Attendance on 19 January 2023
19. The relevant guidance that applies here is the GMC (Good Medical Practice 2014) which states that doctors 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.
20. Mr X attended the Trust with a history of feeling unwell and pain in his buttock region. He had diarrhoea and a fever a few days before admission. A junior surgical doctor assessed him. Our surgeon adviser said the doctor would have been relatively inexperienced. The junior doctor saw Mr X in an assessment cubicle and Miss Y was present at the time. The examination was done with the curtains drawn to protect Mr X’s privacy. Miss Y was behind the curtain and did not directly observe the examination. She told the coroner that the doctor only examined her father on his side and therefore did not examine his abdomen. This is disputed by the Trust as the doctor says that he also examined the abdomen.
21. The doctor has recorded that he carried out a digital rectal examination of Mr X. However, the doctor did not record that he carried out an abdominal examination. The GMC guidance says you, "must make sure that formal records of your work (including patients' records) are clear, accurate, contemporaneous and legible". This did not happen.
22. Our surgeon adviser said it is very unusual for a doctor to do an abdominal examination and not record it in the clinical records. This raises the doubt as to whether the examination was done. We note the doctor told the coroner he carried out an examination of Mr X’s abdomen but there is no evidence in the records to support that. Miss Y told the coroner she heard every exchange between her father and the doctor, and this only related to the examination of his bottom. She maintained her position when challenged at the inquest.
23. In evidence provided to the coroner’s inquest the junior doctor said he saw what he thought was an anal fistula with no signs of an abscess. He then had a telephone conversation with his surgical registrar (a more experienced doctor). The history and clinical findings were presented and a plan to discharge the Mr X to the colorectal outpatient department for follow up management of a presumed anal fistula. Our surgeon adviser said that when the junior doctor discussed the case with the surgical registrar on call, it is important to convey the full history and examination findings. It is not possible to know the exact nature of this conversation and therefore we cannot say if this communication was accurate and detailed. There were no observations done for the Mr X (heart rate, blood pressure, temperature, respiratory rate). There are no nursing notes, and no blood tests were done.
24. Our surgeon adviser explained to make a diagnosis, a clinician needs to take a comprehensive history and do a full examination. This would be in line with the GMC guidance. However, there is no evidence that this happened. Mr X had a recent history of abdominal pain, fever and diarrhoea and basic observations should have been done.
25. The Trust has said that the junior doctor had enough experience to make a clinical diagnosis, and this was supported at the inquest by a Trust consultant surgeon who felt the doctor had adequate clinical experience. However, our surgeon adviser said the doctor diagnosed an anal fistula. At the later emergency surgery (24 January) the consultant surgeon did an examination of that area and confirmed that no fistula was present, and that Mr X had an anal fissure. Our surgeon adviser explained for a patient to develop an anal fistula, it is likely that there would have been a history of anal pain which developed into an abscess that then had a discharge (pus discharge) from the area. However, Mr X did not have this history and there was no obvious pus discharge from the area. Our surgeon adviser said this would make the diagnosis of an anal fistula on 19 January less likely.
26. In the medical records it is detailed that on the second admission (24 January), Mr X had been unwell for 4 days and this started the day after the Trust discharged him from the hospital. Our surgeon adviser’s advice suggests that it is therefore likely that, on the balance of probabilities, Mr X had one continuous surgical problem which had not resolved and caused him to become acutely unwell (rather than two separate conditions on each admission which are unrelated). The coroner’s narrative verdict also suggested this.
27. Our surgeon adviser explained the diagnostic difficulty in this case is that Mr X had a ‘retroperitoneal perforation’ which was confirmed by our radiologist adviser. This is a contained perforation, and it does not give the normal clinical symptoms/signs of severe abdominal pain and signs of peritonitis (tenderness and guarding on examination of the abdomen). They added that often in this uncommon perforation, there is a lack of clinical signs when the abdomen is examined i.e. the abdomen may well feel soft and non-tender with no signs of peritonitis (an infection of the inner lining of the stomach). Often the patient will just look unwell, and they may have abnormal observations (high fever, fast heart rate) and blood tests may show increased markers of infection/inflammation. In a patient presenting with severe anal pain and no obvious cause on clinical examination, our surgeon adviser said a doctor must be suspicious of a deeper abscess which is not clinically obvious. This makes the need for a thorough assessment even more important.
28. In view of the above, Mr X should have had at least one measurement of heart rate, temperature, blood pressure and respiratory rate as part of a complete assessment. If any of these observations were abnormal, it may have triggered the doctor to request blood tests to look for signs of inflammation/infection or it may have led to the surgical registrar to come and personally review Mr X. We are unable to say for certain what would have happened beyond that point. There is a possibility that Mr X may have been admitted, had a CT scan and had inpatient management before he became so unwell. However, it is also possible that no further action would have been taken as the observations may not have shown any abnormalities requiring further action.
