Investigations and treatment on 10 November 2021
20. Mr E recalled that his father’s renal consultant spoke to him before the Hospital attendance on 10 November 2021. The consultant was concerned that Mr L needed treatment for his low blood pressure and, possibly, antibiotics. He suspected Mr L had a urinary tract infection (UTI) and he would be advising an overnight admission to the Hospital. Mr E says the consultant’s referral was ignored.
21. Mr E says doctors should have arranged blood tests, urine tests and a second ECG. He does not accept that emergency department staff were unable to take his father’s blood as the Trust has claimed. He points out that clinicians were able to take his father’s blood two days later when his health had worsened.
22. 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.
23. The CKS explains how clinicians should assess patients who have a suspected diagnosis of atrial fibrillation. It explains the features they should be looking for and what an examination should include. It says blood pressure should be checked manually. They should arrange an ECG and consider arranging additional investigations. This can include blood tests, depending on clinical judgment, a chest X-ray and an echocardiogram (a test that uses sound waves to look at the heart).
24. The Medical Adviser told us the investigations doctors should have carried out, or arranged, for Mr L included observations (including blood pressure, heart rate and oxygen levels), an ECG, blood tests, a chest X-ray and an echocardiogram. They said the timing of these actions is dependent on the clinical scenario and some are appropriate to carry out non-urgently as an outpatient.
25. The clinical records show clinicians in the emergency department took Mr L’s blood pressure manually. They carried out an ECG and a chest X-ray. The ECG confirmed a diagnosis of atrial fibrillation, with right bundle branch block, and the chest X-ray was clear. They asked the dialysis unit to arrange follow up blood tests and arranged an outpatient echocardiogram. The Medical Adviser told us these were appropriate investigations as set out in the CKS. Right bundle branch block and atrial fibrillation would not be reasons to arrange a further ECG. In these circumstances there was no need for a second ECG.
26. The Medical Adviser said a mid-stream urine test would be indicated only if there were specific symptoms of a UTI. These would be dysuria (pain when urinating), urinary urgency or urinary frequency or any other strong clinical concern. Bacteria can be present in urine without causing any problems so routine testing of urine is unhelpful and leads to unnecessary and potentially harmful antibiotic use.
27. The Trust said a triage nurse probably attempted to take blood before logging her request on the system. It accepted this did not meet its standards in terms of the documentation. The Trust said the attempts were unsuccessful but not surprising given Mr L’s history. The nurses decided to wait for a doctor who attended at 7.58pm and decided it was not necessary to arrange blood tests. The plan was to take a sample at the next dialysis cycle.
28. There was no requirement in the CKS that blood tests should have been completed while Mr L was in the emergency department. This was a matter of clinical judgment. The Medical Adviser said there were no clinical signs to suggest Mr L had a blood infection. The documentation suggests he appeared ‘fit and well’ when the emergency medicine consultant assessed him. He did not have a fever and his reducing NEWS2 score did not indicate a blood infection.
29. Mr E says doctors should also have considered physiotherapy or occupational therapy because of his father’s reduced mobility. This was suggested by Mr L’s renal consultant in the letter he sent to the emergency department, although there was no explanation for this recommendation.
30. The Medical Adviser said physiotherapy and occupational therapy assessments would not be a reason to admit someone to hospital. The medical reviews suggest Mr L was ‘alert, orientated, mobile with a stick’ and ‘feels his normal self, wants to go home.’ This indicates that there were no urgent concerns about mobility. The Medical Adviser said it would be appropriate to arrange these interventions as outpatient referrals and this could be initiated either by the patient’s GP, the dialysis team or the medical team at the Hospital.
31. Mr E says his father’s observations, such as his blood pressure, were not monitored properly in the emergency department. He considers clinicians should have monitored blood pressure electronically rather than using a manual blood pressure cuff. He says his father’s NEWS2 score had decreased from four to one. He questions how this could have been accurate.
32. The clinical records show healthcare professionals monitored Mr L’s observations appropriately. They took a manual blood pressure reading, as recommended in the CKS. Clinicians at the dialysis unit calculated Mr L’s NEWS2 score as four on the afternoon of 10 November 2021. On arrival in the emergency department shortly afterwards Mr L’s NEWS2 score was one. The impression is that Mr L’s observations were improving.
