected COVID. Our physician adviser said during Mrs Y’s January admission, the LDH level ceased to be of clear relevance because she tested negative for COVID.
23. Our physician adviser said that a raised LDH in the absence of a suspicion of cancer would not lead to a series of investigations for a hidden cancer unless there were other reasons for suspecting cancer. However, there were no other reasons evident at that time.
24. We consider it was reasonable for the Trust to attribute the raised LDH to a viral illness as there was sufficient evidence to suspect this. Furthermore, because LDH is not used to detect cancer and because it is a non-specific test that has limited uses aside from monitoring treatment response in patients who have cancer and assessing how far conditions such as COVID have progressed.
25. Out physician adviser said that usually, if the patient clinically improves the LDH will not be regarded as relevant. the Trust said in its SI report ‘…at the most, a repeat test in a few weeks’ time would have been the likely outcome.’ Our physician adviser said ‘At the most’ is the operative phrase here as many clinicians would not have repeated the test.
26. Our physician adviser has indicated there was no requirement that a further investigation should have happened. This is because in the absence of additional clinical indications, many doctors would argue further investigation (including repeating the LDH) is not warranted. We note that the Trust doctor chose to repeat the liver function tests with Mrs Y as an outpatient. Our physician adviser said it would only have been appropriate to do this as an outpatient as there was no reason to keep Mrs Y in hospital.
27. Mrs Y attended the Trust's ambulatory care unit (ACU) on 11 February 2021. Mrs X raised concerns that no action appears to have been taken to investigate a second raised LDH level of 1636. She believes that a PET scan would likely have been arranged.
28. The surgical team discharged Mrs Y on 14 February 2021. The surgeon’s plan was for the GP to repeat liver function tests and to follow up the result of the liver autoantibodies (looking for autoimmune diseases that can cause deranged LFTs) and to arrange further investigations for Mrs Y’s anaemia. Mrs Y was discharged with gastroenterology, respiratory and cardiology follow up planned and with ‘safety netting’ advice provided.
29. The Trust said in its SI report that "a raised LDH level in the context of a patient who may have had a viral illness along with abnormal LFTs, a PET scan would not have been indicated at that time. The plan would have been to observe the LDH level and LFTs would be repeated and monitored which they were. If the LDH level had been raised without a recent viral illness having occurred and without abnormal LFTs, then a PET-CT would have been indicated. If the LFTs and LDH had been repeated and were still abnormal or not improving, then a PET-CT would have been warranted".
30. Our physician adviser has confirmed the Trust explanation is reasonable because the raised LDH in the context of the viral illness and abnormal LFTs meant that a PET-CT was not indicated. The records show that Mrs Y went on to have appropriate investigations for the abnormal LFTs (ultrasound and MRCP).
31. We find the imaging was accurately reported and there was no evidence of Mrs Y’s lymphoma. Furthermore, there is no evidence of failings regarding the investigation of the LDH levels as this is not a significant marker in the diagnosis of cancer. Therefore, as there are no evidence of failings regarding this aspect of Mrs Y’s care we do not uphold this part of the complaint.
The Trust failed to manage Mrs Y’s acute kidney injury after her admission on 18 March 2021 32. Mrs X complains the Trust failed to implement the AKI bundle following Mrs Y’s admission on 18 March 2021. The Trust has acknowledged the AKI bundle was not implemented in line with its policy.
33. On 18 March 2021, Mrs Y attended Wexham Park Hospital ED at 5.31am. She had a four day history of shortness of breath, nausea, dizziness, vomiting, lethargy, jaundice, reduced oral intake, low blood pressure and tachycardia (fast heart rate). Her blood pressure on triage was very low (71/50) with a heart rate of 112. Her temperature was also low. Her overall NEWS score was 6 indicating she needed a medical review.