29. Our decision is that there were failings on the part of the Trust regarding the assessment on 19 January. There is a lack of evidence in the records that the doctor carried out an assessment in line with the above GMC guidance. There were no observations or investigations carried out which may have helped to identify the underlying cause of Mr X’s symptoms.
30. However, whilst we have identified failings in Mr X’s care and treatment we are unable to say that but for these failings his outcome would have been different. That said, Miss Y will be left with uncertainty about whether her father’s outcome may have been different if his care and treatment had been managed in line with guidance. We cannot underestimate how difficult and distressing this will be for her. We know Miss Y is heartbroken by the loss of her father which has impacted on her and her family.
31. The Trust has not recognised the above failings in care or apologised to Miss Y for the significant impact she has experienced due to these. We have therefore made recommendations below to address this and provide Miss Y with a personal remedy.
Admission on 24 March 2023
32. The relevant guidance which applies includes the GMC Good Medical Practice as outlined at paragraph 19.
33. The Royal College of Physicians (RCP) National Early Warning Score (NEWS) guidance outlines the recommended response according to the NEWS News Report (rcp.ac.uk). Under this guidance, a patient is assessed and given a score in relation to clinical observations consisting of respiration rate, oxygen saturation, blood pressure, pulse rate, level of consciousness and temperature. A score of 5 or above requires hourly observations to be taken.
34. The Royal College of Surgeons (RCS) have guidelines on ‘Emergency Surgery Standards for unscheduled surgical care (Feb 2011)’. This guidance indicates that a provisional imaging report should have been available within 30 minutes and a definitive report within 1 hour. It also sets the timelines on the acute care in an emergency setting. The guidelines state the following,
“Patients with septic shock who require immediate surgery are operated on within three hours of the decision to operate as delay increases mortality significantly.”
35. The Surviving Sepsis Campaign: International Guidelines for Management of Sepsis and Septic Shock 2021 state a patient at risk of sepsis should receive antibiotics within an hour at the latest and sooner if possible.
36. We have considered what should have happened on Mr X’s arrival in the emergency department on 24 January. The ED doctor should have assessed him and referred him for further investigation to help establish the cause of his symptoms. In view of Mr X’s NEWS score of 9 at 1.30pm nursing staff should have carried out hourly observations to monitor if there was any deterioration in his condition. When the CT scan was carried out the radiology report should have been made available to the ED doctor within the hour. This should have led to a discussion with the surgical team to plan the management of Mr X’s treatment and to decide the urgency of any surgery. The surgery should have been carried out urgently once there were signs Mr X had developed septic shock.
37. Following Mr X’s arrival in the ED at 1.04pm a doctor assessed him at 1.21pm and requested an abdominal CT. This was in line with GMC guidance.
38. A nurse took Mr X’s observations at 1.30pm and his NEWS score was 9. This should have led to his observations being monitored hourly in line with NEWS guidance, but this did not happen. We find this was a failing.
39. The radiology team carried out the CT scan at 2.29pm and reported its findings at 5.30pm. This showed free air and solid faeces outside the bowel indicating a perforation. Our surgeon adviser said the RCS guidelines indicate that when Mr X had his CT scan at 2.29pm a provisional imaging report should have been available within 30 minutes and a definitive report within 1 hour. This meant the report should have been available by 3.30pm. However, it was not available to the ED doctor until 5.30pm. We find this was a failing.
40. Our surgeon adviser said as soon as the report of bowel perforation is confirmed on the CT scan, a patient needs to have intravenous antibiotics. Following receipt of the CT scan results the ED doctor prescribed antibiotics and pain relief for Mr X. This was at 6.15pm but these were not given until 7.45pm.
41. Under the Surviving Sepsis Campaign: International Guidelines for Management of Sepsis and Septic Shock 2021 Mr X should have received IV antibiotics within an hour at the latest and sooner if possible as he was at risk of sepsis. This meant he would have had antibiotics within the period 4.30-5pm. However, he got his antibiotics at 7.45pm which was over 2.5 hours later. We find this was a failing on the part of the Trust.
42. The surgical day team saw Mr X in the ED at 8.15pm and the plan was to admit him to the surgical unit and operate on him the following morning. At 8.59pm there is a clinical note stating, "Patient is NEWS 10 would benefit from being admitted to high level of care 1”. Another surgeon then reviewed Mr X at 11.18pm and they considered he was not well enough to leave his operation until the following morning as he had deteriorated and was in septic shock. The surgeon started the operation at 1am and finished at 3.30am.
43. Our surgeon adviser said that the radiology report indicated there was significant pelvic infection with solid faeces outside the bowel. They said the surgeon who assessed Mr X in the ED does not appear to have realised how serious the perforation was.
44. Our radiologist adviser said the report is unequivocal in identifying a perforation of the large bowel with discharge of faeces into space behind the abdominal cavity (“retroperitoneum”) extending around the bladder in the pelvis and up along the spinal muscles on the left. The potential point of perforation and leakage was identified low in the large bowel above the anus (“rectum”) Our radiologist adviser said in the report leaves no doubt that a catastrophic event with widespread contamination of the retroperitoneum and pelvis with faecal matter has taken place. It implies a very poor prognosis.
