CT scan upon admission
19. Mrs T complains that upon Mrs W’s admission to hospital on 22 February, the team did not conduct a CT head scan despite it being indicated.
20. In response to the complaint the Trust has explained that the ED doctor requested a CT scan as they were concerned about the possibility of bleeding in the brain because Mrs W had an unwitnessed fall, was confused, and was taking blood thinning medication. This was unsuccessful because Mrs W was too restless and unsettled for the CT scan to be completed.
21. The following day Mrs W was moved to the Elderly Assessment Unit and was noted to be delirious, but with no focal neurological deficit. For this reason, it was felt an intracranial bleed was unlikely. The Trust explains that undertaking a CT scan at this point would have required sedation and it was felt the risks of doing this outweighed the benefits.
22. NICE guideline 232 sets out criteria for doing a CT head scan in points 1.5.8 - where the patient has sustained a head injury - and 1.5.9 - where the patient has experienced a loss of consciousness or amnesia.
23. We understand that Mrs W did not fully fall into the criteria for either scenario. This is because it was unclear from the history taken in the ED if Mrs W had suffered from a loss of consciousness, and her husband reported that she was no more confused than usual, indicating there was no evidence of amnesia. The records also do not say if there was any bruising or swelling to the head.
24. However, our adviser explained there would be a low threshold for sending a patient like Mrs W for a CT scan. Older patients are more susceptible to suffering a bleed on the brain. Mrs W was over 65, had an unwitnessed fall, was taking blood thinners, was confused (which was reportedly normal for her) and could not provide a full history.
25. For these reasons, we consider it was reasonable to send Mrs W for a CT scan based on her history and presentation at the time, in line with the GMC’s Good Medical Practice guidance, point 15 b:
“You must provide a good standard of practice and care. If you assess, diagnose, or treat patients, you must: promptly provide or arrange suitable advice, investigations, or treatment where necessary”
26. Unfortunately, the CT scan was unsuccessful because Mrs W was confused and unsettled. We understand that the risks of sedating Mrs W to re-attempt the CT scan would far outweigh the benefits. Our adviser explained that a clinician would not want to take these risks unless there was significant suspicion the head injury had caused damage to the brain or the skull. In this case, there was little suspicion of this because Mrs W did not have any focal neurological deficit, she had no visible head injury, there was no evidence of a head trauma, and she was not experiencing any vomiting.
27. Overall, we have not identified any indications that something went wrong on this occasion. It was appropriate to request a CT scan in the first instance, and when it became apparent Mrs W could not tolerate the examination, an informed decision was made as to whether a repeat scan was needed based on Mrs W’s presentation.
Medication management
• Medication review
28. Mrs T complains that when Mrs W’s medication was reviewed, it was changed, despite her being on the same regime for several years, and she is concerned this was not monitored appropriately.
29. In response to the complaint the Trust says Mrs W’s medications were reviewed at every ward round. When she was seen on 23 February it was noted she possibly had an AKI. The Trust explains that they were unable to confirm this because there were no blood tests on record since 2017 but felt it would be reasonable to suspect there would be some deterioration in kidney function in that time, and there was no way of knowing if this had happened acutely. The consultant felt some of the medications could have been contributing to this deterioration in renal function, and so decided to stop bumetanide and ramipril tablets.
30. Bumetanide is a medication which helps the body get rid of excess fluid and salt, it can also improve heart function in people with heart failure. Ramipril is a medication used to treat high blood pressure and heart failure.
31. When Mrs W was reviewed on 24 February, it was noted her blood pressure had been quite variable and too low at times. The consultant reviewed the medication again and stopped the spironolactone tablet and reduced the bisoprolol tablet because they could have been contributing to these symptoms.
32. Spironolactone is a medication used to treat bluid up of fluid in the body and can also be used to treat high blood pressure. Bisoprolol is a medication used to treat high blood pressure and heart failure, it is also used to treat atrial fibrillation.
33. Mrs W was also taking digoxin to control her heart rate in atrial fibrillation. A blood test had been done to check her digoxin level, because a high level of digoxin can cause low heart rate. The level was slightly above normal and so this medication was also stopped.
34. The Trust has commented that ideally, they would wean some of these medications, such as bisoprolol, but when they are causing harm, they do not have time and there is a greater risk from continuing them than stopping them without weaning. The Trust added that observations were checked on a regular basis to ensure the stopped medications did not need to be reintroduced.
