University Hospitals of Leicester NHS Trust

University Hospital of Leicester NHS Trust

3. Mrs A complains about the care and treatment provided to her mother-in- law, Mrs B, by University Hospital of Leicester NHS Trust (the Trust) between September 2023 and January 2024. She says the Trust:

• did not operate on Mrs B’s gallbladder • did not take the families view into account when deciding not to operate on the gallbladder • did not test her for clostridium difficile (C.diff) before discharging her.

4. Mrs A says the Trust’s failure to operate on Mrs B’s gallbladder meant she suffered from recurring bouts of C.diff, which contributed to her death. She says its failure to test her for C. diff before discharging her meant she was sent home with it and died without dignity. She says the failure to take the families view into account meant they had to watch her die an undignified death. If the gallbladder had been operated on, she would have had a chance of life.

5. Mrs A seeks an acknowledgement of failings and service improvements.

The Practice

6. Mrs A complains about the care and treatment provided to her mother-in- law, Mrs B, by the Practice between December 2023 and February 2024. She says the Practice:

• prescribed medication which was not readily available at the pharmacy • assessed Mrs B via video call instead of in person • did not explain what to expect when a person is put on end-of-life care.

7. Mrs A says the Practice’s failure to make sure the medication was readily available meant Mrs B’s C. diff was not treated optimally, resulting in prolonged suffering and a longer than necessary hospital stay. She says this failure made her death even worse and the family had to witness this. She says the Practice assessing her by video call was undignified and caused emotional distress for the family. She says the Practice’s failure to communicate regarding end-of-life care meant the family did not know what to expect and this made the death of Mrs B even more distressing for them. She says the family have lost faith in the NHS.

8. Mrs A seeks an acknowledgement of failings and service improvements.

9. Mrs B was admitted to the Trust on 28 September 2023 with reduced eating and drinking, abdominal pain and reduced opening of the bowels. The Trust carried out investigations which revealed she had gallstones and cholecystitis (inflammation of the gallbladder, often caused by gallstones blocking the cystic duct). The Trust treated the inflammation with antibiotics.

10. On 1 October, Mrs B tested positive for C. diff. This is an infection of the bowel, usually as a result of taking antibiotics. The Trust discharged her on 6 October.

11. Mrs B was admitted to the Trust again on 21 October. The Trust diagnosed her with inflammation of the colon caused by C.diff, inflammation of the gallbladder, overflow diarrhoea (watery faeces caused by constipation), low potassium, magnesium deficiency, arterial fibrillation (irregular often fast heartbeat) and decompensated cardiac failure (heart failure that has progressed). A CT scan showed mild worsening of the colon which the notes document was likely to be as a result of C.diff. The Trust prescribed antibiotics for her C. diff and discharged her on 21 November.

12. On 4 December a GP from the Practice visited Mrs B as she was experiencing diarrhoea. The Practice carried out a stool test and on 6 December. This returned positive for C. diff and on 8 December (a Friday) it prescribed antibiotics. The medication was unavailable from several local pharmacies until 12 December.

13. Mrs B was admitted to the Trust again on 10 December with abdominal pain and loose stools. It diagnosed her with C. diff and a CT scan revealed ongoing inflammation of the colon and gallbladder. It treated her C. diff with antibiotics. On 25 January 2024 the Trust tested her for C. diff and this returned as negative. The Trust carried out a sigmoidoscopy (an investigation to examine the lining of the bowel) which revealed no evidence of inflammation and discharged her on 31 January.

14. On 1 February 2024 Mrs B deteriorated. Her family rang for an ambulance and the paramedic referred her to the home visiting service. This is a wider team of clinicians who work with GP Practices in the area, to meet the needs of patients. On 2 February the home visiting service noted she was at the end of life and made a referral to the Practice. The Practice organised a video call with the home visiting service clinician at Mrs B’s home. It assessed her and prescribed end-of-life medications.

The Trust

Gallbladder

18. 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.

19. The Trust said it did not operate on Mrs B’s gallbladder due to her advanced frailty and multiple health issues. It said in over 90% of cases C. diff can be managed with antibiotics and it provided antibiotics to manage her recurrent C. diff infections. It said its decision not to operate was appropriate considering her poor health.

20. GMC guidelines say when diagnosing and treating patients, clinicians must adequately assess the patient’s condition taking account of their history and arrange suitable treatment.

21. The medical records note Mrs B required a four times daily package of care, was dependent on a hoist for transfers and had a past medical history that included heart failure and chronic kidney disease.

22. The clinical study shows gallbladder surgery has a considerably higher risk of death in patients over the age of 80 years old who have significant dependency (reliant on other people for assistance with daily living tasks) and co-morbidities such as heart failure.

23. Our surgeon adviser said the Trust’s assessment of the risks associated with surgery were reasonable and in line with the evidence from the clinical study. Our adviser said the Trust’s decision not to operate on Mrs B’s gallbladder was a clinically appropriate decision in light of her age, advanced frailty and other health issues. This was in line with GMC guidelines which say clinicians must adequately assess a patient’s condition taking account of their history.

