Incorrect treatment at the ED
16. Before we decide if we should conduct a detailed investigation of a complaint, we look at whether there are signs the organisation has got something wrong. We do this by comparing what should have happened with what did happen. We have done this and have not found any indications that something has gone wrong.
17. Mrs A complains the Trust wrongly referred her husband to a renal ward, rather than to the cardiac ward when he had presented with shortness of breath. The GP had made a referral under the Patient Care Advice Line, who advised he was sent to LGI under the cardiology team.
18. Mrs A said in her complaint that her GP had referred her husband under cardiology, due to his shortness of breath and swelling in his legs. She felt that he should have been on a speciality ward rather than an assessment ward.
19. The Trust said in its response that he was seen within six minutes of arriving at the ED. He had blood tests and an ECG. It also said he received calcium gluconate, insulin and 10% dextrose to correct high potassium levels. He then had an ultrasound scan of his kidneys, an ECHO and urine tests.
20. It also said in its response that Mr A was found to have heart failure which was causing fluid on his lungs. It explained there had been a deterioration in kidney function which was also contributing to the breathlessness. It also explained his potassium level was unusually high due to the kidney failure and so he was referred to General Medicine at SJH.
21. We discussed this element of the complaint with our ED adviser. Our ED adviser commented that the primary care assessment link was completed by the GP and that the cardiology ward does not always take referrals from the GP. Mr A did not get sent to the cardiology ward but was seen by emergency physicians in the ED.
22. Mrs A said in her complaint that her GP had referred her husband under cardiology, due to his shortness of breath and swelling in his legs. Our ED adviser commented that the GP would not have been aware of the very high potassium result from Mr A’s presentation that morning.
23. We discussed with our ED adviser, whether what happened to Mr A on his arrival at the ED, was in line with the standards of care to be expected. They said when a patient presents to ED with a number of non-specific symptoms, like in this case, there is not any specific guidelines other than following the GMC’s ‘Good Medical Practice’.
24. This states that doctors must adequately assess the patient’s conditions, taking account of their history (including the symptoms) and where necessary, examine the patient. They should also promptly provide or arrange suitable advice, investigations or treatment and refer a patient to another practitioner when this serves the patient’s needs.
25. Our ED adviser said that Mr A had a good assessment, which took into account his previous cardiac history and that he had chronic kidney failure. They also said there are many things that it could have been at this point, potentially a heart attack, a fluid overload as a result of the kidney failure, or possibly associated with pneumonia.
26. Our ED adviser also commented there was a lot of oedema (water) in his legs and that the next step would be determining why this was. We can see an ECG was performed along with a blood test. From the blood test it showed a high potassium level. Our ED adviser said that Mr A’s potassium result of 6.8mmol/l would be classed as life threatening, as anything over 6.5mmol/l is classed as severe. If it is severe or life threatening, emergency treatment is indicated.
27. From the clinical records we can see the Trust performed an ECG to look at the impact of the high potassium on the heart trace, as there are some signs that the heart is being affected by the high potassium. Our ED adviser said that the very high potassium level required immediate treatment, and the blood test is then rechecked after the initial emergency treatment for high potassium. This shows that the potassium level has lowered, which is still mildly elevated but heading in the right direction.
28. From the records we can also see in addition to the kidney problem, Mr A also had fluid on his lungs. Our adviser said this could have been due to worsening kidney function and heart failure. This then caused Mr A to retain a lot of fluid and impaired his ability of the heart to pump. Our ED adviser said that the renal team was the correct department to be treating him and they acted correctly. A cardiology ward would not have been the correct place for him at this time.
29. We next discussed with our adviser if Mr A would have received treatment that was any different, being on an assessment ward rather than a cardiology ward.
30. Our ED adviser said that the cardiology team would not be the most appropriate team to manage the kidney failure. There was no treatment that would be offered on the cardiology ward at this time that could not be given elsewhere with cardiology supporting to the ward he was on.
31. We understand this is a common situation in hospitals when a patient is admitted with several medical conditions. The patient will be referred to the specialty that manages the most serious or life threatening condition.
32. In Mr A’s case this was his very high potassium because of the kidney failure. The emergency management moved the potassium out of the blood stream, but Mr A required ongoing management by the medical team to assist the body in removing the excess potassium and fluid.
33. In conclusion, the evidence shows Mr A presented with heart failure as a result of kidney failure with the associated life threateningly high potassium. The evidence indicates the emergency treatment of this high potassium was correct and in line with guidance. A very high potassium level effects heart function.
34. The kidney failure results in fluid retention, which makes it harder for the heart to work correctly. The kidney failure needed emergency care. We understand that SJH had an in-reach service from cardiology for ward patients admitted there and an on site kidney failure team. This would be the safest and most appropriate ward for Mr A to have been admitted to initially.
35. Considering all of the evidence we have seen, we can see that the Trust acted within guidance. This is because it seems it arranged suitable advice and investigations, and referred to suitable practitioners (renal and medical assessment). There are no indication of failings on this matter.
Taken for an ECHO when too unwell
36. Mrs A says that on 7 March 2023, Mr A was very short of breath when a porter came to take him for an ECHO. She says she left and when she rang two hours later to see if he was back from the scan, she was told Mr A had had a cardiac arrest and was being transferred to ICU.
37. The Trust said in its response that, before the ECHO, Mr A’s oxygen saturations were running between 96-99% and that his respiratory rate was between 18 and 19 breaths per minute, both of which are regarded as normal. The Trust acknowledged that Mrs A felt that he was too short of breath to go down for the ECHO, but that it was extremely important for the scan to go ahead.