35. The ‘Think Kidneys’ guidance explains that to optimise the prescribing of medications in a patient with AKI, the clinician should consider if the patient is receiving any medication which may impair renal function such as: ACE inhibitors and diuretics. ACE inhibitors are medications used to treat high blood pressure. Diuretics are medications which increase urine production and the excretion of water from the body. The guidance advises withholding these medications during an episode of AKI.
36. Mrs W was taking ramipril (an ACE inhibitor) and bumetanide (a diuretic), and so we understand it was standard practice for the team to withhold these medications given Mrs W’s presentation.
37. We can see from the records Mrs W’s blood pressure was variable throughout her admission. Our adviser says the management of blood pressure can be complicated in older patients, as their blood pressure varies a lot more, and they are more vulnerable to these changes.
38. The ESC guidance recommends avoiding any low blood pressure episodes amongst elderly patients with high blood pressure. The SPS guidance recommends taking a full medication history and reviewing medications which may be causing or contributing to low blood pressure. Once identified, the medications should be stopped or suspended, where possible.
39. Upon admission to hospital, Mrs W was on medication to control her blood pressure, and we understand it was reasonable to suspend this medication to prevent her from experiencing symptomatic episodes of low blood pressure. This would have helped to prevent falls and is more important than preventing periods of high blood pressure.
40. Overall, we consider there are indications that the medical team managed Mrs W’s medications appropriately. It was clinically indicated that the medications needed to stop whilst she was acutely unwell. For these reasons, we have not identified something went wrong in the management of Mrs W’s medication.
• Provision of sleeping tablets
41. Mrs T complains that despite Mrs W having trouble sleeping for two weeks during her admission, sleeping medication was not prescribed.
42. In response to the complaint, the Trust explained that delirium can cause changes in the sleep-wake cycle, and result in disrupted sleep. There is evidence that sedative medications such as sleeping tablets can prolong delirium and result in increased daytime sleepiness which contributes to an increased risk of falling and reduced oral intake. For this reason, it was felt that the risk of sedating Mrs W for sleep disruption because of delirium outweighed the benefits.
43. The NICE CKS for managing insomnia states hypnotics should not be prescribed to older people. There are no listed exceptions to this, and so we consider there are no indications that Mrs W should have been prescribed sedative medications to help with her sleep.
44. Our adviser explained that hypnotics and sedatives are two different medications and are used in different scenarios. Sedatives can be used in patients with delirium to help calm them, but there are no indications these were needed in Mrs W’s case either.
45. For this reason, we have not identified any indications something went wrong in this aspect of Mrs W’s care.
Treatment of sepsis and acute kidney injury
46. Mrs T is concerned that Mrs W’s care was centred around a presumed diagnosis of dementia, but no formal diagnosis was made. The family are concerned this meant diagnoses of sepsis and an AKI were missed and not treated appropriately. In addition to this, Mrs T complains that they were not told Mrs W was suffering from sepsis or an AKI during the admission, and says the family only discovered this when they received Mrs W’s death certificate.
47. In response to the complaint, the Trust explained that initially, when Mrs W was reviewed in the ED the nurses and doctors were under the impression she had a diagnosis of dementia. On arrival to the Elderly Assessment Unit, it was recognised that she did not have a formal diagnosis but was suffering from delirium. The Trust says no treatment decisions were made based on a diagnosis of dementia.
• Sepsis
48. In response to the complaint the Trust has explained that Mrs W deteriorated on the morning of 13 March, and she was noted to be drowsier. She was reviewed by the elderly care consultant who was concerned that she might have had a new intracranial event such as a stroke or another subdural haematoma (a bleed between the skull and the brain). The consultant arranged another CT head scan, which did not show any changes in the brain. The consultant also arranged blood tests and spoke the family about her concerns regarding Mrs W’s deterioration.
49. The Trust says Mrs W was reviewed later in the day, and she remained very poorly. The blood tests showed there had been a significant deterioration in her renal function, indicative of an AKI and her liver function tests were newly abnormal. The consultant arranged for her to have IV fluids and started her on tazocin (antibiotics), to cover for an infection related to her gallbladder. The seriousness of Mrs W’s illness was communicated to the family who were present on the ward.
50. Mrs W was reviewed again on the morning of 14 March. She remained very unwell despite IV fluids and antibiotics. Her heart rate had increased, and she had developed fast atrial fibrillation. The consultant prescribed digoxin which successfully brought her heart rate down. Despite this, Mrs W continued to deteriorate. It was felt that Mrs W was dying, and the family were informed of this.