34. An ED doctor saw Mrs Y at 6.03am and recognised typical ‘B symptoms’ (of haematological malignancy), weight loss, lethargy, loss of appetite, fevers. Examination then revealed she appeared dry (dehydrated) with a prolonged capillary refill time of 4 seconds (how long it takes for the colour to return to the skin when pressing down, indicative of how well someone’s body is perfused with blood, it should be less than 2 seconds). It is noted she had very dark urine, no oedema (swelling on the ankles) and was very jaundiced. The bloods revealed Acute Kidney Injury (AKI), or kidney failure. The creatinine (waste product that is measured to assess how well the kidneys are clearing the blood) had risen. Her lactate was elevated (suggesting low oxygen levels in the blood due to her low blood pressure). The diagnosis was of AKI and possibly malignancy. Mrs Y was given intravenous fluids (1L over 1 hour) and trimethoprim (an oral antibiotic for a UTI). She was admitted under the medical team.
35. Both the Trust’s own deteriorating patient policy and the AKI care bundle indicated fluid balance monitoring should have been commenced. Mrs Y’s case hit multiple criteria for this including a suspected sepsis, AKI, vomiting, reduced oral intake and dehydration.
36. Our acute medicine adviser said the use of the AKI care bundle would have prompted the doctor towards the potential diagnosis of sepsis and thus administration of intravenous antibiotics, as well as delivering a more rapid fluid input for resuscitation. There was a delay in administering antibiotics and Mrs Y’s urine output should have been more accurately and closely monitored every hour. The records indicate that Mrs Y had a urostomy bag but this was not connected to a urometer which would have helped with the monitoring of her urine output. Better monitoring would have helped assess her response to treatment, therefore guiding further escalation actions. However, this did not happen.
37. The Trust acknowledged in its SI report the junior doctor did not request strict urine output monitoring, It acknowledged “this was a significant omission given the diagnosis of an acute kidney injury, which in itself should have prompted the use of the AKI bundle.”
38. We find there was a failing on the part of the Trust regarding the implementation of the AKI bundle. We have considered the impact of this failing below.
Failure to escalate a NEWS score of 8 on 19 March 2021Q3 39. Mrs X complains that nursing staff on Y 17 failed to escalate a NEWS score of 8 for 5 hours on 19 March 2021 leaving her sister’s condition to deteriorate. Mrs X says she has never received an explanation from the Trust regarding this.
40. On 19 March at 2am, Mrs Y’s blood pressure was 91/57 and her heart rate was 101. Her overall NEWS score was 3. Our acute medicine adviser said the frequency of observations, going strictly by the Trust’s deteriorating patient’s policy, was a minimum of 4 hourly, which should have been done by 6am. However, our acute medicine adviser said this is only a minimum frequency and the registered nurse should decide on the frequency of observations.
41. Our acute medicine adviser said that given the blood pressure was low, it should have been checked again during the night in order to assess the response to treatment being provided. This is supported by the NICE Sepsis guidelines where there is a focus on monitoring response to treatment and acting accordingly. If it had been checked then it is possible that her care could have been escalated sooner which may have resulted in Mrs Y being admitted to the ICU overnight rather than later that day.
42. When the observations were done at 7.18am, Mrs Y’s NEWS score was 8, with a blood pressure of 81/59 and a respiratory rate of 28. These observations indicate that Mrs Y had not responded adequately to treatment and was critically ill.
43. The Trust’s deteriorating patient’s policy indicates that a NEWS score of 8 should trigger a 2222 call for the NEWS response team, and the nurse should have immediately informed the Mrs Y’s medical team. Therefore, she should have been seen before 7.30am (giving time for the NEWS call team to arrive). However, this does not replace the clinical judgement of the medical and nursing teams monitoring patients and their response to treatment, and Mrs Y’s blood pressure should have been monitored more closely overnight and escalated if indicated. An escalation call to the medical team was not made until 8.14am. The Trust has acknowledged that there was a delay in an emergency medical review being made.
44. We find there was a failing on the part of the Trust regarding the escalation of Mrs Y’s care to the medical team. We have considered the impact of this failing below.
Failure to administer IV fluids on 19 March 2021 45. Mrs X complains that nursing staff on Ward 17 failed to administer IV fluids on 19 March 2021 (12 noon) which a consultant reported as a “Clinical Triggers Event” on 23 March. The consultant’s report described this as a "Loss or compromise of chance for successful treatment".
