15. Mr A told us he could recognise how unwell his mother was when she was in the ED, and he could not understand how the medical team did not see it. We understand how worrying and upsetting this must have been for Mr A.
16. We looked to see whether the initial assessment in the ED was in line with guidance. As outlined in paragraph eight, Mrs A was seen and assessed within an hour of arrival. The relevant guidance is the Manchester Triage Group, Emergency Triage. This is a tool of clinical risk management, where all patients arriving in the ED undergo a structured procedure to assess their urgency.
17. Our adviser told us Mrs A fell within the ‘yellow category’. This covers urgent patients who should be seen within 60 minutes. Criteria include symptoms like those Mrs A was experiencing, such as persistent vomiting and severe abdominal pain.
18. From the triage we can see the Trust acted in line with the guidance outlined, under the category relevant for the symptoms Mrs A was experiencing.
19. The medical records do not show any follow up triage category. Our adviser told us Mrs A’s vital signs, under the Manchester Triage Group flow sheet for abdominal pain, would place her in Category 4 at presentation. This means the initial triage should be followed up within three hours.
20. An Advanced Clinical Practitioner (ACP) began to assess Mrs A at 4.06pm. ACPs are highly skilled healthcare professionals who have undergone advanced education and training. They work under a consultant, who has responsibility for ensuring the work is in line with expected standards.
21. The ACP’s assessment was within an hour of the initial triage and so was in line with the guidance in paragraph 20.
22. The results of a Venous Blood Gas (VBG) test, carried out at 3.40pm, were available to the ACP. A VBG is a simple blood test that helps medical practitioners understand how well the body is managing oxygen, carbon dioxide, and acid levels. The test is useful in emergency situations because it provides quick results.
23. The VBG showed Mrs A had a physiological state known as ‘metabolic acidosis’. This is when the body has too much acid, which can make patients feel tired, confused, and cause rapid breathing and heartbeat. Our adviser told us this was an indication Mrs A was becoming critically unwell. Mrs A had also had high levels of lactate, which is a key marker in bowel obstruction.
24. The VBG gave enough of a clinical picture to allow staff to recognise the seriousness of the situation and start treating Mrs A appropriately.
25. It was with this information that the ACP carried out a full examination. This examination was carried out in line with the Paramedic Specialist in Primary and Urgent Care Core Capabilities Framework guidance, which says the ACP will:
‘ [take into account] the presenting complaint, past history, medications, allergies, risk factors and other determinants of health to create a mutually agreed action plan.’
‘ Apply a range of physical assessment techniques appropriately […]’ and ‘Interpret the […] findings from the consultation in order to determine the need for treatment and/or further investigation and/or escalation.’
26. ACPs work under a consultant who has responsibility for ensuring the work is in line with expected standards. In this case the assessment met the standard for the supervising doctor, as outlined in GMC good medical practice. This says:
‘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 […] 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.’
27. Our adviser said the symptoms Mrs A was experiencing, and the VBG results, made a diagnosis of bowel obstruction the more likely diagnosis. This is what the Trust identified and treated Mrs A for. The ACP made a referral without delay for a surgical opinion at 4:49pm. This was in line with the guidance outlined in paragraphs 26 and 27.
28. The ACP also made a referral for CT imaging, which was carried out at 6:50pm. This was in line with the RCS guidance on emergency general surgery (acute abdominal pain). This says abdominal CT is invaluable in the assessment of bowel obstruction, and that it should ideally take place the ‘same or next day’.
29. Mr A raised concerns that the Trust lost a blood test and was worried this may have impacted the timeliness of the care and treatment the Trust gave. We do not think this had a negative impact. This is because the observations, examinations, VBG results and scans all informed the clinical picture. Our adviser told us the treatment the Trust gave was supportive of, and appropriate for, Mrs A’s physiological state and would not have been altered by the blood results that went missing.
30. One of Mr A’s concerns was that he felt the Trust was not carrying out the standard observation checks needed, such as blood pressure. He told us he thought there should have been more observations, given how poorly his mother was.