51. The Trust explained that Mrs W had evidence of kidney, liver, and heart dysfunction, because of suspected infection, and therefore fit the criteria for sepsis. It explained that the consultant recognised this when reviewing the blood tests on 13 March and treated this in line with NICE Sepsis guidance, and the Trust’s antimicrobial guidelines.
52. The consultant put ‘sepsis of an unknown source’ as part of the cause of death on Mrs W’s death certificate because she suspected and treated an infection/sepsis related to her gallbladder. They were unable to give a definite source of infection because it was not possible to confirm a gallbladder infection with an ultrasound scan because Mrs W was too unwell to undergo the scan.
53. We can see that Mrs W became drowsy and more confused on 13 March. There are many possible causes for this, including infection. The consultant initially held off prescribing antibiotics, and in Mrs W’s case this was appropriate as they were awaiting the results of blood tests and a chest X-ray. We understand there was little to suggest that Mrs W had an infection, or sepsis.
54. Mrs W’s chest X-ray was reviewed, and the results were reportedly similar to one taken on 23 February, which would indicate there was little to no evidence of infection. It is not noted that Mrs W was presenting with any other signs of a chest infection such as a cough.
55. Mrs W’s blood test results showed an abnormality in her liver function tests (LFTs) and a rise in the white blood cell count. This would indicate that she was likely to be suffering from a bacterial infection. Whilst Mrs W did not fully meet the criteria for sepsis, Mrs W was prescribed a strong antibiotic which we understand was reasonable in her case. There were no definite signs of where the infection was, but the abnormal LFTs would suggest infection of the gallbladder or biliary ducts (tubes that connect the liver, gallbladder, and bowel) as probable sites of infection.
56. In line with NICE guidance, Mrs W received the three cornerstones of treatment for sepsis, which are antibiotics, IV fluids and oxygen in a prompt manner.
57. Overall, there are indications that Mrs W was treated appropriately in line with national guidance when it became clear she had a suspected bacterial infection. For this reason, we have not identified any indications of service failure relating to this part of the complaint.
• AKI
58. The Trust says when Mrs W deteriorated on 13 March, the consultant recognised she was at risk of acute kidney injury prior to receiving the blood test results. She began treating Mrs W with fluids immediately, and they were given subcutaneously as it was difficult to gain IV access with a cannula. Later in the day when Mrs W was able to be cannulated, fluids were given directly into a vein.
59. The Trust explains that when an AKI was confirmed on blood tests, a urinary catheter was inserted to allow monitoring of urine output. It considers this was in line with NICE guidance, and the family were informed of this in the afternoon of 13 March.
60. We understand that when treating an AKI, the first few steps of management include stopping any medication which may be causing or contributing to the injury and determining if the patient is in fluid overload. Where there are signs of fluid overload, no fluids will be given.
61. The renal association AKI guidelines recommend optimisation of haemodynamic status using appropriate fluid therapy, which includes giving IV fluids to all patients who are suspected to be dehydrated (and not overloaded). Because Mrs W was on diuretics and was confused, she likely had poor oral intake, and this would predispose her to dehydration.
62. Supplementary IV fluids are given to see improve urine output and promote resolution of the AKI. Repeat blood tests would be done, usually on the same or next day depending on the severity of the AKI, to see if there has been any improvement.
63. Based on the advice we have received, there are indications that Mrs W received appropriate treatment in line with the guidance outlined above. There are no indications that there was a delay in treating the AKI, as the clinicians acted upon the blood test results in a timely manner.
64. For this reason, we have not identified any indications of service failure relating to this part of the complaint.
• Communication about diagnoses
65. The Trust has acknowledged that whilst the consultant had multiple discussions with the family about the deterioration and the cause, she may not have explicitly explained this would fit the criteria for sepsis. The Trust has apologised for the unintentional anxiety this caused.
66. The GMC’s Good Medical Practice explains that doctors must be considerate to those close to the patient and be sensitive and responsive in giving them information and support (33). Similarly, the NMC’s Code explains that nurses must communicate clearly, and take reasonable steps to meet people’s communication needs (7, 7.1).
67. In our review of the records, we can see that the consultant advised the family of the blood results which indicated an AKI. They discussed the plan for treatment, further investigations which were needed, and the consultant gave their view on the likely prognosis and risk of death. However, as acknowledged in the Trust’s response, it is not documented that the consultant explicitly explained it would fit the criteria for sepsis.