24. In summary, taking into account the evidence we have seen and the clinical advice we have received, we have not seen indications the Trust should have operated on Mrs B’s gallbladder. We have seen the Trust considered the risks of surgery which were in line with evidence from clinical studies.

Views of the family

25. The Trust said the surgical team deemed surgery to not be an option for Mrs B due to her frailty and health issues. It said she required a four times daily package of care, was dependent on a hoist for transfers and had a history of heart failure and chronic kidney disease.

26. GMC guidelines say clinicians must be considerate of those close to the patient and be sensitive and responsive in giving them information and support.

27. We have reviewed Mrs B’s medical records and can see her family raised concerns the issues with her gallbladder were leading to recurrent C. diff infections and questioned whether gallbladder surgery would put an end to this cycle.

28. Mrs B’s family raised a concern on 23 October and it is documented the Trust contacted the surgeon for advice. The Trust contacted the family on 25 October and explained she was not a suitable candidate due to her age and frailty.

29. The records show the family raised this concern again on 14 December. The Trust contacted the surgeon again and updated the family on 17 December that she was not a suitable candidate for surgery due to her chronic kidney disease and frailty.

30. The family raised a concern again on 27 December 2023 and 4 January 2024. The records document the Trust explained Mrs B was too unwell for surgical anaesthesia and therefore the surgery could not be carried out.

31. On 16 January the family raised their concern again and the Trust advised the risks of surgery and anaesthesia were too high.

32. Our surgeon adviser said the decision to operate on a patient is a clinical one. They said the Trust’s interaction with the family was appropriate and in line with GMC guidelines which say clinicians must be responsive in giving families information and support.

33. In summary, taking into account the evidence we have seen and the clinical advice we have received, we have not seen indications to suggest the Trust did not take the families views seriously. We have seen the decision to carry out surgery is a clinical one and the Trust explained its reasons for not operating on Mrs B to her family on four occasions in this period. We have not seen indications the Trust did anything wrong and will be taking no further action.

Testing for C. diff

34. The Trust said it discharged Mrs B on 31 January 2024 as her C. diff infection had resolved and she was clinically stable enough to return home. It said she expressed a wish to return home and her deterioration following this was unforeseen. It said her discharge was coordinated with her safety and wellbeing in mind and it prescribed medication to help with her ongoing diarrhoea. It said a negative C. diff test along with the reassuring sigmoidoscopy result meant she was stable enough to be discharged home.

35. NICE guidelines say clinicians should only retest patients for C. diff if the symptoms have resolved and then recur. Our surgeon adviser said the Trust’s decision not to retest Mrs B for C. diff before she was discharged was appropriate and in line with NICE guidelines as she had completed a course of first line antibiotics, her symptoms had improved and the C. diff test result was negative.

36. In summary, taking into account the evidence we have seen and the clinical advice we have received, we have not seen indications the Trust should have tested Mrs B for C. diff again before she was discharged. We have seen the Trust treated her C. diff with the appropriate antibiotics and her symptoms improved. This is in line with NICE guidance and the advice we have received. We have not seen indications the Trust did anything wrong and will be taking no further action.

The Practice

Medication

37. The Practice apologised to the family for the inconvenience and stress caused by the medication not being available in the local pharmacies. It explained it does not have capacity to ring around pharmacies before issuing a drug, to make sure it is in stock.

38. GMC guidelines say clinicians must provide a good standard of care. When diagnosing and treating patients, clinicians must adequately assess the patient’s condition and promptly provide or arrange suitable treatment where necessary.

39. We have reviewed Mrs B’s records and can see on 4 December a GP from the Practice visited her as she was experiencing ongoing diarrhoea. The Practice arranged for a stool test and on 6 December this showed Mrs P Jerran’s had C.diff. The advice from microbiology was to prescribe vancomycin (a type of antibiotic).

40. Our GP adviser said vancomycin is the first line treatment for C. diff. They said this was appropriate and in line with GMC guidelines which says clinicians must arrange suitable treatment. Our adviser also said there is no requirement for clinicians to check the medications they prescribe are available locally. We therefore cannot be critical of the Practice for the medication not being available.

41. In summary, taking into account the evidence we have seen and the clinical advice we have received, we have not seen the Practice should have checked the medication it prescribed was available in local pharmacies. We have seen the Practice assessed Mrs B and treated her in line with the appropriate guidelines by prescribing the first line treatment for C. diff. We have not seen indications the Practice did anything wrong and will be taking no further action.

Video call

42. The Practice said it received a call from the family on 2 February at 8.38am to say a paramedic considered Mrs B was nearing the end of her life. It said it spoke to a clinician from the home visiting service who was also at Mrs B’s home. It said it organised a video call with Mrs B and the home visiting service. It said it documented she responded to voice and was drowsy. It said it issued end of life medications and made a referral to palliative care.

