Doncaster Trust
23. Mrs R first attended the Doncaster Trust ED on 23 December 2019 because she had chest pain and was coughing up blood.
24. BMJ Best Practice guidance on the assessment of haemoptysis recommends a patient’s history is taken, the patient is examined and blood tests, a chest X-ray and CT scan are done. Doctors at the Doncaster Trust completed all these actions to try and diagnose the cause of Mrs R’s problems. This was in line with the guidance.
25. The CT scan showed Mrs R had pneumonia and a thoracic aortic aneurysm. Doctors referred her to the cardiology team and they referred her to the cardiothoracic surgery team at the Sheffield Trust on 31 December. It was recorded in the discharge documents that as the aneurysm was not ruptured, the surgery would be elective, rather than urgent.
26. Our cardiology adviser explained that the thoracic aneurysm was sufficiently large to warrant consideration of surgical repair on an elective basis.
27. GMC Good Medical Practice guidance says:
You must provide a good standard of practice and care. If you assess, diagnoses or treat patients, you must:
• Adequately assess the patient’s conditions, taking account of their history, their views and values; where necessary, examine the patient • Promptly provide or arrange suitable advice, investigations or treatment where necessary • Refer a patient to another practitioner when this serves the patient’s needs
28. Doctors assessed Mrs R, arranged appropriate investigations, referred her to the cardiology team and then the cardiothoracic team in line with this GMC guidance.
29. Mrs R attended the Doncaster Trust ED again on 19 February, 27 February, 28 March and 23 April 2020 with further episodes of haemoptysis. Having reviewed the records we have seen evidence that on each occasion Mrs R’s history was taken, she was assessed, investigations were arranged and she was referred to the on-call medical team for further assessment and investigation.
30. Bloods tests and a chest X-ray were done on 19 February and antibiotic treatment was started. On 27 February a CT angiogram was done and a respiratory review took place on 28 February. This review led to an outpatient bronchoscopy on 5 March. Blood tests and an X-ray were repeated on 28 March and 24 April.
31. Our ED Adviser has explained that an ED doctor’s primary role is to assess and manage emergencies. If a patient has an ongoing problem which is already being followed-up by a local specialist team, as was the case for Mrs R, then an ED doctor’s options are limited to either refer back to that team or, if the patient appears well with no reason for admission, to discharge them.
32. On each admission to A&E we have seen evidence of relevant assessments and investigations. It was noted that Mrs R had been previously referred for cardio-thoracic surgery and the actions of the ED team were in line with the relevant GMC guidance noted above.
33. On 29 April the respiratory team referred Mrs R to the Aortic MDT at the Sheffield Trust and it was noted that Mrs R had not heard anything further following the cardiothoracic referral made in December 2019. In this letter the respiratory team at the Doncaster Trust set out the history of haemoptysis and the investigations it had done.
34. The respiratory team’s actions were in line with the relevant GMC guidance
35. Mrs R attended A&E again on 7 July and 16 September. Each time Mrs R was suitably assessed by the ED team in line with the GMC guidance.
36. Overall, we have seen evidence that the actions of the Doncaster Trust were in line with relevant guidance. Mrs R was assessed and appropriate referrals were made to the respiratory and cardiology teams when she attended the ED and she was appropriately referred to the cardiothoracic team.
37. We recognise Miss R’s concerns about the repeated ED admissions and hope that our investigation reassures her about the actions of the Doncaster Trust during this period, as the repeated episodes must have been difficult and distressing.
38. We specifically asked our respiratory adviser whether more should have been done by the Doncaster Trust and he confirmed that the Trust’s actions were appropriate. The Trust had referred Mrs R to the Sheffield Trust on 31 December 2019 and a further referral was made in April 2020. We have not seen any evidence the Doncaster Trust should have communicated any further details with the Sheffield Trust.
Sheffield Trust
39. Mrs R was referred to the cardiothoracic team at the Sheffield Trust on 31 December 2019. In the Sheffield Trust’s response, it said it received the referral on 9 January 2020, but this referral was not graded and passed to the aortic team until 5 March. The Sheffield Trust is unable to explain why this happened.
40. The Sheffield Trust discussed Mrs R’s case at the MDT meeting on 14 April and she was reviewed by the cardiothoracic team on 12 May. The cardiothoracic team recommended a TEVAR. A coronary angiogram was arranged for 24 July to confirm Mrs R’s suitability for the surgery. It was recorded that no cardiology follow up was required and the TEVAR surgery was booked for 9 September.