33. The Medical Adviser told us a NEWS2 score of four or less indicates Mr L’s observations were in the normal range. The individual observations (such as heart rate, blood pressure, temperature) do not indicate Mr L was seriously unwell while he was in the emergency department on 10 November 2021. Under the system used at the Trust his observations needed to be taken every four hours. There was no need of any more frequent observation at that stage.
34. We recognise Mr E believes staff at the Hospital should have done more for his father. We find the clinicians followed the relevant standards when Mr L attended the emergency department at the Hospital on 10 November 2021. They arranged appropriate investigations in line with the CKS. They also followed Good Medical Practice by carrying out adequate assessments and arranging appropriate further investigations.
Leaving the Hospital on 10 November 2021
35. Mr E believes the decision not to admit his father on 10 November 2021 was a ‘failed discharge.’ He disagrees with the Trust when it said the decision was ‘appropriate.’ He says there was no follow up referral for blood tests or other investigations in the community.
36. Decisions about whether doctors should admit people to hospital are made on a clinical basis and are a matter of judgement. We have explained above how doctors must follow Good Medical Practice. This also says doctors must provide effective treatments based on their assessment of the patient’s needs.
37. The Medical Adviser told us Mr L was well enough to leave the emergency department. The medical consultant in the department carried out initial investigations and provided appropriate treatment. The treatment was bisoprolol for atrial fibrillation, discontinuation of blood pressure lowering medication (amlodipine) and further outpatient tests (blood tests and echocardiogram). This was in line with Good Medical Practice.
38. The medical consultant’s letter to Mr L’s consultant says he gave him a blood form so he could hand it to the dialysis team at his next attendance. It stated an outpatient appointment had also been arranged. It is not possible to categorically confirm that clinicians gave Mr L a blood form, either from a supply that had already been printed or one that was printed at the time. It is also not possible to see details of the outpatient appointment that did not then take place. On balance, our view is it is more likely than not that the medical consultant’s letter was accurate in relation to these follow up arrangements.
39. Mr E said his father lived home alone and was ‘elderly and vulnerable.’ He says clinicians should not have arranged for a taxi to take him home.
40. The Trust said there are strict criteria about when ambulances can be used, and Mr L did not meet those. Mr L had capacity and was mobile with a stick. He was considered clinically well enough to travel in a car. The Medical Adviser agreed with the Trust. The clinical records do not suggest Mr L was immobile. They said a taxi is a suitable and often more timely mode of transport for a patient leaving the department and it appeared this was appropriate in Mr L’s case.
41. Mr E also says staff failed to notify him they had not admitted his father to the Hospital. Mr E says a doctor sent a letter to his father saying he was sent home because he was ‘so well.’ He says this was sent after his father died and he believes it was an attempt to justify the decision.
42. There is no suggestion in the clinical records that Mr L lacked capacity to make decisions about his medical care on 10 November 2021. The Medical Adviser said it would not be expected, during such a short attendance, that clinicians at the Hospital would contact Mr L’s family. The exception would be if Mr L asked for staff to contact his family. There is no evidence that he requested such contact.
43. The Trust has confirmed the letter from the consultant was dictated and then printed on 11 November 2021. The Medical Adviser told us the letter in question is in keeping with the medical review the consultant documented on 10 November. There is no reason for us to suspect this letter was completed after the event. Clearly, doctors considered Mr L was well enough to leave the Hospital and this is supported by various records detailing the investigations and observations completed during his attendance.
44. We find doctors followed Good Medical Practice when they planned for Mr L to leave the Hospital on 10 November 2021. We recognise Mr L disputes this and considers his father was not well enough to go home and we appreciate his strength of feeling about these issues. This is understandable given the rapid decline in his father’s health over the following days. We have seen no evidence to suggest the care clinicians provided fell below the relevant standards.
Investigations and treatment on 12 November 2021
45. Mr E says doctors failed to take troponin tests quickly enough and then delayed obtaining the results when they were available from the laboratory. He is dissatisfied that the request seems to have been categorised as ‘routine.’ This meant the test results were only available in the department at 4.36pm. He believes this contributed to a failure of doctors to diagnose a heart attack until later in the day.