38. We discussed this element of the complaint with our cardiology adviser. They adviser said the ECHO was requested by cardiology to follow up on the fluid around Mr A’s heart, to see if it needed draining.
39. The reports state there is pericardial constriction. This is a condition where the pericardium (the sac surrounding the heart) becomes thickened and scarred which limits the heart's ability to fill with blood. Another registrar reviewed the electronic referral, the notes and report and advised the repeat to take place on 7 March 2023.
40. Our adviser said the relevant guidance here would be the NICE Guidance ‘MIB205’. In this it discusses the NEWS scoring system. This is a system for scoring the physiological measurements that are routinely recorded at the patient's bedside. Its purpose is to identify acutely ill patients, including those with sepsis, in hospitals in England.
41. The NEWS scoring system measures six things: respiration rate, oxygen saturation, blood pressure, pulse rate, level of consciousness or new-onset confusion and temperature. It then generates a score and the higher a score, the more intervention is needed for that patient.
42. We can see from Mr A’s clinical records before the ECHO that he was stable and had a NEWS score of zero. This is the lowest score that is possible to have and as such, Mr A was classed as low risk. As a result of this, there is no documented reason why he could not have the ECHO.
43. We next asked the adviser if the ECHO could have been carried out at the bedside. Our cardiology adviser said that generally the machines are better and the image quality is better on the main machine, not a mobile machine for bedside use. They also referred back to the NEWS score being at zero. We understand this means there was not a particular reason to do it at the bedside and it was of paramount importance that Mr A had the ECHO to determine if the fluid around his heart was still there.
44. Taking into consideration all of the evidence we have available, we have seen no clinical indication that Mr A should not have had the ECHO on 7 March. We appreciate that Mrs A said that Mr A was very short of breath when he went down for the ECHO. Having consider everything carefully, we have seen it was important for the ECHO to go ahead in order to determine what next steps should be taken in his treatment.
45. Overall, we consider the Trust acted in line with the GMC guidance we referred to earlier. It seems it was seeking to promptly investigate Mr A’s symptoms, as the GMC guidance recommends. It also seems to have worked within the NICE guidance when deciding on the investigations. We have not seen any indications of failings on this matter and as a result will not be looking at this issue any further.
Poor communication around Mr A’s care
46. Our service model guidance says we should attempting a resolution where it appears that, with minimal intervention, we could achieve a satisfactory result for the complainant. This could include asking an organisation to provide financial redress, or to consider service improvements.
47. Mrs A complains that communication from the Trust was poor. She said that communication between the hospitals regarding Mr A’s transfer between the cardiology ward at LGI and the renal ward at SJH was not adequate. She also says that it was not communicated clearly that Mr A was approaching the end of his life.
48. She also says she only found out about Mr A’s cardiac arrest as she rang to see he had come back from his ECHO. She also says that the person who informed her of the cardiac arrest was rude and blunt.
49. The Trust acknowledged in its response that Mr A being transported between the two hospitals throughout his stay was not ideal. It explained this was where the optimal care for his condition at each point would be. The Trust also apologised if it did not communicate clearly with Mrs A towards the end of his life.
50. In the clinical records, there is no record of the phone call that Mrs A made to the Trust when she was informed of Mr A’s cardiac arrest. Even if there was a record of the call we would find it difficult to reach a judgement on whether there was a failing, as the Trust was not clear on who received the call from Mrs A.
51. We discussed Mrs A’s concerns regarding the communication with the Trust. The Trust said, whilst it could appreciate the family’s concerns about the communication regarding the transfers between the two different hospital sites, much of it was out of it’s control. It gave the example of the transport between the two sites and often having to wait for an appropriate slot and that emergencies on the day can mean that an arranged transfer is then delayed.
52. From looking at the clinical records, we can see that there are thorough handover notes each time Mr A was transferred between wards and detailed observations and conversations between clinicians recorded throughout the time that he was at the Trust. We can also see that each time that Mr A was transferred between wards, it was out of necessity, but the fact that it was between two different sites added to the family’s confusion at an already very distressing time.
53. The Trust acknowledged Mrs A’s frustration and has previously apologised for this.
54. We next discussed with the Trust about the poor communication towards the end of Mr A’s life. As we explained earlier, the Trust previously acknowledged it did not communicate clearly at the end of Mr A’s life. It said it had recently implemented more training around end of life care with staff throughout the Trust.
55. The Trust also said that in March 2024 it implemented an electronic form called ‘Care of the dying person – medical and MDT digital plan of care’. This includes a prompt to discuss a number of key things with the patient and those important to them, including side effects of medicines, along with an initial and ongoing communication plan to raise awareness of the electronic form across the Trust.
56. The Trust also agreed to a financial remedy of £120 to Mrs A for the distress that the poor communication during the time that Mr A was in hospital caused her.
57. Our NHS Complaint Standards explain organisations should find suitable and appropriate ways to put things right for people who raise a complaint. For financial outcomes, our Severity of Injustice Scale sets out the amounts we might expect.
58. Mrs A told us how the communication from the Trust whilst Mr A was at the Trust, made a difficult time so much harder. The distress we consider Mrs A experienced from the poor communication matches with level two of that scale. This describes cases involving minor failures in communication which caused a small degree of distress or worry against a background of bereavement. This level of the scale is between £120 and £550. We consider a total remedy of £120 to Mrs A is in line with our guidance here.
59. We feel that this is an appropriate resolution to the poor communication that Mrs A feels she received from the Trust. This is alongside the reassurance the Trust has given on service improvements and the apology it has already provided to Mrs A. Based on this, we consider we have resolved this part of her complaint. We will not take any further action.
60. We understand that this has been an extremely challenging time for Mrs A and her daughter. We would like to thank her for bringing this complaint to our attention.