43. GMC end of life guidelines say treatment and care at the end of life is delivered by multi-disciplinary and multi-agency teams who work together to meet the patient’s needs.

44. We reviewed the records and can see the clinician from the home visiting service assessed Mrs B and noted she was at the end of life. It made a referral to the Practice to prescribe end-of-life medications and referred her to the district nursing team for support over the weekend. The records show the Practice spoke to the clinician via video call and noted Mrs B responded to voice, did not speak much and was lethargic. The Practice then called the family, explained it had authorised the medications, advised them to call the single point of access to obtain them (this is the central point for health advice, information and signposting in the local area) and confirmed the palliative care team were due over the weekend.

45. Our GP adviser said GP’s do not work in isolation. They are one part of a wider team who work together to make sure the needs of patients are met. They said the Practice delegates home visits to the home visiting service. They said it would not have been reasonable for the Practice to have visited Mrs B as she had already been assessed by a competent clinician. They said a home visit would not have provided anything further in her care. This is in line with GMC end of life guidelines which say end of life care is delivered by multi-disciplinary and multi-agency teams who work together to meet a patient’s needs.

46. In summary, taking into account the evidence we have seen and the clinical advice we received, we have not seen the Practice should have visited Mrs B at home on 2 February. We have seen she was assessed by a competent clinician who was part of the wider team to deliver care and that the Practice authorised the appropriate medications and made the appropriate referrals. We have not seen indications the Practice did anything wrong and will be taking no further action.

Communication

47. The Practice said the NHS has many arms to it and it referred Mrs B to the relevant departments in a caring and timely manner.

48. GMC guidelines say clinicians must recognise that those close to a patient may want or need information about the patient’s diagnosis and the likely progression of the condition in order to help them provide care and recognise and respond to changes in the patient’s condition.

49. Our GP adviser said communication with the family is the responsibility of the whole team providing care and not just the Practice. They said GP’s are part of a wider team who work together to deliver care and meet the needs of patients.

50. We have reviewed Mrs B’s medical records and can see on 2 February the Practice spoke with her family, updated them on the end of-life pathway and informed them of the plan to collect the end-of-life medications. During the call the family raised concerns about a failed discharge from the Trust. The Practice agreed, due to the concern raised, to send off a stool sample to clarify if Mrs B had C. diff again and advised the family she wasn’t suitable for treatment due to now being on the end-of-life pathway.

51. The records document the family were happy with the explanation and were aware of her prognosis.

52. On 3 February a clinician from the district nursing team visited and it is documented the family had no immediate concerns.

53. On 4 February the district nursing team referred the family to a hospice nurse (not part of the Practice) and advised the family to ring the single point of access if they needed any further advice or support.

54. On 6 February the family contacted the Practice and expressed unhappiness with its care. A GP from the Practice visited the same day and it is documented the family wanted more information about what was happening and why. It is documented the Practice assessed Mrs B and explained she was on end-of-life care. The notes say the Practice said this was due to frailty and the impact of continuous infections on her recovery.

55. The same day, a clinician from the hospice service provided support to the family and it is documented the family were happy with this.

56. We can see evidence that between 2 and 7 January the wider team were delivering care to Mrs B and communicating with her family. This is in line with GMC end of life guidelines which say end-of-life care is delivered by multi-disciplinary and multi-agency teams. It is also in line with GMC end of life guidelines which say clinicians must recognise those close to the patient need information about their condition. Our adviser said it would have been the responsibility of the wider team to contact the Practice if it was felt it needed to provide further input.

57. In summary, from the evidence we have seen and the clinical advice we received, we have not seen the Practice should have communicated differently. We have seen the Practice worked within the wider team to deliver care. We have also seen when the Practice became aware the family needed more information it attended the home on the same day and provided further information. We have not seen indications the Practice did anything wrong and will be taking no further action.

58. We appreciate this was a very difficult time for Mrs A and her family. It was clearly very distressing to witness her mother-in-law’s visible and fast deterioration and we do not wish to diminish this. It is understandable Mrs A would hope more could have been done for Mrs B and feel it was not. We hope it provides some reassurance that we have not seen indications of failings in the care Mrs B received. We also hope she is assured the Trust and Practice acted appropriately when communicating with all parties.

1. We have carefully considered Mrs A’s complaint about the care provided by the University Hospital of Leicester NHS Trust (the Trust) and the Practice to her mother-in-law, Mrs B. We are sorry to hear of the circumstances leading up to Mrs B’s death. We recognise the significant impact these events had on the family and offer our sincere condolences for their loss.

2. We have decided not to consider Mrs A’s complaint further. We have seen indications the Trust and the Practice made appropriate clinical decisions throughout Mrs B’s care. We hope our explanation helps to show the Trust and the Practice followed appropriate guidelines when making decisions surrounding her care. We hope this reassures Mrs A we have not seen signs Mrs B’s care fell below the expected standards.