46. Mr E also says doctors delayed prescribing anticoagulants despite his father having signs of a heart attack.
47. The doctors attending to Mr L should have followed Good Medical Practice, which we have explained earlier in this report.
48. The Hyperkalaemia Guideline explains how doctors should identify and manage hyperkalaemia. This is a condition where there is a higher than normal level of potassium in the blood. It is common in patients with kidney failure. The Hyperkalaemia Guideline recommends giving patients insulin-glucose with additional salbutamol and calcium.
49. The ACS Guideline explains how healthcare professionals should manage people who have ACS. It aims to improve survival and quality of life for people who have heart attacks. When a heart attack is suspected it says people should be given a single loading dose of 300mg aspirin as soon as possible. For people with a suspected NSTEMI (a type of heart attack where one of the smaller coronary arteries is blocked) the ACS Guideline recommends treatment with anticoagulants. It also says doctors should consider using heparin.
50. The Trust accepted there was a delay in confirming Mr L’s troponin levels. It said this is unlikely to have had any impact on Mr L given the extent of his heart attack. The Trust said all requests from the emergency department are treated as urgent by laboratory staff. The coroner concluded that nothing could have been done differently in respect of medical care that could have affected the outcome for Mr L.
51. The clinical records show Mr L was already taking clopidogrel (an anticoagulant). Paramedics also gave him 300mg of aspirin before he arrived at the Hospital.
52. The clinical records show that a doctor in emergency medicine reviewed Mr L at 11am. They took Mr L’s history and examined him. They arranged for him to have ECG and a blood test for troponin. They diagnosed hyperkalaemia and gave Mr L insulin-glucose and salbutamol to try and lower the potassium level. They also prescribed intravenous calcium to try and protect the heart. These were administered between 12.30pm and 1.15pm. The Emergency Medicine Adviser and the Medical Adviser both said this was in line with the Hyperkalaemia Guideline.
53. Just after 11am clinicians took blood samples from Mr L for testing. One of these tests was for troponin. This first troponin test haemolysed, meaning the red blood cells had broken down and so the sample was not suitable for testing.
54. At 2.25pm a medical registrar (a senior grade doctor) reviewed Mr L. They confirmed the previous diagnosis of hyperkalaemia. At 2.51pm repeat blood samples were taken for further testing, including troponin. The troponin result was available at 3.50pm and showed evidence of a heart attack. A consultant physician reviewed Mr L a few minutes later, starting at 4.05pm. They diagnosed a NSTEMI and treated Mr L with additional clopidogrel (an anticoagulant), aspirin and enoxaparin (heparin). The records show these were administered at 4.45pm. The Medical Adviser told us doctors followed the ACS Guideline when they treated Mr L.
55. The clinical records are clear that once doctors diagnosed the heart attack, they provided appropriate treatment for Mr L. Mr L was already taking clopidogrel before his admission to the Hospital. Paramedics also gave him aspirin. Following the diagnosis of NSTEMI they gave him additional clopidogrel and heparin. The ACS Guideline does not suggest doctors should provide this treatment before diagnosis. The treatment can be harmful and increases the risk of bleeding or strokes. We have seen no evidence of any undue delay in treatment.
56. The Medical Adviser said they agreed with the coroner that Mr L was critically unwell when he arrived at the Hospital on 12 November 2021. The chance of him surviving was extremely low from the outset. There is no evidence to suggest doctors could have done anything differently that could have led to his survival.
57. We find the doctors who treated Mr L followed Good Medical Practice, the Hyperkalaemia Guideline and the ACS Guideline on 12 November 2021. There is no suggestion that test results were not prioritised or that there were significant delays in administering medication. We recognise Mr E strongly believes there were failings in care and treatment that contributed to his father’s death. We are persuaded the clinical records do not show any evidence of such failings.
Clinical records
58. Mr E says the notes from 10 November 2021 had been ‘dishonestly rewritten’ following his father’s death and his complaint. He disputes the nursing records which refer to an attempt to take blood. He says if this had happened there would be a computerised record and patient identification labels would have been generated to place on the containers for the samples. He said there is no evidence of any identification labels being affixed to the emergency department records.
