The Trust did not admit Mr H on his first visit to the ED
24. Miss H complains the on his first visit to the ED on 25 August 2021, the Trust did not admit her brother. She says the Trust did not read the notes she had from Salford Royal hospital and rather than admit her brother, discharged him with instruction to drink more as he was dehydrated.
25. In its responses to Miss H’s complaint, the Trust acknowledged it should have admitted her brother on his first attendance at the ED on 25 August. It explained it should have contacted Salford Royal Hospital at this time and, had it done so, it would have admitted Mr H. It went on to say this would have enabled earlier monitoring, but it is unlikely it would have prevented his death.
26. When a patient arrives in the ED, they should be ‘streamed’ into the right care path. For instance, patients with a non-life-threatening conditions may be prescribed painkillers and instruction to attend their GP. A person with more serious symptoms that are time-critical can be admitted. This is explained in NHS England's Principles for clinical streaming.
27. We spoke with our cardiology adviser to help understand what should have happened when Mr H first attended the ED. Our adviser explained the Trust acted to find whether the collapse was due to hypotension (low blood pressure) or arrythmia (abnormal heart rhythm), finding it to be due to orthostatic hypotension (a fall in blood pressure).
28. Our adviser said that after monitoring Mr H for a reasonable time, his heart rate was stable at 80 beats per minute and did not place him at risk, hence the discharge. The medical records show his heart rate settling at 80 beats per minute.
29. Our adviser explained the Trust acted in line with NICE’s Overview - Transient loss of consciousness ('blackouts') in over 16s, whereby referral for cardiovascular assessment is not needed when the collapse is due to orthostatic hypotension. This diagnosis is shown in the medical notes on Mr H’s first attendance at the ED.
30. From the medical notes, and our adviser’s comments, it is reasonable to consider discharge when a patient does not have other medical issues.
31. However, our adviser explained it would have been helpful to investigate Mr H’s history before discharge. They felt the Trust was missing key information about Mr H’s cardiac condition (severe mitral stenosis, a narrowing of the mitral heart valve) and that if it had known of this, it may have considered performing an ECHO cardiogram and lowering the threshold for admission.
32. From our consideration of this issue, we can see both the Trust and our adviser agree Mr H should have been admitted on his first attendance at the ED.
33. Our adviser explained admission would have been unlikely to have made a difference, and it is sadly unlikely Mr H would have survived. This is because the cause of death was due to an arrythmia (an electrical disturbance in his heart), a sudden event which did not show in any of Mr H’s tests and was not the known valve disease.
34. The Trust’s response states it should have contacted Salford Royal Hospital for more information, therefore the Trust did not follow GMC ‘Good Medical Practice’ guidelines as section 15a requires doctors to ‘adequately assess the patient’s conditions, taking account of their history’. In its responses to Miss H’s complaint, the Trust acknowledges it did not do this on his first attendance at the ED.
35. The Trust has apologised for not considering the notes from Salford Royal Hospital and not admitting him on the first visit to the ED.
36. The Trust should have read the notes from Salford Royal Hospital provided by Miss H. Had this happened, the Trust would likely have reduced the threshold for admission for her brother. This would have prevented the upset to Mr H’s family of seeing him collapse at home again, and the need to call an ambulance to take him back to hospital.
37. The Trust has acknowledged this to be case and apologised in its response to Miss H’s complaint. The apology does not acknowledge the impact this is likely to have had on Miss H and her family.
38. We consider, from the information we have seen, it is unlikely earlier admission would have stopped Mr H from suffering the cardiac event leading to his death. This is because the symptoms and tests carried out did not indicate risk of the arrythmia which caused his death.
39. The Trust has apologised for not admitting Mr H on his first attendance at the ED, acknowledging it ought to have admitted him. Whilst the delay in admittance is unlikely to have caused his death, the apology does not acknowledge the impact to Miss H and her family of witnessing Mr H collapsing at home and then needing to be taken back to the hospital by ambulance.
