14. For clarity, we explain our current view under separate headings
Failure to follow up after March discharge
15. When D was discharged from hospital on 3 March 2021, there was a plan to follow up with a gastroscopy to investigate for varices and, if needed, to treat them. The British Liver Trust website explains varices are ‘small veins that have become twisted and swollen… Varices can leak or burst, causing serious bleeding called a variceal bleed.’ A person can bleed a lot and might vomit blood or have blood in their stools.
16. In its responses, the Trust acknowledged a failure in the way D was referred for a gastroscopy and explained what happened. There was a plan to do the procedure before D was discharged, but this was not possible due to more urgent cases having to take priority. Our adviser says that this was reasonable; records show D remained stable during this admission with no indication of bleeding so the gastroscopy could be done as an outpatient.
17. In the Trust’s response, the consultant gastroenterologist acknowledged his request had been for D to have the procedure as soon as possible. However, he did not tell the gastroscopy team that it was urgent. The gastroenterologist and the Trust acknowledged the appointment should have been booked within four to six weeks, and if it had, D would have been seen within two weeks of that.
18. Our adviser explained there is no published guidance on how quickly such a procedure should be carried out, but his clinical opinion is in accordance with the Trust’s acknowledgment that it should have been done in that time scale. It would have been in line with Good Medical Practice (2013) which says:
You must provide a good standard of practice and care. If you assess, diagnose or treat patients, you must: • adequately assess the patient’s conditions, taking account of their history… • promptly provide or arrange suitable advice, investigations or treatment where necessary
19. The gastroenterologist’s acknowledgement of his own error is a reasonable explanation. He had not checked to ensure he had requested it on an urgent basis and there was not enough information in it to alert the gastroscopy team that there was a possibility of significant varices. The Trust also acknowledged that the liver day unit review was done two weeks later than it should have been. We consider the Trust’s response is in line with the NHS Complaint Standards in being open and honest about what happened. It explained what had happened and the doctor acknowledged his own role and need to change his practice in this regard.
20. We have considered what impact the failure had. Our adviser says that a timelier gastroscopy would have shown varices, which would have been banded. So the bleed as it happened in August might have been avoided.
21. Mrs B is understandably concerned about what effect it would have had on her son’s chances of survival. From what we saw, an earlier gastroscopy might have delayed D’s death by a matter of days or weeks. Our adviser explained this would have been very poor quality of life with likely hospitalisation.
22. There is evidence that when D was readmitted to hospital in August, he had restarted or had continued to drink alcohol. A doctor in the Emergency Department noted he had had an alcoholic drink the previous evening. Later that evening a doctor noted ‘Mrs B told me that he had been drinking alcohol before hospital admission and expressed her frustrations’.
23. Our adviser explains the main cause of D’s death was the continued alcohol consumption on top of very severe liver disease. People can die of other things due to the frailty and susceptibility to other illnesses caused by the liver disease. Sadly, D was at risk of developing or worsening other life-threatening complications such as alcoholic hepatitis, infection, renal dysfunction and hepatic encephalopathy (brain dysfunction). Furthermore, D would possibly have had a variceal bleed anyway as banding is not 100% successful, especially when the patient continues to drink.
24. We consider the Trust has fully acknowledged and apologised for its failures in this regard and taken appropriate action to avoid a recurrence. From what we saw, we do not think D’s death could have been prevented.
Ascites
25. Ascites is the buildup of fluid in the abdominal cavity. The most common cause is liver disease. It can cause discomfort and breathing difficulties. The main treatment is sodium restriction; a low salt diet and the use of diuretics, which are medicines that increase urine production and help get rid of excess fluid. Sometimes patients have the fluid drained with a needle and tube.
26. D developed ascites during his last admission. We considered Ms B’s complaint that it should have been drained sooner and the failure to do so caused him unnecessary pain.
27. The records show that doctor noted on 3 August there was ‘no clinically detectable’ ascites and 6 August, an ultrasound scan showed D had ‘mild to moderate ascites’. An ascitic tap was carried out on 8 August. This is when a sample of the fluid is obtained for testing.