59. Mr E has asked the Trust to provide a copy of the record showing request for blood tests that were sent to the laboratory on 12 November 2021. He also says there is a lack of any medical notes until 2.25pm and no evidence of any medication being administered before then. He believes the Trust is deliberately withholding medical records from him. He refers to missing electronic records relating to blood tests. Mr E says a nurse may have amended clinical records after the event for both of his father’s Hospital attendances.
60. Good Medical Practice says doctors must keep records that are clear, accurate and legible. It says they must make records at the same time as the events they are recording or as soon as possible afterwards. Documents should include relevant clinical findings, decisions made, actions agreed, information given to patients, drugs or treatments prescribed or given and who is making the record and when.
61. Our Principles of Good Administration say organisations must be ‘open and accountable.’ It says public organisations must be transparent and handle information as openly as the law allows. They should handle and process information properly. They should also create and maintain reliable records as evidence of their activities.
62. The Trust explained there was an incorrect time of admission documented for 12 November 2021. It said that records from the 10 November were likely still in the department and mistakenly merged with the current information. It seems this was a genuine error.
63. The Trust said electronic patient labels are usually generated when a patient is triaged in the emergency department. Staff recalled there was an issue with the supply of blank labels at the time of Mr L’s attendances. It suggested this was the reason no labels were attached to the emergency department booklet. It considered this was sufficient information to confirm the records were Mr L’s.
64. The Trust did not have any concerns with the nursing records, which it believed to be in the correct sequence. It did find one entry that was not dated or timed and said this would be addressed using its audit programme. The Trust considers it had sent Mr E all documents that were part of his father’s records.
65. We have reviewed the clinical records relating to Mr L’s care and treatment on 10 and 12 November 2021. We are persuaded they are, aside from the exceptions mentioned above, accurate and were completed as soon as possible after the events documented. The records are consistent and were completed by several different clinicians.
66. The Trust has provided a plausible explanation for the lack of identification labels. It is not proportionate for us to carry out a forensic analysis of the concern about whether labels were or were not printed. It is unlikely such information would be available now given the passage of time. In any case, we cannot see that if there was a discrepancy between the Trust’s position about the labels and the physical evidence, this would have had any impact on Mr L’s treatment. At the time of Mr L’s attendance on 10 November 2021 observation and test results did not show he needed to remain in the Hospital.
67. The Medical Adviser said they have no concerns with the veracity of the information provided. The records contain all the information we would expect to see when conducting a detailed investigation. We find doctors followed Good Medical Practice in terms of their record keeping.
68. We have seen no evidence to support Mr E’s view that there are other clinical records the Trust has refused to share with him. We find the Trust’s records to be reliable and there is no indication it has not been transparent with Mr E or that its staff completed records fraudulently. The Trust has followed our Principles of Good Administration in ‘being open and accountable.’
69. We can see Mr E is adamant there have been significant failings in the Trust’s record keeping and in sharing information with him. We hope he is reassured we have seen no evidence of any faults in this respect.
Communication on 12 November 2021
70. Mr E says doctors failed to advise him that his father’s health was worsening. He referred to the conversation he had with a doctor in the hour before his father died. He recalled a conversation about a potential transfer to a specialist cardiology team in Liverpool. He understood the specialist team had agreed to accept his father once his condition had stabilised. He says the notes suggest this was not the case and that the specialist team had refused to accept his father and suggested he should be given palliative care.
71. Good Medical Practice says doctors must communicate effectively with patients and their relatives. It says they must be considerate to those close to the patient and be sensitive and responsive when giving them information and support.
72. The Trust said it is not standard practice to notify family members when there are small changes in observations or patients are moved to a different location unless there are specific concerns at the time or signs of deterioration. There were no such concerns for Mr L. It said his death was not expected even at the time of the phone call with the doctor shortly before he died.
73. The RCA report notes that Mr E called his father at 10.13am. He asked his father to request a call from someone at the Hospital so that he could decide whether he needed to travel to the Hospital. He spoke to his father again around two hours later.