31. The NICE guideline ‘Acutely ill adults in hospital: recognising and responding to deterioration’ recommends adult patients in acute hospitals should have observations recorded at initial assessment. Observations should then be monitored at least every 12 hours, unless a decision has been made at a senior level to increase or decrease the frequency of monitoring for an individual patient.
32. We can see this happened. The medical records show observations were taken when Mrs A was triaged and then observations were repeated at 5pm, then much more frequently when Mrs A’s condition deteriorated, at 6.16pm, 6.25pm, 6.35pm and 7pm.
33. The Trust gave Mrs A fluids when she began to deteriorate. Our adviser told us this is common practice when a patient is very unwell as it supports blood pressure and the cardio-vascular system. When a patient has a bowel obstruction, as Mrs A was suspected to have, they can lose fluids as they have often vomited and are unable to absorb fluid via the bowel.
34. This treatment was in line with the GMC guidance which says to ‘promptly provide or arrange suitable advice, investigations or treatment where necessary’. It was also in line with the professional advice on intestinal obstruction and ileus on Patient.info, which says ‘[fluid] resuscitation is very important. Correction of fluid and electrolytes considerably reduces the operative risk before surgery for obstruction’.
35. There is no time on the sheet to show when the first fluids were given. It is reasonable to assume this was at 5pm because the records show Mrs A’s blood pressure had dropped at this point. This also aligns with the chart showing the Trust gave the second infusion at 6.35pm.
36. We also looked at the drugs the Trust gave Mrs A, as Mr A told us his mother was left to suffer. We can understand how upsetting it must have been for Mr A to see his mum deteriorate.
37. Mrs A presented with abdominal pain and vomiting. The ambulance service dealt with the pain early and gave her both paracetamol and morphine. The records show her pain score on arrival was zero and there is no evidence she was left to suffer pain in the ED without the correct treatment.
38. There was also no evidence of delays in the treatment the Trust gave Mrs A for her feelings of nausea. We can see the Trust gave Mrs A anti-sickness drugs at 5pm. This was immediately after the assessment outlined in paragraph 26. This is in line with the GMC guidance, which says:
‘prescribe drugs or treatment, including repeat prescriptions, only when you have adequate knowledge of the patient’s health and are satisfied that the drugs or treatment serve the patient’s needs’.
39. We can see when Mrs A’s deterioration continued the Trust gave antibiotics at 7.10pm. Whilst there is no rationale for the antibiotics written in the records, this was a reasonable decision for the Trust to take, to try to counter any undiagnosed or unknown cause for the deterioration. This was in line with the GMC guidance outlined above.
40. The Trust gave Mrs A care and treatment to manage her symptoms from the time of her arrival to the time she was moved to the resuscitation area of the ED at 6pm.
41. The records show a nurse identified Mrs A’s deterioration, as outlined in paragraph 33, and appropriately escalated this issue to the nurse-in-charge and the doctor. This was in line with NEWS, a tool used in hospitals for monitoring patients' health and ensuring that any signs of deterioration are addressed promptly. Mrs A’s fall in blood pressure meant an urgent review was needed. This happened and Mrs A was moved to the resuscitation area at 6pm.
42. The resuscitation area of an ED is equipped similarly to ITU and the same treatments, medical equipment and resources are available as in an Intensive Care Unit.
43. The time from admission to being moved to the resuscitation area (where there was an intensive care outreach team) was three and a half hours. We recognise this will have felt like a long time for the family. During this time, Mrs A was receiving all care and treatment in line with guidance. Our adviser told us Mrs A would not have received different treatment even if she had been moved sooner.
44. The team managed Mrs A’s condition from the point she began to deteriorate at 5pm and made arrangements over the next hour to move her. She was given intensive support prior to being moved. It can take time to arrange resources to move patients and so it is reasonable to conclude she was moved as soon as the circumstances allowed.
