Hospital admission 15 to 23 May 2022
18. Mrs A says this admission was due to her husband having pneumonia, but he also developed abdominal pain during the admission which was thought to be due to an infection. Therefore, we have asked our surgeon adviser about the care that Mr B received during this admission.
19. Our surgeon adviser has reviewed the relevant records and highlighted that Mr B was reviewed by a surgical registrar on 22 May 2022 where he reported ‘rectal pain’ and pain over incisional hernia. The registrar seemed to focus on Mr B’s incisional hernia and there was no recorded assessment of his rectal stump. There is no mention of abdominal pain before this, and Mr B’s abdomen is described as ‘soft and tender’ on 23 May 2022.
20. Nevertheless, we consider there was a missed opportunity at this point (22 May 2022) to examine Mr B’s rectum by performing a digital rectum examination. On considering these findings, our surgeon adviser says it could then have been suggested to Mr B that he take some suppositories or have an enema to help empty his rectum of any mucus. This would have helped to ease any pain Mr B was suffering. NHS guidelines on Digital Rectal Examination and Digital Removal of Faeces indicate that digital rectal examination can be used as part of patient assessment followed by administration of suppositories or enema if necessary.
21. We consider this was a failing by the Trust regarding Mr B’s management as he was not given a rectal examination when this was necessary as part of his assessment, contrary to the relevant NHS guidance. We appreciate this will cause Mrs A some doubt and uncertainty about her husband’s care which is emotionally distressing for her. We have made recommendations about this. We have not identified any other failings in Mr B’s management by the Trust during this admission.
22. It should be noted however, that Mr B’s symptoms of abdominal area pain and rectal spasms did not last long. Mr B had some spontaneous discharge of mucus from his rectum and in most of Mr B’s ward assessments, our surgeon adviser says he did not have any abdominal pain.
23. Our surgeon adviser says the correct working diagnosis for Mr B was an acute lung infection and a secondary concern about a possible lung malignancy. Based on our consideration of Mr B’s records, they do not imply that his abdominal pain was caused by an infection.
24. As regards the term ‘rectal impaction,’ our surgeon adviser has said that using this term in Mr B’s case is unhelpful. This is because it normally implies that a patient is unable to open their bowels, and the rectal impaction is blocking their bowel. In Mr B’s case, his rectum is out of circuit, but his gut system is working correctly with a normal functioning stoma. Mr B’s rectum had retained mucus which is likely to have been present for months or years. It was not an acute surgical emergency and not something which was responsible for his admission to hospital.
25. By 23 May 2022, Mr B had been treated for his conditions and there was no basis to keep him in hospital as his conditions could be managed from home with external support. Our surgeon adviser says there was no issue with his discharge but has pointed out that many patients with life-limiting conditions (like Mr B) re-present after discharge if their medical conditions worsen.
Hospital admission 25 May to 2 June 2022
26. Unfortunately, Mrs A says that Mr B had to go back to hospital on 25 May 2022 after his abdomen burst. The Trust thought he was suffering from faecal impaction which could be treated, but Mrs A says appropriate treatment was not provided.
27. The records indicate that Mr B was suffering from a bowel fistula which is an abnormal opening in the stomach or intestines that allows the contents to leak into another part of the body. Given this, our surgeon adviser says a stoma bag was placed over the skin discharge from Mr B’s bowel fistula. It is noted that he was eating and drinking and not acutely unwell.
28. The PMC guidance on the management of enterocutaneous fistulas highlights that protection of the skin is a vital early step in patient management. The use of stoma devices to support wounds is considered to be appropriate practice in such circumstances.
29. Therefore, our surgeon adviser says the correct treatment was provided in accordance with the PMC guidance. Mr B did not show any signs of peritonitis which is redness or swelling of the abdomen or stomach, and he was eating and drinking. As such, our surgeon adviser says there was no indication that he needed any additional management.
30. Mr B also had a CT scan on 25 May 2022. It showed a large rectal bolus of retained mucus, and the records suggested consideration of treatment with an enema. Our surgeon adviser says there is no evidence this was done. Therefore, we consider this was a missed opportunity to reduce Mr B’s rectal specific pain which had been reported when he reached hospital.
31. We consider this was a failing by the Trust regarding Mr B’s management as he was not given an enema to try and relieve his pain, contrary to the relevant NHS guidance. We appreciate this will cause Mrs A some additional doubt and uncertainty about her husband’s care which is emotionally distressing for her. We have made recommendations about this. We have not identified any other failings in Mr B’s management by the Trust during this admission.
32. As for Mr B’s discharge from hospital, our surgeon adviser says he was fit for discharge on 2 June 2022, but it must be acknowledged that he was an extremely medically unfit patient who had poor baseline function.
Hospital admission 9 to 19 June 2022
33. Mrs A says Mr B was readmitted on 9 June 2022 due to severe breathlessness and low O2 levels. His symptoms including rectum pain were investigated and he was discharged on 19 June 2022 with a plan that he would recuperate at home with appropriate support.
34. On this admission, our surgeon adviser says Mr B had an ongoing infection in his lung, but there is no specific reference to any acute surgical problems.
35. Having considered the relevant records, Mr B’s condition was managed appropriately during this admission, as was his discharge on 19 June 2022, in the context of his overall condition which was poor. We have not identified any failings in Mr B’s care during this admission.
