14. Mrs A told us her daughter had a long history of aspiration pneumonia. She said she thought the Trust should have considered Miss B’s history of previous problems when she was admitted in October 2022.
15. We looked at the records of the care and treatment the Trust gave Miss B on 16 October when she was admitted with suspected aspiration pneumonia to see if it was in line with guidance.
16. The GMC guidance says:
‘[Doctors] must provide a good standard of practice and care. If you assess, diagnose or treat patients, you must: • adequately assess the patient’s conditions, taking account of their history (including the symptoms and psychological, spiritual, social and cultural factors), their views and values • where necessary, examine the patient • promptly provide or arrange suitable advice, investigations or treatment where necessary • refer a patient to another practitioner when this serves the patient’s needs.’
17. We consider the initial clinical assessment when Miss B arrived at hospital was in line with this guidance. Our adviser explained the doctor took a detailed history, undertook a physical examination and drew up a clear care and treatment plan that gave the differential diagnosis of aspiration pneumonia.
18. When a doctor chooses one condition as a differential diagnosis, it means they consider that condition as a possible explanation for the patient's symptoms.
19. The records show the treating doctor was aware of Miss B’s history, including her gastric issues, and this underpinned the care and treatment plan.
20. The Trust followed the treatment plan and we consider it gave care and treatment in line with the GMC guidance that says: ‘In providing clinical care you must: • prescribe drugs or treatment, including repeat prescriptions, only when you have adequate knowledge of the patient’s health and are satisfied that the drugs or treatment serve the patient’s needs • provide effective treatments based on the best available evidence • take all possible steps to alleviate pain and distress whether or not a cure may be possible • consult colleagues where appropriate • respect the patient’s right to seek a second opinion • check that the care or treatment you provide for each patient is compatible with any other treatments the patient is receiving, including (where possible) self-prescribed over-the-counter medications.’
21. The records show Trust had full knowledge of Miss B’s recurrent pneumonia and doctors consulted colleagues where appropriate, including getting a copy of the GP summary on 17 October to ensure the staff were as well informed as possible. This showed a history of all her care and treatment.
22. The Trust gave care and treatment in line with the NICE guidelines which say, ‘start antibiotic treatment as soon as possible after establishing a diagnosis of community-acquired pneumonia, and certainly within 4 hours’. The Trust started Miss B’s antibiotics within one and a half hours.
23. Our adviser explained there is no specific guidance on investigations for recurrent aspiration pneumonia. The Trust described in the discharge summary the ongoing investigations it planned. Our adviser confirmed this was in line with the guidance outlined in paragraphs 16 and 20.
24. The planned investigations included repeat chest X-rays, a follow up in the respiratory clinic and planned impedance studies (this measures movement of liquid and air up and down the oesophagus).
25. The records show the Trust was exploring all options to look for the cause of the problem, including advising Miss B to stop vaping and to get rid of her parrot, both of which are known to have links with pneumonia.
26. The discharge summary shows the Trust provided care and treatment that was fully informed by the ongoing investigations it was carrying out into the causes of Miss B’s recurrent incidents of aspiration pneumonia, which were unexplained at that stage.
27. In consideration of the advice we have received, and with reference to the GMC and NICE guidance, we did not see any indications of failings in relation to the Trust’s investigation and treatment into Miss B’s symptoms during the October 2022 admission to hospital. We hope the information we have shared to explain how we have reached this decision will be helpful to Mrs A.
28. We understand why the family were so upset about the incorrect information the Trust shared when Miss B was admitted in December 2022. The Trust has acknowledged that it shared incorrect information and apologised for this.
29. Mrs A told us the family are upset that the Trust complaint response said it could not explain where the incorrect information had come from. We looked at the records to see if the Trust was correct or whether there was more it could do to reassure Mrs A about where the information was from.
30. We can see the Trust noted ‘known to take methadone’ under the heading PMH (past medical history) on the triage form in the emergency department at 11.08am when Miss B first arrived by ambulance. The notes do not show who passed on this information, or where this information came from.
31. We have not seen anything to explain where the information came from, and so we consider the Trust’s complaint response was accurate.
32. We consider there was an indication of a failing in the Trust sharing this incorrect information. We understand why this was such a shock, at an already very upsetting time.
33. The Trust has properly apologised for sharing this incorrect information with the family. It has issued a learning alert to emergency department staff to double check the accuracy of information. We consider this was the correct action for the Trust to take and we do not think there is anything additional we should ask the Trust to do to address this.
34. We were sorry to hear about Miss B’s sad death and the impact this experience has had on her family. We thank Mrs A for bringing her complaint to us and recognise how strongly she feels about what happened. We hope we have explained in this statement the reasons we have decided not to take further action on her complaint.