45. An important area of concern for Mr A was the issue of whether the Trust should have given Mrs A oxygen treatment sooner. Mr A was worried this may have impacted her cognitive function and told us how distressing it was when his mother did not recognise him. We understand how upsetting it was when Mrs A became less aware and Mr A was not able to communicate with her.
46. The records show that when Mrs A began to deteriorate at 5pm she was still alert. There is no evidence she needed oxygen any sooner than she was given it, or that the decisions about oxygen affected her cognitive function. Our adviser gave more detail about what the records show.
47. The observation chart shows that at 3.05pm, Mrs A’s oxygen saturations were 96% whilst breathing room air. This is a good level and shows supplementary oxygen was not needed at that time.
48. The next entry is at 5pm but the oxygen level is not legible. Mrs A was breathing room air at that point and there is nothing to show she needed oxygen, as the other observations recorded show she was alert.
49. The following entry at 6.16pm shows Mrs A was still breathing room air and her oxygen level was 94%. This is a little low but still a non-dangerous level and does not show a need for oxygen therapy.
50. At 6.25pm the oxygen level was again in the normal range at 98%. At this time, it is noted Mrs A was breathing supplementary oxygen at 15 litres per minute, a high dose.
51. From the evidence it appears the Trust started oxygen therapy some time between 6.16pm and 6.25pm.
52. The initial ED triage assessment found that Mrs A had no oxygen requirement and had no cognitive problems. Whilst her condition began to deteriorate at 5pm, this did not affect her cognition as the records show she was still alert.
53. It is reasonable to conclude the Trust began oxygen therapy when Mrs A’s condition further deteriorated, when her blood pressure dropped at 6pm. It is likely the Trust gave Mrs A oxygen at that time to ensure she was in the best possible condition to withstand any ongoing treatment she may need when she transferred to the ITU.
54. There is no evidence that a deficit of oxygen affected Mrs A’s cognitive function. When a person is critically unwell it is often the case that oxygen is not reaching the cells in their body. This is not because they are not breathing enough oxygen, but because their overall physical condition is preventing the oxygen being breathed from reaching the cells.
55. Mrs A’s cognitive function was more likely affected by a combination of her symptoms, her falling blood pressure and her underlying condition, all of which the Trust were treating as we have explained.
56. Mr A is concerned that the staff did not appreciate how unwell his mum was and they were not giving her sufficient attention. We recognise how hard it will have been for Mr A to have been with his mum when she was unwell, and we understand he feels her needs were not properly attended to. The records show that the Trust did realise how unwell she was, and this is reflected in the care and treatment given to Mrs A.
57. Mr A told us the Trust prejudged Mrs A and disregarded his concerns.
58. It is difficult to judge communication from written records. It can be the case that communication does not meet the expectations of families for a variety of reasons. Mr A has identified that the ED was hectic. It can be difficult in such a busy environment to meet people’s expectations.
59. We have not seen any evidence to suggest the Trust prejudged Mrs A. As outlined in this report, the care and treatment was in line with guidance.
60. We accept Mr A’s experience made him feel distress and we are sorry to hear he has been left feeling this way. There is no evidence of communication with the family in the ED records. For this reason we cannot be assured communication was as it should have been, or that the Trust gave the family the opportunity to raise concerns while Mrs A was in the ED.
61. The GMC guidance says, ‘You must be considerate and compassionate to those close to a patient and be sensitive and responsive in giving them support and information.’
62. There is no evidence this happened and so this is a failing.
63. The Trust apologised during the local complaint resolution, and this is appropriate. Our Principles say public bodies should identify and acknowledge poor service and apologise for it. There is nothing to suggest this is a wider systemic issue as there is later evidence of good communication, with the ITU staff updating the family at 12.44am on 19 May. We think the apology is sufficient and there is no further action the Trust should take.
64. We accept how upsetting this experience was for Mr A’s, and we thank him for sharing details of what happened. We hope this report has clearly explained the reasons for our decision.