Hospital admission 24 July to 2 August 2022
36. Mr B's final hospital admission was between 24 July and 2 August 2022 when he was taken to hospital with severe abdominal pain. He had emergency surgery on 24 July 2022. Unfortunately, after surgery, Mr B's prognosis was poor, and he was placed on end-of-life care. He sadly died on 2 August 2022.
37. Mr B had an emergency laparotomy and total colectomy on 24 July 2022 as he had suffered a perforated bowel. Our surgeon adviser says that Mr B had end stage life shortening medical conditions of COPD (on home oxygen) and heart failure from before this episode of care started in May 2022. Therefore, his chances of surviving this type of surgery were always limited.
38. By the time of surgery, our surgeon adviser says Mr B had a predicted mortality rate of approximately 80%, according to his p-possum score. This does not take into account a recent severe lung infection in a patient like Mr B who was also on home oxygen, so his mortality rate could well have been even higher than this. In many similar situations, consideration could have been given to not operating at all due to the limited chances of Mr B surviving. Nevertheless, we understand why Mr B and Mrs A would have wanted the Trust to try everything possible to save Mr B’s life.
39. A consultant assessed Mr B prior to the emergency operation and stated ‘I have grave concerns re survivability from this operation.’ and ‘I had a long discussion with Mrs A…(re plan) details the plan the first day after the operation, where it was stated that Mr B would not be suitable for reintubate if his condition worsened and not suitable for resuscitation’. Our surgeon adviser says these were sensible clinical decisions, clearly recorded and made by a consultant in intensive care. Another documented conversation on 24 July 2022 (on admission to ITU) records that Mrs A was not aware of how high risk her husband’s condition was at that time and the ITU team were explaining that he may not survive.
40. We have not seen any failings with the care provided to Mr B by the Trust during this admission. Our surgeon adviser says it was appropriate for the Trust to start end of life care (by 31 July 2022) as Mr B had no realistic chance of survival at this point despite the emergency surgery he had. He was unresponsive and had essentially ‘slipped into a coma.’ Mrs A, who was present at the time, disputes this. Despite being heavily medicated at the time and as a result, often being asleep, Mrs A says her husband was still able to respond to her in limited ways such as nodding, shaking his head, and smiling.
41. We note that Mrs A questioned whether he was suitable for renal dialysis. Our surgeon adviser says that in order to do kidney filtration Mr B would have needed to have more invasive ‘lines’ placed and when there was no chance of survival, this would have been inappropriate for him. This is reflected by the Trust records on 28 July 2022 which state: ‘in the event of needing renal replacement therapy, this would not be appropriate’. The issue of kidney filtration was also independently discussed with a Consultant Nephrologist who also agreed with the ceiling of care and that kidney filtration or long-term dialysis was not a sensible option for Mr B.
42. Our surgeon adviser says the records reflect during this admission that the clinical team at the Trust had pre-emptively thought of all potential clinical scenarios and planned a level of care which they thought would be appropriate and in Mr B’s best interests to avoid undue suffering. We hope this provides some reassurance to Mrs A about the care provided to her husband at the end of his life. Unfortunately, by 31 July 2022, it is documented that the clinical team felt Mr B was dying. Therefore, it is noted that a telephone call was made to Mrs A, and a conversation took place to explain the situation. We appreciate how distressing this must have been for Mrs A.
43. We have noted from the records that Mr B had a bowel operation in 2008 for complicated diverticular disease from which he had a permanent colostomy bag. This operation involved removing the sigmoid colon, stapling off the rectum and forming a colostomy.
44. Our surgeon adviser says Mr B’s rectal stump is out of circulation (no food residue in it) and has been like that since 2008. The rectal lining produces mucus, and this can cause the mucus to build up in the rectal stump. This is likely to have been like this for many years. During the intervening years, Mr B also developed an incisional hernia.
45. It is important to understand that the mucus in the rectal stump was not responsible for Mr B’s death. On the CT scans and at the emergency operation, our surgeon adviser says his rectal stump was intact and not perforated. The area of perforation happened in the proximal colon just up from the stoma. This is completely unrelated to any issues with the rectal stump. The cause of the perforation in the proximal colon is unknown and difficult to understand as the stoma had been working in the lead up to the acute perforation.
46. We note the findings of the independent medical report about Mr B’s care that Mrs A has provided. The report reflects some of our findings in that no one did a rectal examination, and the administration of enemas and/or suppositories would have likely removed some of this mucus from the rectal stump and reduced Mr B’s rectal spasms.
47. Unfortunately, Mr B developed a bowel fistula (identified during his second admission) where a perforation allows bowel content to discharge into the skin. This was treated conservatively. Then in July 2022, Mr B developed a second perforation in the part of the bowel just proximal to the stoma which resulted in emergency surgery. Our surgeon adviser says this perforation was responsible for his death. It is likely that these issues with Mr B’s bowel were responsible for most of his abdominal pains during the admissions and not chronic rectal mucus in a healthy rectal stump. The mucus in the rectal stump is completely unrelated to his colonic perforation and not the cause of Mr B’s death.
48. If Mr B had been given enemas, our surgeon adviser says they may not have been completely effective in removing all the mucus that had built up in his rectal stump. Also, conducting a manual evacuation under general anaesthetic would not have been sensible given Mr B’s overall poor health especially his lung infection. As above, it is not the case that the mucus in Mr B’s rectum caused bowel perforation and his sad death. This was due to the second perforation that he suffered in July 2022.