74. Mr E called his father again at 3.25pm. His father passed his phone to a nurse. Mr E recalled being told about his father’s blood pressure, potassium levels and episodes of loss of consciousness. He said the nurse told him about the hyperkalaemia diagnosis. However, the nurse was unable to answer all his questions and agreed to ask a doctor to contact him.
75. The Trust said a registrar attempted to call Mr E at 5pm, but there was no answer. This was at Mr L’s request during his review around forty minutes earlier. Mr E returned the call at 5.19pm. The notes the registrar made suggest he told Mr E about his father’s heart attack. Mr E wanted his father to be transferred to the cardiology team in Liverpool. His understanding of the call was that this was a possibility. However, the registrar documented that the cardiology team would not accept Mr L.
76. The only clinical record relating to phone calls between clinicians and Mr E was at 5.19pm. The registrar noted he told Mr E his father was ‘not good.’ In terms of a potential transfer the registrar wrote ‘I said I have already discussed [with the cardiology team in Liverpool] and they are not taking him urgently.’
77. It is clear from the records that it only became apparent to doctors at the Hospital that Mr L was seriously unwell around 4pm. Mr L requested that someone should contact Mr E during this review. The evidence shows a doctor tried to contact Mr E around one hour later and was then able to speak with him about his father’s health. There is no way the doctor could have known Mr L was going to die a short time afterwards.
78. It is not possible for us to establish exactly what was said during the phone call. Mr E clearly has a different recollection to the doctor. We can only say there was a discussion about a possible transfer, but this was not possible at that point because of the severity of Mr L’s illness.
79. There is only a brief mention in the records about contact with the specialist cardiology team. At 4.05pm a consultant referred to discussion with the specialist team as part of Mr L’s management plan. The only other reference was to the phone call between Mr E and the registrar at 5.19pm. It is likely events moved too fast for the doctors to make any further contact with the specialist team or for them to be able to make a detailed record of the call.
80. We find there is no evidence to suggest doctors failed to communicate effectively with Mr E. It is unfortunate that Mr L became seriously unwell so quickly and this meant Mr E could not be with him before he died. We cannot say this was because of any faults by clinicians at the Hospital. We find doctors followed Good Medical Practice.
RCA
81. Mr E says the RCA investigation showed the Trust was not being ‘open and honest.’ He says it failed to identify the issues he complained to us about and did not challenge the information provided.
82. The Principles of Good Complaint Handling says public organisations should be ‘open and accountable.’ This includes providing honest, evidence-based explanations and giving reasons for decisions. It also says organisations should act ‘fairly and proportionately.’ This includes ensuring that complaints are investigated thoroughly and fairly to establish the facts of the case.
83. We can see the Trust used the RCA process to respond to the specific complaints Mr E raised about his father’s care. In addition to providing an analysis of Mr L’s attendances on 10 and 12 November 2021 it included a section of the report to address ‘family’s questions.’
84. The RCA report drew on information from Mr L’s clinical records. It included a detailed chronology based on Mr E’s recollections in addition to the clinical records. Its conclusion was there were no failings relating to treatment. It accepted there was a failing relating to an issue we have not included in this investigation. The RCA made recommendations based on the failings identified. It produced an action plan to address these.
85. The ‘family questions’ section included responses to 24 points Mr E raised in his complaint. We can see these responses were based on Mr L’s clinical records. We can see no evidence of any significant errors in relation to the Trust’s responses to Mr E’s questions.
86. We find the RCA provided evidence-based explanations and reasons for decisions. The RCA report shows the Trust investigated Mr E’s complaint thoroughly and fairly to establish the facts of the case. We consider the Trust showed it was ‘open and accountable’ and it acted ‘fairly and proportionately.’ We do not consider there were any failings in care and treatment and agree with the RCA report’s conclusions.
Conclusion
87. We can see how his father’s unexpected death has been extremely distressing for Mr E. We have carefully considered what he has said and reviewed all the available evidence. We recognise Mr E has strong views that more could have been done. We have seen no evidence of any failings in clinical care and treatment or about the issues relating to communication and complaint handling we have investigated. We do not uphold Mr E’s complaint.