41. On 1 September Mrs R had a pre-operative assessment. At this assessment the consultant anaesthetist noted that Mrs R had several investigations at Doncaster and recorded ‘Doncaster cardiology notes to be requested for review’. On 4 September the Sheffield Trust called Mrs R to advise her the surgery booked for 9 September had been cancelled.
42. On 18 September the consultant anaesthetist reviewed Mrs R’s cardiology notes and cardiopulmonary exercise test report from the Doncaster Trust notes and confirmed that the surgery could go ahead.
43. We have considered the delays in booking the TEVAR surgery. The Sheffield Trust did not take any action when it received the first referral on 9 January. The Sheffield Trust could not explain why this referral was not found until 5 March. The Trust explained in its response to Miss R’s complaint, that there was no capacity to discuss Mrs R at an MDT until 14 April. It added that the next available clinics after this date were full and therefore Mrs R could not be seen until 12 May. We have not seen any evidence that the Trust took action to expedite the referral despite the delay in processing it.
44. There was an avoidable delay from 9 January to 5 March, eight weeks, when the referral was delayed.
45. Mrs R’s surgery was an elective procedure and the NHS Constitution says that patients should wait no longer than 18 weeks from referral to treatment as set out on the NHS England website:
‘patients have the right to access certain services commissioned by NHS bodies within maximum waiting times, or for the NHS to take all reasonable steps to offer a range of suitable alternative providers if this is not possible’
46. The DH referral to treatment consultant-led waiting times rules suite, explains that the 18 week timing starts when a referral is made and stops when the first definitive treatment starts.
47. In Mrs R’s case the referral was received by the Sheffield Trust on 9 January 2020 with her surgery was booked for 9 September. The time from 9 January to 9 September was 35 weeks, almost double the proposed wait set out in the NHS Constitution.
48. The PHSO Principles of good administration say that:
‘Public bodies should provide effective services with appropriately trained and competent staff.’
and
‘Public bodies should behave helpfully, dealing with people promptly, within reasonable timescales and within any published time limits. They should tell people if things take longer than the public body has stated, or than people can reasonably expect them to take’
49. The delay in actioning the referral received on 9 January is not in line with this guidance. This does not demonstrate an effective service and Mrs R was not dealt with promptly. The Sheffield Trust has not been able to explain why or how the referral was delayed and the Sheffield’s Trust’s actions here, indicate failings in its processes. We consider this is maladministration as there was an avoidable delay of 8 weeks for which there is no explanation.
50. Had the referral been assessed earlier the same treatment would have been proposed. Therefore, if the eight week delay in referral had not happened, Mrs R’s surgery date would have been arranged eight weeks earlier than it was.
51. The second delay was that Mrs R’s surgery on 9 September was cancelled. The cancellation happened because a decision was made at the preassessment clinic, on 1 September, that the cardiology notes were needed from the Doncaster Trust. The Sheffield Trust said there was a delay in getting these. The anaesthetist reviewed the notes on 18 September and confirmed the surgery could go ahead. Surgery was planned for 4 November.
52. The Sheffield Trust has explained the process it follows for requesting notes:
‘We request (other hospital) notes once we have seen the patient in Preop Assessment if we think it is necessary to understand what has happened before and whether it will have an impact on the patients care. Sometimes it does and sometimes does not, but we don’t know until we see them. How long it takes (for the notes to come) depends on the hospital from where we request the notes. The quickest I have seen is a week but it can be longer. It has been known to be 4 weeks or longer as sometimes the responding hospital can’t find the notes and we have to continuously ask the hospital’s medical records. We do keep reviewing our records and as soon as they have been received the admin team at Preop let us know. We don’t have a SOP (standard operating procedure) as it is so variable and we are depending on another organisation.’
53. Relevant again here are the PHSO Principles of Good Administration:
‘Public bodies should behave helpfully, dealing with people promptly, within reasonable timescales and within any published time limits. They should tell people if things take longer than the public body has stated, or than people can reasonably expect them to take’
54. The Sheffield Trust have explained that at its quickest it takes seven days to receive records from another organisation. Requesting the notes on the day of the pre-operative assessment when the surgery is booked for eight days later, leaves little opportunity for the notes to be available in time. We provisionally consider this was a failing. In its response to the complaint the Sheffield Trust acknowledged that the records should have been requested much sooner in preparation for the appointment.