45. Our surgeon adviser said the degree of infection and solid faeces outside the bowel meant Mr X was going to need an operation to resolve his problem. Our surgeon said this should have been done on the same day rather than delaying it to the following morning as there was the risk of Mr X’s condition deteriorating which it did when he developed septic shock. Our surgeon adviser said by the time surgery was carried out Mr X’s chances of survival were very poor.
46. The NEWS score of 10 recorded in the clinical note at 8.59pm indicates that Mr X was very unwell. Our surgeon adviser said consideration should have been given at that stage to carrying out the operation sooner. This would have been line with the RCS guidelines which state a patient in septic shock should be operated on within 3 hours. At 8.59pm Mr X fell within this category. However, this did not happen, and we find this was a failing.
Impact
We have identified there were failings on the part of the Trust regarding,
• failure to carry out observations in line with NEWS guidance • delay in reporting the CT scan on 24 January • delay in administering antibiotics on 24 January • delay in carrying out Mr X’s operation
47. The Trust has acknowledged in its response that observations after 1.30pm were not carried out in line with NEWS guidance. Our surgeon adviser explained the purpose of the observations is to help the early detection of a deteriorating patient and to facilitate escalation in care. Without observations, it is difficult to know at what point Mr X’s condition started to deteriorate and to quantify the overall impact of not repeating observations.
48. However, Mr X’s NEWS score was 4 at 6.32pm which had improved from earlier. Therefore, the indication is there was no evidence of deterioration at that point. The Trust apologised that observations were not done in line with guidance. However, it is a source of upset for Miss Y that her father’s care was not managed in line with guidance.
49. We have identified there were delays in the radiology team reporting the CT scan. This subsequently led to delays in Mr X receiving IV antibiotics. Our surgeon adviser told us the impact of the delay in receiving antibiotics is hard to quantify in terms of increased mortality.
50. In one study about the impact of delay in administering antibiotics there was a 35% increase in mortality for every hour delay in giving antibiotics for patients in septic shock but no difference for patients who had sepsis without septic shock. Mr X does not appear to have been in septic shock until 8.59pm at which time he had been receiving antibiotics.
51. In the circumstances, it is not possible to say if the delay in administering antibiotics resulted in Mr X developing sepsis shock and significantly impacted his sad outcome. However, this uncertainty will be a source of distress to Miss Y. The Trust has apologised to Miss Y for the delay, but it has not fully recognised the extent of the failing or the impact on Miss Y.
52. Our surgeon adviser explained an earlier operation may have improved Mr X’s chances of survival, but we cannot be certain of that. There has been a review in 2021 which identified that a delay of an hour in carrying out surgery of a patient with septic shock reduced their chances of survival by 5%. Mr X did not have septic shock in the afternoon, but he had developed this by the time the surgeon noted he had a NEWS 10 at 8.59pm. Based on the RCS guidance he should have had an operation within 3 hours i.e. 12am. However, it was 1am when surgery was started, which was a delay of one hour. We cannot say that on the balance of probabilities his outcome would have been different if his operation had been carried out earlier. However, Miss Y has again been left with uncertainty about her father’s outcome. This will be a source of significant distress for her, and we do not underestimate that.
53. The Trust has not fully acknowledged the failings in care provided to Mr X or the significant impact this has had on Miss Y. We have therefore made recommendations below to address this.
Communication
54. Miss Y says there was poor communication about how ill her father was and that she would not have gone home if she had been told. At 8.15pm a surgeon explained to the family that it was likely Mr X would “likely need theatre and a stoma”.
55. At this point, the clinical team did not consider Mr X’s condition to be critical and they mention that he would need surgery the next day. At that stage he had signs of sepsis (which was being treated with intravenous fluids and antibiotics) but no signs of septic shock. However, our surgeon adviser said that the clinical assessment by the day team failed to appreciate just how critically ill Mr X was at that stage and because of this, the team did not communicate to the relatives the risk of an acute deterioration. Indeed, the clinical note at 8.59pm indicated his condition had deteriorated to a situation where he was in septic shock and need an urgent operation, but the family were not told this until after the consultant had seen him at 11.18pm.
The GMC Good Medical Practice
‘You must be considerate and compassionate to those close to a patient and be sensitive and responsive in giving them support and information.’
56. We consider that there was a missed opportunity when the surgeons spoke to Miss Y and her mother to explain how ill her father was and that he would require surgery sooner. Miss Y says if she knew the risk of deterioration and how poorly her father earlier, she would have stayed with him until he went for his operation. She says this was a missed opportunity for her to say a proper goodbye as when she saw him after the operation, he was unconscious. We recognise that this missed opportunity to spend that time with him will be further source of distress and upset to Miss Y. This has not been acknowledged or put right by the Trust.