40. We Have made recommendations to put this right, which are detailed below.
The Trust did not transfer Mr H to Salford Royal hospital
41. Miss H complains the Trust did not transfer her brother to Salford Royal Hospital for specialised treatment after he was readmitted. He had been under the care of Salford for both his MPS and associated cardiovascular issues. She says the Trust had been readying him for discharge at the time of his heart failure. Miss H says she has been left wondering whether Salford Royal Hospital would have decided surgery was needed.
42. In its complaint responses to Miss H, the Trust explains that from a cardiac perspective when Mr H first attended the ED, he showed atrial fibrillation which is ‘a common fast heart rate and does not cause collapse or sudden death’. It went on to say this did not give any sign of what was wrong or likely to happen to Mr H.
43. The Trust explained that, had Mr H been admitted and monitored, with his heart rate reducing, a pacemaker would have been the expected treatment. It also explained the fitting of a pacemaker in a patient with MPS is complicated and a transfer to Salford Royal Hospital may have been needed if this had taken place.
44. However, it could not confirm it could have arranged this before Mr H’s collapse on 29 August 2021. The Trust explained in its response that the collapse was not due to his known valve disease, but due to an ‘electrical disturbance’(arrythmia) in his heart causing it to slow then stop.
45. The NICE - The technology - National Early Warning Score that alerts to deteriorating adult patients in hospital explains the use of ‘NEWS’ scoring whereby a patient's vital observations are scored showing any deterioration, the lower the score, the less risk.
46. GMC’s Good medical practice section 15 requires medical professions to provide ‘suitable advice, investigations or treatment’ and ‘refer to another practitioner where this best suits the patient’s needs’.
47. Intensive care society – Transport of critically ill adults, recommendation 14.4.1. says ‘The decision to transfer a patient to another hospital, must be made by a responsible consultant, in conjunction with consultant colleagues from relevant specialities in both the referring and receiving hospitals’.
48. West Yorkshire Critical Care and Major Trauma – Transfer guidelines explains the categories of patient type for transfer to another hospital, with Mr H meeting the criteria of ’clinical transfer’ which is the ’transfer of a patient to another hospital for care or facilities that are not available within the referring hospital’.
49. Our metabolic adviser explained Mr H’s consultant at Salford had placed him on ‘conservative management’ for his cardiac issues which means avoiding surgery due to high risk for the patient. Our adviser assumed this was due to the high-risk Mr H’s airway would present during any surgery. They explained they did not see any need for surgery prior to the cardiac event of 29 August.
50. We asked our cardiac adviser whether the Trust followed the correct process in not transferring Mr H to Salford Royal Hospital. They explained the medical notes show there were conversations about whether he should be transferred to a specialist hospital following his ECHO cardiogram on being admitted to hospital.
51. They said plans for a transfer would have needed consideration by a multi-disciplinary team meeting (MDT), a meeting between medical professionals and any other professionals involved in a patient’s care (i.e., the Trust and Salford Royal hospital), and it was unlikely this would have happened before Mr H died.
52. The intensive care society guidance supports this, explaining that before a transfer can take place, consultants, and associated staff at both referring and receiving hospitals should discuss the transfer.
53. In addition, suitably qualified staff must travel with the patient and risk assessments need to take place. The guidance does not give specific timescales for transfers.
54. The Trust’s own policy reflects this, giving priorities and risk levels depending on symptoms. It categorises a patient with a NEWS score of 1 as low risk, with the need for transfer for specialist care as priority 4, low priority.
55. We can see from the records that conversations were held with Salford Royal Hospital on 27 August 2021 where the Trust was informed of Mr H having a cardiology appointment at Salford on 2 October. This is noted as being the follow up treatment for Mr H in his discharge plan.
