Discharge on 14 March
12. Mrs X says her husband was discharged on 14 March 2023 when he was not well. He was re-admitted less than a week later. In the Trust response dated 11 December 2023 it said that he was discharged following clinical investigations and blood tests. It said Mr X was considered medically well enough to be safely discharged.
13. The Trust admitted Mr X via the emergency department on 7 March 2023. He was noted to have been unwell for 2 weeks and had a fall four days prior with bruising to his right upper limb. He had experienced some urinary symptoms and an episode of diarrhoea. He had a background of type 2 diabetes and osteoarthritis. He was noted to live with Mrs X, mobilise with a stick and did not require care support at home.
14. Our physician adviser said that initial investigations were highly suggestive of infection with a raised white cell count and a markedly elevated C Reactive Protein (CRP). CRP is a protein produced by the liver that indicates inflammation in the body which could be caused by infection, diseases, trauma and heart risk.
15. The doctor carried out a clinical examination and our physician adviser said the observations were unremarkable except for signs of a right wrist fracture which was later confirmed on X-ray.
16. The medical team diagnosed Mr X with a suspected urinary tract infection, alongside some dehydration and a blood pressure drop on standing. Appropriate treatments were commenced, including intravenous antibiotics and intravenous fluids. The medical team discussed Mr X’s fractured wrist with the orthopaedic team. The fractured wrist was managed with a backslab (a slab of plaster that does not entirely encircle the limb) and the plan was for Mr X to be followed up as an outpatient.
17. The advice from our physician adviser indicates Mr X received appropriate treatment during the inpatient stay. He was noted to have a delirium due to the infection during the admission. He continued on intravenous antibiotics which were appropriate for the treatment of a urinary tract infection.
18. Prior to discharge on 14 March 2023, the physiotherapy and occupational therapy teams carried out assessments of Mr X on the ward. The therapy team and a doctor also spoke to the family. It is noted that repeat blood tests showed an improvement by the day of discharge, with a CRP now of 20 (near to normal) which our physician said would suggest a good response to treatment. A multidisciplinary discharge plan was completed with all relevant safety checks having been made. He was discharged to complete two further days of oral antibiotics at home.
19. Our decision is Mr X’s discharge was in line with the principles of a hospital discharge as outlined in Hospital discharge and community support guidance - GOV.UK (www.gov.uk) (31 March 2022). It included involvement of the multidisciplinary team, addressing post-discharge care needs (follow up of wrist fracture) and involvement of family members. Mr X was discharged back to his own home as would be expected in these circumstances.
20. Our physician adviser further explained that from a medical perspective, Mr X did not require any treatments or support that would necessitate remaining in an hospital as set out in “Annex D – Criteria to reside” of the above document. In the circumstances, we do not uphold the complaint.
Failure to treat an abscess in Mr X’s pelvic region
21. The relevant guidance here would be GMC Good Medical Practice 2013: 15 You must provide a good standard of practice and care. If you assess, diagnose or treat patients, you must:
a 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
b promptly provide or arrange suitable advice, investigations or treatment where necessary
c refer a patient to another practitioner when this serves the patient’s needs
22. On the second admission to hospital 19 March Mr X had signs and symptoms in keeping with a severe infection, and this was treated appropriately. Initial investigations were suggestive of a pneumonia (including raised white cell count, CRP and chest X-ray signs of consolidation).
23. Our physician adviser said the clinical picture was complicated by some other examination and blood abnormalities and these were investigated further in case of significance (such as representing alternative causes of infection). Mr X received investigations of a swollen left wrist/arm which ultimately did not reveal any serious cause. Concerns were raised for possible intra-abdominal complications, and these were extensively investigated (initially with an ultrasound of the abdomen, followed by a CT thorax, gastroscopy and CT thorax/abdomen/pelvis) with opinions from appropriate specialists. The final CT performed raised queries about possible abnormalities including mild oesophageal dilation (narrow food pipe), pancreatic masses, and small bowel abnormalities.
24. Our physician adviser explained the suspicion of a pelvic abscess arose from the CT scan performed 15 April. The CT was reported by a radiologist and further discussed with the surgical team who planned a CT guided aspiration (sampling or drainage of the fluid) to be performed. The scan was reviewed again in the hepatobiliary MDT (Multidisciplinary Team) meeting 26 April. (Hepatobiliary refers to anything related to the liver, gallbladder, bile ducts, and pancreas). This meeting was to discuss the pancreatic abnormalities that were noted on the scan and compare to previous imaging from the years before, but the pelvic abnormality was also considered. It was noted that the suspected pelvic abscess was “likely to represent a large bladder diverticulum (a pouch or sac that forms in the bladder wall, which can cause the bladder to become enlarged) as seen on prior examinations dating back to October 2020.
25. Our physician advise said this would mean that it was unlikely to be the source of ongoing severe infection, and aspiration of the area would not be clinically beneficial. Mr X’s condition markedly deteriorated shortly after this meeting and he died two days later. We note that pelvis abscess was included on the death certificate alongside pneumonia as the cause of Mr X’s infection. However, our physician adviser said it was not clinically confirmed nor did a post-mortem take place.
26. Our physician adviser explained Mr X had a severe and persistent infection. He appears to have received a continuous course of strong antibiotics, with guidance when required by microbiology specialists. The source of the infection or infections was extensively investigated. Alongside this management Mr X clearly experienced a dramatic general decline in his health. He had very poor oral intake necessitating artificial feeding via nasogastric tube, occasions of low blood glucose requiring adjustment of his diabetes treatments, and markedly reduced physical function. This combination of factors caused a severe frailty which alongside the medical complications, Mr X was unable to survive. Our physician adviser has indicated that there is no evidence to suggest a change in the management of Mr X’s care would have meant he could have survived.
27. Having considered the available evidence including the advice of our physician adviser our decision is there were no failings in the care and treatment provided to Mr X prior to his sad death. Therefore, we do not uphold the complaint.
Conclusion
28. We recognise that the death of Mr X has greatly affected Mrs X and her family and we do not want to detract from that. We have thoroughly investigated her complaint and we hope we have clearly explained how we have reached our decision.