68. It is important for us to acknowledge that we were not present at the time to independently know what, and how, things were said. We accept that the diagnosis may not have been made explicitly clear to the family in conversation. We also recognise that in some instances, each person involved in the same conversation can come away with a different perception of its contents and what happened. One person’s perception of what was said does not invalidate another person’s opposing perception of the same comment.
69. Overall, there is evidence that the seriousness and nature of Mrs W’s condition was explained to the family when she began to deteriorate further, and that the consultant was clear about the plan for treatment and what would happen next. We can also see the consultant has apologised for any miscommunication, and the impact this had on the family.
70. We consider this is in line with the NHS Complaint Standards with regards to giving fair and accountable responses and promoting a learning culture. We consider there is nothing further for us to add to this part of the complaint as the Trust has provided a fair and proportionate remedy to the impact faced by the family.
Delay in carrying out a CT scan following a head injury on 8 March 71. Mrs T complains that Mrs W injured her head on 8 March, but a decision to carry out a CT head scan was not made until 12 March. She also complains that the family were not contacted when the injury occurred.
72. In response to the complaint the Trust explained that Mrs W was noted to have a bruise on her head on 8 March, but there was no history of a fall. Patients nearby on the ward reported she had hit her head on the table. Mrs W was reviewed by the junior doctor on the ward who did not think this had caused an acute deterioration and so did not warrant a CT scan of her head at that point. The Trust says the ward staff informed Mrs W’s daughter of the bruise.
73. It explained when Mrs W became more confused on 11 March, the nursing staff felt she needed to be assessed in the ED. The Trust says the CT scan did not show any new changes in the brain but did show she had evidence of an old bleed on the brain. The radiologist described the bleed as chronic, which meant it must have happened at least three weeks prior but could have happened at any point before that. The Trust concluded that because the CT scan did not show any acute changes in Mrs W’s brain, there was no evidence to suggest the delay in doing the CT scan contributed to the subsequent acute deterioration.
74. We have considered NICE guideline 232, which is outlined in point 22 above. We cannot see that Mrs W fully fit into the criteria for either scenario on 8 March. We understand that a bruise to the forehead would not put her into the criteria and is not a standalone indication for a scan.
75. For this reason, we consider it was appropriate not to send Mrs W for a CT scan at that the time of the incident, as she did not show any clinical features of deterioration. Once Mrs W began to show signs of deterioration, it was appropriate to request a CT scan given there would be a low threshold for investigation in a patient such as Mrs W (as explained above in point 24). The medical records align with the Trust’s account of informing Mrs W’s daughter about the incident shortly after it occurred, and so we consider there are indications communication about this matter was in line with the GMC and NMC guidance outlined in point 66 of this statement.
76. For these reasons, we have not identified any indications something went wrong in this area of Mrs W’s care.
Communication with Mr W
77. Mrs T complains that there was a lack of communication with Mrs W’s husband, Mr W, following her admission to hospital.
78. In response to the complaint, the Trust says when Mrs W attended the ED, Mr W attended with her. He stayed with her and was given hot drinks and food. When Mrs W was to be transferred to the Elderly Assessment Unit, the staff in the ED booked patient transport to ensure he returned home safely. The Trust acknowledges the ED notes say Mr W had told medical staff they had children, but that they did not live locally, and this was not explored further by the team. No other contact details were obtained at this point.
79. The Trust explains Mrs W was reviewed during the consultant ward round on 23 February and the usual practice would be to contact the patient’s next of kin to discuss the outcome. It acknowledges that a conversation should have taken place to update Mr W and advise him that Mrs W would be moved to ward F6. No conversation took place. The Trust has acknowledged this fell below the expected standard of communication and has apologised for this. It has acknowledged this was a missed opportunity to ask Mr W if any other family members needed to be contacted.
80. The Trust says when Mrs W was moved to ward F6, staff recall speaking with Mr W. On 24 February it is recorded that the therapy team asked nursing staff to contact him, as they could not see his contact details on the system. The Trust has acknowledged there is no evidence in the records this request was acted upon by the team.
81. On 27 February, the therapy team again requested contact was made so that they could gather more information. There is no evidence this contact was made. The Trust has acknowledged this was below the expected standard of communication and has explained this has been highlighted with the team for their reflection and learning.
82. On 1 March, one of the nursing team spoke with Mr W over the phone about how he was managing and how Mrs W was presenting in hospital.
