Ambulance
21. Mr L complains paramedics did not suspect Mrs L had an aneurysm when they visited her at home on 4 November or explain this concern to hospital staff. This is despite NHS 111’s triage system suspecting this problem.
22. The Trust explained the NHS 111 service is designed to assesses a patient’s symptoms so it can provide care in the most appropriate time frame. It is does not provide a diagnosis, as this is the responsibility of a doctor.
23. The Trust said the initial triage was based on Mrs L reporting she woke at approximately 3.30am with pins and needles in her neck and head. She was left with chest pain, as well as vomiting. This meant an aneurysm could not be ruled out.
24. It said when paramedics arrived they examined Mrs L. Her symptoms did not include sweating or clamminess, no abdominal pain or diarrhoea, and normal urine output. The Trust says if some of these symptoms were positive they would lead the paramedic to suspect an aneurysm, but they were not.
25. Instead, paramedics spoke with Mrs L and she told them about a recent fall and related head injury. Their examination looked for problems associated with this. They documented Mrs L was generally unwell with a possible concussion or a collection of blood inside her skull (a haematoma), and transported her to hospital.
26. Our paramedic adviser directed us to the JRCALC Clinical Practice Guidelines, which is the guidance paramedics should follow when providing pre-hospital care. JRCALC Guidelines say paramedics should assess why the patient called for help and account for their medical history.
27. JRCALC Guidelines also set out which symptoms should lead a paramedic to suspect a patient has an aneurysm. This includes abdominal pain or backache, collapse, hypotension (especially when a patient usually has high blood pressure), a history of smoking and decreased blood supply to their extremities.
28. The JRCALC Guidelines also tell paramedics how to diagnose patients who report a headache, like Mrs L.
29. Headaches are very common, and a feature of illnesses with varying severity. It is vital paramedics take a detailed history to identify more serious symptoms. These more serious symptoms include loss of function or altered sensation, and vomiting without another obvious cause.
30. JRCALC Guidelines says these symptoms are ‘red flags’, and a sign of a serious problem. If a patient does have these symptoms then the paramedic should transport them to hospital for further care.
31. Paramedics should handover care to ED in line with NICE Guidance. It explains they should provide relevant information about the patient’s condition. This should be up-to-date and accurate.
32. The paramedics noted Mrs L had a headache with new neurological deficit (dizziness) and vomiting, and had experienced chest pain in the night. This chest pain was still present and worse when taking a deep breath. The paramedics recorded she suffered with high blood pressure and had banged her head when she fell two weeks earlier.
33. Paramedics did not diagnose Mrs L when they visited her at home as this is not their role. However, her symptoms indicated she had a serious problem with her head and the paramedics took her to hospital. This was in line with the JRCALC Guidelines which recommend transporting the patient to hospital when they show red flag symptoms.
34. When paramedics arrived at hospital with Mrs L they gave ED a report of her symptoms. These symptoms were documented in ED’s triage document, which demonstrates the paramedics shared them in line with NICE guidance.
35. We acknowledge the NHS 111 service suggested an aneurysm as a potential cause for Mrs L feeling unwell. We consider this triage does not replace a diagnosis from a medical professional. Paramedics were aware of these symptoms when they assessed her, as well as other possible explanations for her symptoms.
36. We have found paramedics assessed her symptoms in line with the JRLAC Guidelines. They transported her to hospital appropriately and explained her symptoms to doctors there.
37. We understand the heartbreak Mr L and his family have experienced. We hope our decision will give some closure on this exceptionally upsetting issue.
Initial hospital diagnosis and communication with family
38. Mr L also complains hospital doctors did not diagnose his wife’s aneurysm. He complains they instructed him to go home and collect an overnight bag for her, and she sadly passed away whilst he was doing so.
39. To establish what should have happened, we have referred to Good medical practice. Section 15 says doctors should adequately assess a patient’s condition and provide suitable advice, investigations or treatment where necessary. They should also give patients and their families information they need to know, like their condition and its likely progression.
40. When it comes to diagnosing an aneurysm, the most often reported and ‘telltale’ symptom is a sudden stabbing or tearing feeling in the chest that spreads down the back.
41. Other symptoms include: • a loss of blood pressure • different blood pressure in each arm • nausea • vomiting • headache.
42. Our ED adviser explained these other symptoms are not unique to an aneurysm, and different health problems can also cause them. Therefore, diagnosing an aneurysm is not always straightforward - especially if the patient does not report a tearing sensation.
43. The triage nurse received Mrs L from the paramedic team at 11.55am. The nurse recorded Mrs L reported numbness in the hands and feet, as well as nausea. However, there was no mention of chest pain or a tearing sensation in her chest. At approximately 1.15pm Mrs L’s blood pressure was low and she had vomited in the waiting room.
44. The junior ED doctor saw Mrs L at 3.15pm and found she had a headache and vomiting which were not getting better. They also identified she had low blood pressure and it was different in each arm. She had a cold sensation, a weak pulse in one leg, and central chest pain. She described it as more like ‘pressure’, but it was not radiating down her back.
45. The doctor made a differential diagnosis of a kidney injury. A differential diagnosis is a of way identifying a problem when several different illnesses can cause the same symptoms.
46. We now know the diagnosis was wrong. However, our ED adviser explained given Mrs L’s presentation and blood test results, at this stage it was appropriate to diagnose a kidney injury. When the doctor did make this diagnosis they attempted to treat it appropriately in line with Good medical practice.