55. We understand that the anaesthetist needed to see the records before making a decision about Mrs R’s fitness for surgery, and we have no criticism of this decision. However, the process of requesting records on the day of pre-operative assessments, makes it inevitable that surgery has to be cancelled. This was not in line with the PHSO principles. This second administrative failing led to further delays in Mrs R’s TEVAR surgery.
56. Miss R complains that a new date for surgery was offered after Mrs R had died, but there was no information about why the Trust considered that Mrs R was fit for the surgery. We understand that it was very upsetting for Miss R to receive details of a new surgery date after her mother had died.
57. The telephone call advising of the new surgery date took place the day after Mrs R had sadly died. We do not think the Sheffield Trust would have been aware that Mrs R had died within such a short timeframe. Whilst it is very unfortunate that the call was made, we do not think this amounted to a failing.
Impact of the failings identified
58. We have found that the Sheffield Trust did not process the referral until eight weeks after it was received.
59. Our surgical adviser has commented that had the referral been assessed earlier a TEVAR would still have been the relevant treatment. Had the referral been acted upon eight weeks earlier, it is more likely than not the surgery would have been offered in July rather than September.
60. The second failing was that the relevant notes were not available at the pre-operative assessment on 1 September, and this led to the surgery planned for 9 September being cancelled.
61. If the notes had been available at the pre-operative assessment, then it is more likely than not that the Trust would have decided Mrs R was fit for surgery on 1 September, and the surgery would have been done as planned on 9 September.
62. We cannot be certain what the outcome of the surgery would have been for Mrs R. A study in the Journal for Vascular surgery quoted survival rates for TEVAR surgery at around 98%, so we are satisfied it is likely she would have survived the procedure.
63. Our surgical adviser has said that on the balance of probabilities, the TEVAR surgery would have reduced the frequency and severity of Mrs R’s haemoptysis. There is no specific research that tells us how quickly a patient’s condition will improve after the TEVAR procedure. We asked our surgical adviser for their view based on their extensive experience of TEVAR surgery. Our surgical adviser told us that on the balance of probabilities the TEVAR surgery, which would have depressurised the aneurysm, over time would have reduced the frequency and severity of Mrs R’s haemoptysis episodes. With regard to the specific episode of haemoptysis and aspiration from which Mrs R died on 18 October 2020, our surgical adviser has said that on the balance of probabilities, this episode would have been prevented had the surgery taken place in September.
64. Mrs R’s post-mortem showed her cause of death as:
1A Aspiration pneumonitis 1B Recurrent haemoptysis and intraparenchymal haemorrhage 1C Thoracic aortic aneurysm
65. Mrs R’s post-mortem is evidence that her aortic aneurysm led to her haemoptysis episodes which in turn led to the aspiration pneumonitis from which she died.
66. The failings we have identified delayed Mrs R’s surgery to the point of it not happening at all. We recognise that Mrs R’s case was rare but based on the evidence we have seen, we believe there were two missed opportunities for Mrs R to have the surgery she needed. If this had happened, it is more likely than not, that Mrs R’s death in October 2020 could have been avoided.
67. Had the surgery taken place earlier it also follows that other episodes of haemoptysis which Mrs R experienced in 2020 could have been prevented. These were extremely distressing for Mrs R and her family. Miss R told us her mother had suffered emotional trauma in the months before her death as she had significant worry about experiencing another episode of haemoptysis. We also appreciate that her death following her collapse at home was a traumatic experience for her family.
68. In its response the Sheffield Trust has explained that as a result of its investigation it has put in additional processes to address the issue of lost referrals. The Sheffield Trust has said that it is setting up a tracking system to ensure referrals are monitored and managed by the admin team, which would flag any issues with delays. Whilst it is encouraging that the Sheffield Trust has taken some action, its response does not provide a detailed view of the actions taken to prevent similar problems in future; which senior staff are responsible for the changes it has proposed; under what timescales it expects to have resolved the issues; or how it will review whether the changes have been successful or not. The Trust has taken no action in relation to the notes not being available at the pre-operative assessment.
69. Based on the evidence we have seen we are not persuaded the Sheffield Trust’s actions are robust enough to prevent recurrence of the same issues.