28. Late on 11 August, D’s NEWS score had gone up to 10. NEWS is a system for scoring measurements, including respiration rate, oxygen saturation, blood pressure, pulse rate, level of consciousness and temperature, in order to help identify patients who are deteriorating. A score of over 7 requires an urgent response. (The increase in his NEWS score was not due to the ascites.)
29. A doctor reviewed D and on examining his abdomen, found he had mild tenderness and moderate ascites.
30. In the early hours of 12 August, another doctor reviewed D. The main concern at that time was melena (black stools, probably caused by internal bleeding). The doctor noted his abdomen was ‘distended due to ascites’, which was described as grade 2. This is moderate and does not indicate it needed draining at that time.
31. The consultant’s ward round later that morning notes ascites and the plan included abdominal drain. So it appears that the ascites built up during the evening and early morning of 11 and 12 August.
32. Later that evening a doctor recorded a ‘long discussion’ with Mrs B, which included reference to an ascitic drain. The doctor noted ‘I explained that would be unreasonable’, which meant the time of night, and that they could look to do that in the morning.
33. The Trust’s response said that the latest a drain is inserted is 3pm. It does not say why but our adviser explains a drain needs to be monitored for up to six hours. When the night shift starts at 9pm, there is a lower level of staffing. It is therefore not unreasonable to have this as a cut-off time for a non-urgent procedure.
34. The consultant’s ward round on 13 August noted ‘large ascites… Need drain’, with the expectation that it would be done that day if one of his colleagues was in agreement. That other doctor reviewed D at 1.30pm. She agreed that a drain was indicated but asked colleagues to give him an enema first. We saw no indication why she made this request. It is not a standard procedure before inserting an ascitic drain. Our adviser says that for patients with liver disease, they might be suspected of having constipation, which could be adding to the distension. They might have wanted to address that first and decide whether to place the drain.
35. The next day (14 August, which was a Saturday), a doctor reviewed D at 2pm and noted he was ‘complaining of abdo discomfort/fullness [due to] gross ascites’ and the plan included ‘drain ascites for comfort’. The ascitic drain was inserted at 6.30pm. It is stated why the 3pm cut-off time was not implemented. However, the drain appears to have been in place for six hours without incident.
36. The Trust’s response said that drain was placed on 13 August, but we have found that it was placed on the evening of 14 August.
37. A patient can have large amounts of fluid present without having it drained. Doctors will probably only drain ascites if the abdomen is tense, as it is an easier procedure. If not, there can be more complications; it can be more difficult to do and can cause additional pain and discomfort. It may not achieve the drain.
38. We acknowledge that the drain could have been done sooner. There is no mandated timing and no guidance as to when it should be done. It is difficult to say exactly at which point it could be started. In D’s case, it was for symptom relief. Throughout his admission, D’s pain was monitored and around the time of the developing ascites, the pain scores were low. This suggests he was not that uncomfortable, although we acknowledge this was not Mrs B’s perception. The increased discomfort was recorded on 14 August shortly before the drain was started.
Use of paracetamol
39. Mrs B was concerned that D was given paracetamol and this worsened his condition given his liver disease. Our adviser explained that paracetamol is the safest analgesia to use for a patient with advanced liver disease. Any other analgesia increases the risk of gastrointestinal problems (for example, NSAIDs like ibuprofen) or encephalopathy (which can be brought on by opioids/codeine). We can reassure Mrs B that paracetamol would not have contributed to his liver failure.
40. The BNF ‘Prescribing in hepatic impairment’ states: ‘In severe liver disease many drugs can further impair cerebral function and may precipitate hepatic encephalopathy. These include all sedative drugs, opioid analgesics…’ And ‘Oedema and ascites in chronic liver disease can be exacerbated by drugs that give rise to fluid retention e.g. NSAIDs and corticosteroids.’