47. Further, as doctors reasonably did not suspect an aneurysm at this point it would not have been possible for them to warn Mr L about how serious her condition was or how it would actually progress.
48. We understand how devastating the loss of Mrs L has been and hope our decision on this part of the complaint brings some reassurance.
Communication between staff
49. Mr L complains departments did not communicate amongst themselves to escalate his wife’s care as soon as they should have done.
50. Mrs L’s blood pressure was still exceptionally low after three and a half hours in hospital and three bags of fluid. As she was not getting better, our ED adviser explained the doctor should have considered potential emergency problems such as internal bleeding, heart attack or sepsis.
51. In line with Good medical practice doctors should refer a patient to another practitioner when this best meets their needs. The Trust’s Senior doctor role cards set out an ED consultant should review a patient before referral to a specialist. Therefore, in line with this, Mrs L’s condition meant her care should have been escalated to a senior specialist or consultant sooner.
52. To understand the Trust’s view of what happened we have considered its patient safety incident report. This was an internal investigation of what happened. It looked at whether the Trust took appropriate steps to diagnose and treat Mrs L, and if it could have identified her aneurysm sooner.
53. The report found Mrs L’s symptoms were vague. It also explained the doctor who first saw Mrs L was working their first shift at the Trust. This meant they were unaware of the handover policy. Further, there was significant overcrowding in ED.
54. The Trust’s Standard Operation Procedure for times of overcapacity explains what should happen during periods of overcrowding. It says patients are in danger if there are over 40 patients in ED. Normal care is not possible in these situations. Its investigation report found ED was looking after 42 other patients when Mrs L attended.
55. We acknowledge the mitigating circumstances of what happened and understand the acute pressures ED had at the time. However, we cannot ignore the fact the referral did not happen as set out in guidance.
56. The Trust’s complaint response explained a consultant reviewed Mrs L at 4.40pm and completed the referral to a specialist doctor. Whilst a referral was made, we have seen no record of consultant involvement in Mrs L’s records. We cannot say the escalation happened as it should have done.
57. Not escalating Mrs L sooner or informing a consultant is a failing. We have therefore considered the impact of this.
58. Mr L says if the Trust had known about his wife’s aneurysm then she might have got the operation she needed to survive. He says if that was not a possibility then he and his family would have been able to spend the final moments with her.
59. We cannot say exactly what would have happened had a specialist or ED consultant reviewed Mrs L. She had some of the features associated with an aneurysm, although as above, other conditions could have caused them.
60. Our ED adviser explained Mrs L’s continued low blood pressure in combination with her other symptoms means it is possible a more experienced doctor would have considered Mrs L had a more serious problem, such as an aneurysm.
61. Our ED adviser added a consultant would be better placed to accurately diagnose Mrs L given their experience. However, her symptoms and a reasonable working diagnosis meant this was not guaranteed.
62. We cannot definitively say an accurate diagnosis would have happened. However, there was a lost opportunity to know for certain if she would have been diagnosed. Not knowing this is an injustice to Mr L.
63. Further, we have also considered if whether the impacts Mr L has claimed would have been avoided if care was escalated sooner.
64. Our ED adviser explained an aneurysm can only be repaired with specialist emergency heart surgery. Not all hospitals have the appropriate staff and equipment to perform it. An operation must happen promptly to maximise the chance of success.
65. The Trust does not have the facilities to provide the operation Mrs L needed.
66. We understand Mr L feels there was an opportunity to transfer her to a suitable hospital for treatment. This would have meant a hospital off the Isle of Wight. Unfortunately, given Mrs L’s poor condition and rapid deterioration we do not believe a transfer was possible even if her condition had been diagnosed accurately.
67. However, at the time Mrs L died Mr L and the family were not in hospital as they were getting her an overnight bag. Mr L says if he knew about her condition then he would not have left. This meant there was a potential lost opportunity for Mrs L’s family to spend time with his her immediately before she died.
68. We are sorry for the upset this knowledge might cause Mr L. We hope it provides some closure to him in time and recognise that does not take away from the pain our finding might bring.
69. As we have identified an injustice arising from this failing we have considered what the Trust has done to put things right. To do this we have compared how the Trust responded to Mr L’s complaint to the NHS complaint standards.
70. These standards say the organisation should make changes to stop the same thing happening again. Additionally, the organisation should return the person affected to the position they would have been in if the poor service had not occurred. If that is not possible, they should compensate them appropriately.
71. The Trust identified the doctor did not escalate Mrs L’s care as they should have done in line with its policy. Consequently, it reiterated the necessary professional standards to ensure patients are assessed properly before transfer.
72. The Trust’s clinical governance lead also met with Mr L and shared the findings of its serious incident investigation. They apologised to him in person for the sad events he experienced and acknowledged just how distressing they have been for him and his family.
73. We welcome how seriously the Trust has taken this issue and can see it has understood the significant upset Mr L has experienced. We also understand the impacts of hospital overcrowding on staff and that they have also been affected by the sad events Mrs L experienced. We acknowledge the pressures individuals faced at this difficult time.
74. Whilst these actions are reassuring we do not believe reiterating professional standards goes far enough to stop the same thing happening again. This is because it seems the problem did not arise solely from lacking professional standards, but unfamiliarity with the local policies at the Trust.
75. Additionally, Mr L is left not knowing if things would have been different. This has caused him immense distress and the Trust’s apology has not properly compensated him for this impact.
76. We have therefore set out the recommendations we have made to put this right below.