56. We can see the Trust were checking Mr H and recording his NEWS rating had been ‘1’ consistently before 28 August, when it started to increase. NICE guidance says a score of ‘1’ is low risk. The Trust therefore considered Mr H might be fit for discharge, making plans for this from the date he was admitted.
57. From the above information, we do not think Mr H’s symptoms appeared to be linked with Scheie syndrome or cardiovascular disease, therefore he did not show any clear need for transfer to Salford Royal Hospital.
58. We consider the Trust acted appropriately in monitoring Mr H once admitted to hospital. It completed an ECHO cardiogram but did not show anything of concern. His NEWS score was 1, low risk, and there was no indication of him needing lifesaving surgery.
59. In addition, it is unlikely a transfer to Salford could have been arranged before Mr H’s death. The guidelines in respect of inter hospital transfer support this likely to have been the case.
60. We appreciate Miss H believing Salford would be better placed to help her brother and that she will have been distressed that the transfer did not happen.
Did not keep the defibrillator in a ready to use state, delaying its use when needed.
61. Miss H complains the Trust took several minutes to untangle the defibrillator, delaying its use on her brother.
62. In its response to Miss H, the Trust has confirmed this was the case, explaining it took four minutes to ready it for use. It said that across this time, manual CPR continued. It explained the delay was unlikely to have changed what happened. It also said it has put in place measures to prevent reoccurrence, with there now being checks on equipment each evening.
63. In addition, the Trust said it was unlikely the delay in defibrillation contributed to Mr H’s death. It explained his collapse was witnessed and chest compressions began at once, something that would have not been the case had he been in the bathroom or walking about the corridors.
64. The letter went on to say that whilst defibrillation did shock his heart back, there was a delay in stabilising his airway, due to his MPS.
65. We have been unable to find any national guidance in respect of maintenance or the care of defibrillators in a hospital setting. The Trust has its own policy, ‘Cardiopulmonary Resuscitation Policy’, whereby the resuscitation officer is responsible for making sure systems are in place and followed for ‘maintaining resuscitation equipment in good working order’.
66. Our metabolic adviser said a major issue for patients with MPS condition is that abnormalities of the airway make intubation and ventilation difficult. They explained that when surgery is needed, an airway management plan will be in place, but in an emergency such as this, there were no options as to how to act as there would not be a plan in place.
67. It appears that the Trust did not keep the defibrillator in a ready to use state but the delay of four minutes this caused is unlikely to have prevented his death
68. This is because chest compressions started as soon as he collapsed, with the defibrillator successfully restarting his heart. However, because of the restricted airways caused by MPS, staff were unable to stabilise his airway.
69. Therefore, we consider the delay in being able to stabilise Mr H’s airway due to his MPS is more likely to have affected what happened. Regardless of which hospital Mr H was in, there was no time to plan airway management to minimise the difficulty in stabilising his airway.
70. The Trust has acknowledged the defibrillator should have been ready to use. In its response to the complaint, it said it has introduced new checks to ensure it is not tangled and is ready for immediate use going forward.
71. We acknowledge this situation will have been upsetting to see and will have caused Miss H great distress.
Our recommendations
72. In considering our recommendations, we have referred to our ‘NHS Complaint Standards_’. These say an organisation should take ‘full accountability for mistakes identified’. It also says it should look what action it can take to learn from mistakes.
73. We consider the Trust ought to have admitted Mr H on his first attendance at the ED. However, there is no evidence to support he would have survived had this happened.
74. In its response to Miss H’s complaint, the Trust confirms this and apologises for not having admitted her brother and for not reading the notes she had with her from Salford Royal hospital. It does not apologise for the impact of the family witnessing Mr H’s further collapse at home.
75. In view of this, we recommend the Trust should write to Miss H within 28 days, apologising for the impact of its failure to admit Mr H in the first instance, It should acknowledge the distress and upset this caused.
76. We have partly upheld Miss H’s complaint.
77. We acknowledge the loss of Mr H has been very upsetting for Miss H and her family and that it has been extremely hard to deal with this.