41. The BNF advises caution – but not avoidance - with the use of paracetamol for patients with chronic alcohol consumption and/or hepatic impairment. The records show that the number of times D had paracetamol was in line with BNF advice.
Fall
42. Mrs B was understandably upset that D fell out of bed. A nurse assessed D’s risk of falls soon after admission in the early hours of 2 August. The outcome was that he needed bedrails in place because of impaired judgment and lack of awareness. The purpose was to reduce his risk of falling from his bed.
43. However, D fell from his bed on 11 August after transfer form ICU. In its response letter of March 2022, the Trust said it found that D’s fall could have been prevented. It happened when a rail had been left down by a member of staff, for which the Trust apologised unreservedly. It also apologised that staff had delayed in telling Mrs B that D had fallen.
44. NICE QS86 says ‘when a person falls, it is important that they are assessed and examined promptly to see if they are injured. This will help to inform decisions about safe handling and ensure that any injuries are treated in a timely manner.’
45. At around 7pm, a nurse found D was on his knees leaning on his bed. He said that doctors had left the bedrail down. Three members of staff helped him back into bed. D said he had hit his head. The nurse asked the on-call doctor to review him. The doctor did neurological observations and found his consciousness level was not affected; his existing encephalopathy (brain disorder) was already causing a certain amount of confusion but there was no apparent worsening. She sent D for a CT scan to investigate a possible brain injury. This showed what was described as a relatively minor injury and ‘small bleed’. In line with Good Medical Practice, which says doctors should consult colleagues where appropriate, a gastroenterologist spoke to the neurosurgery team about this and they said there was no need for further treatment.
46. Our adviser confirms that from his review of the records, there is no indication the incident contributed to D’s deterioration and death. We appreciate the incident added to Mrs B’s distress, especially as she saw D had bruising on his face. We agree the fall should not have happened. The Trust was open and honest about this and apologised to Mrs B. Staff took appropriate action at the time to check for significant injury. The Trust’s subsequent investigation identified additional actions that would help staff monitor patients with liver conditions who had fallen. We do not think there is more we could reasonably expect them to do.
Deterioration
47. Mrs B says that on 15 August 2021, staff failed to notice D’s collapsed state and sudden deterioration. She said staff delayed treating D’s condition as they could have done and this was likely, at least in part, due to his history of alcohol use.
48. Records show doctors were still actively considering a gastroscopy until the end. They had made a decision on ceilings of care (this refers to the maximum which will be done for patients who are very poorly). However, they were still actively managing D. This means they were hoping to treat him to improve his condition and prolong his life, rather than following an end-of-life approach, which would focus on symptom control and comfort only.
49. A doctor reviewed D at around 8.20pm and spoke to an anaesthetist about a possible gastroscopy. The advice was to wait and see and call the anaesthetics team again if it was definitely indicated. Sadly, D died around an hour and a half later.
50. Having reviewed the records, our adviser says that D deteriorated suddenly at the end. D was already critically ill so a sudden deterioration was not unexpected. We saw no evidence of any unreasonable delays in noticing or reacting to his deterioration.
DNACPR
51. A ‘Do Not Attempt Cardiopulmonary Resuscitation’ (DNACPR) decision means that if a patient’s heart or breathing stop suddenly, doctors and nurses will not try to resuscitate them. Mrs B says she agreed to a DNACPR when D was in ICU, but this was never reconsidered when his condition improved, and he moved from ICU to the ward.
52. The records include a form which notes the decision not to carry out CPR if D were to go into cardiac arrest. As D lacked capacity, it was discussed with Mrs B. This is in line with the resuscitation guidance, which says that if a patient lacks capacity, the decision should be discussed with somebody close to them. It is not necessary to obtain the patient or relative’s consent when CPR has no realistic prospect of success.
53. While D was deemed to no longer need to be in the ICU, and his condition had improved slightly, our adviser has seen that he was still gravely ill and if he had gone into cardiac arrest, he would not have been expected to survive. The decision that D would not benefit from resuscitation was reasonable. There is no indication that the DNACPR order should have been withdrawn.