46. Our acute medicine adviser explained a person’s fluid status is either dehydrated (as in this case), euvolemic (meaning ‘about right’) or overloaded with fluid. When assessing a patient’s fluid status, a doctor takes into account factors such as their history (such as vomiting/reduced oral intake), their examination (such as blood pressure including when standing up, dry mucous membranes, capillary refill, the presence or absence of crackles on the chest, the jugular venous pulse in the neck (how distended the vein is) and the presence of absence of oedema (swelling) on the legs. Blood tests and other investigations can also guide this assessment. In this case, it was apparent Mrs Y was dehydrated due to her inadequate intake of fluid for some time prior to coming to hospital, she would have a ‘fluid deficit’, meaning the volume of fluid needed to correct her dehydration. This would be in line with the NICE Guidelines on intravenous fluid therapy in adults in hospitals.
47. The IV fluids were to help rehydrate Mrs Y and also to provide fluid resuscitation (rapidly administering fluid to help improve her critically low blood pressure). As such, it is important that these are administered urgently and not interrupted. This did not happen.
48. We find there was a failing on the part of the Trust regarding the administering of IV fluids as identified by the consultants “Clinical Triggers Event”. We have considered the impact of this failing below.
Impact
49. We have identified there were failings during Mrs Y’s admission in March 2021 regarding • The implementation of the AKI bundle • The escalation of a NEWS score of 8 • The administering of IV fluids
50. We have considered the impact of these failings on Mrs Y.
51. The medical team managing Mrs Y’s care suspected she had sepsis and this was initially recorded on the post mortem report as the primary cause of death. However, there was a discussion between the Trust’s medical team and the coroner’s pathologist at the inquest. As a result of this the coroner concluded sepsis played no part in Mrs Y’s death bur rather her death was due to overwhelming lymphoma which had spread to her organs leading to multiorgan failure.
52. Our acute medicine adviser said the cause of death was multi-factorial. Ultimately, these problems stemmed from the lymphoma. They said it is clear from the medical evidence that the lymphoma involved many vital organs. Our acute medicine adviser said even though there were no bacteria found in the blood (besides that which was almost certainly from contamination from the skin), this does not mean that there was not an element of sepsis. However, the coroner’s verdict was this played no part in Mrs Y’s death and we are unable to contradict that finding. We also consider kidney failure was not a cause or significant contributor to Mrs Y’s death.
53. We do consider the implementation of the AKI care bundle, the delay in escalation of Mrs Y’s care in relation to the elevated NEWS and the administering of fluids would have had some impact on the general effectiveness of the medical care provided to Mrs Y. However, our acute medicine adviser said the extent of this impact would have been minimal. Our acute medicine adviser said that ultimately, the aggressive nature of Mrs Y’s lymphoma was such that at the time of her admission, death was by far the most likely outcome, even with optimum care.
54. We note that the Trust has acknowledged there were failings in the care provided to Mrs Y. It has explained in its SI report the steps it has taken to avoid a recurrence and these appear appropriate in the circumstances. However, we do not consider the Trust has fully acknowledged or apologised for the impact that these failings have had on Mrs X. It is a source of great upset and distress for her to know Mrs Y’s care was suboptimal during her final days. We have therefore made recommendations below to address this. Our decision is that we partly uphold these parts of the complaint.
Complaint handling/Serious Investigation 55. Mrs X complains that there was undue delay on the part of the Trust in investigating her concerns about Mrs Y’s care and treatment and carrying out a serious incident investigation. This resulted in Mrs Y’s inquest being delayed on two occasions.
56. Mrs X says the continual delays caused her huge emotional distress, mental stress, and anxiety. The Trust has acknowledged in its letter dated 22 August 2022 that it had not followed its process for a serious investigation. It apologised for the distress caused by the significant delay. It also explained the steps it was taking to avoid a similar occurrence.
57. We welcome the Trust’s apology and the actions it has taken which are appropriate in the circumstances. However, whilst the Trust has apologised to Mrs X for the distress caused by the significant delay we do not consider this fully provides a remedy to Mrs X. We consider Mrs X is entitled to a further personal remedy in line with our above principles. Therefore, we have made a recommendation below to address this.