83. On 3 March, the Trusted Assessor (a staff member who is trained to assess people and their home environment for adaptations) contacted one of Mrs W’s daughters. It became apparent they did not know Mrs W had been admitted to hospital. A meeting was arranged for 5 March so the Trusted Assessor could complete an assessment. Mrs W’s daughter visited the ward later that day and was updated by the nursing team about the admission so far.
84. The ward manager for F6 has provided an apology on behalf of the ward team that they did not speak with Mr W when asked to do so by the therapy team. The Trust has recognised that if this had been acted upon, they could have taken contact details from him for both his daughters much earlier and ensured he made them aware of their mother’s admission. The ward manager has shared this with the team to ensure they are in communication regularly with the next of kin, especially if they have not visited for a few days.
85. We can see the Trust got things wrong on this occasion with regards to the level of communication with the family. Steps should have been taken much sooner in the admission to obtain additional contact details, especially as there were concerns about capacity and how Mr and Mrs W were managing at home.
86. We can see the Trust has acknowledged where mistakes occurred, and that the level of communication fell below the expected standards. We can also see that the Trust has provided an apology for these failings, and for the impact this has had on the family. It has also spoken with the teams who were responsible for ensuring effective communication, to ensure service improvements take place, which will reduce the likelihood of this happening again to someone else.
87. We consider this is in line with the NHS Complaint Standards with regards to giving fair and accountable responses and promoting a learning culture. We consider there is nothing further for us to add to this part of the complaint as the Trust has provided a fair and proportionate remedy to the impact faced by the family.
Communication with Mrs T when Mrs W deteriorated
88. Mrs T tells us she attended the hospital when she was told Mrs W was deteriorating. She says she was taken into a room and given a bereavement pack, and as they were leaving the room, they were told Mrs W had passed away. Mrs T feels she was not given the opportunity to be with Mrs W when she was dying.
89. In response to the complaint the Trust says Mrs T and her siter had arrived to visit Mrs W, and they had been made aware by the doctor how unwell she was. The Sister on the ward documented that the family wanted an update before going to see Mrs W, and so they had a conversation in a private room.
90. The GMC’s Good Medical Practice explains that doctors must be considerate to those close to the patient and be sensitive and responsive in giving them information and support (33).
91. As we have explained earlier in this statement, there is evidence on 13 March that the consultant was providing updates to the family on Mrs W’s deterioration and what they were doing to investigate and treat it. Similarly, on 14 March, the consultant got in touch with the family to advise there had been no improvement, and that Mrs W was continuing to deteriorate. The consultant also advised that they had decided to focus on palliative care, rather than active treatment/tests, as it was not improving Mrs W’s condition.
92. The family had asked about prognosis, and the consultant advised Mrs W had hours to days at most. The consultant also offered open visiting. The family visited the ward shortly after this telephone conversation and spoke with the consultant before going to visit Mrs W. Very sadly, she had died whilst they were speaking with the consultant.
93. There are indications that the consultant had been sensitive and responsive when updating the family and responding to their questions about prognosis. It appears this was a case of very unfortunate timing, and we do not consider there is anything more the consultant could have done in this situation.
94. Overall, we do not consider there is much more we can add to this, other than what has already been explained. For these reasons, we do not consider there are any indications of service failure relating to this part of the complaint.
Communication with Mrs W’s GP
95. Mrs T tells us that the Trust failed to inform Mrs W’s GP of her death, and this was made apparent when a condolence card was sent to Mrs W, regarding her husband’s passing. Mr W very sadly died one week after Mrs W, on 21 March 2023.
96. In response to the complaint the Trust says a discharge letter informing the GP of Mrs W’s death was completed, finalised, and sent to the GP. Having checked the systems which record this, the Trust explained that an error was made marking the letter as being sent out on the database.
97. The Trust has apologised that the information was incorrectly marked as being sent out when it had not been. It has acknowledged how important it is for GPs to be notified and has recognised the distress and upset this has caused Mrs T and her family. The Trust also explained the team has now got a new system in place which will prevent this from happening in the future.
98. We can see the Trust got things wrong on this occasion and that it has acknowledged this and provided a remedy for Mrs T, as well as ensuring system improvements to reduce the likelihood of this happening again. We consider this is in line with the NHS Complaint Standards with regards to giving fair and accountable responses and promoting a learning culture. For this reason, we will not be taking any further action on this part of the complaint.