Chemotherapy
15. Miss A says clinicians should have recognised on 8 March 2022 that her mother’s chemotherapy should not have gone ahead because of her back injury. She says the chemotherapy and the fracture combined to cause her mother’s body to break down.
16. The Manual for Cancer Services says healthcare professionals must have a documented discussion with the patient before each cycle of chemotherapy. It refers to blood test results and says these must be within agreed parameters to continue with any treatment. It also says there should be a discussion about the toxicities, meaning the effects the treatment will likely have on the patient. It says the patient’s performance status should also be recorded.
17. Performance status is a scoring system that allows clinicians to establish whether a patient is well enough to have chemotherapy. People who score zero are able to carry out all normal activities without restriction. A score of one means they are restricted in strenuous activity but can undertake light work. A score of four means someone is completely disabled and confined to a bed or chair. The Oncology Adviser told us that, in general, patients should have a performance status of between zero and two to start treatment.
18. Good Medical Practice says doctors must provide a good standard of care. This includes carrying out adequate assessments, taking account of the patient’s history and examining them if necessary. Doctors should also arrange timely treatment and appropriate investigations or referrals if needed.
19. The Oncology Adviser told us it is standard practice for cancer services in the UK to use a specific form to document the information required in the Manual for Cancer Services. The Trust used an Oncology Assessment Form. A clinician completed this on 9 March 2022. They noted Mrs A’s observations and that she was taking pain relief for back pain. But they did not record Mrs A’s performance status or sign the form. There is not enough information in the records to show what Mrs A’s performance status was. This means we cannot say whether she was fit enough have chemotherapy on 9 March 2022. This fell below the standard expected in the Manual for Cancer Services.
20. The Oncology Adviser told us Mrs A’s back pain was unrelated to her cancer and was due to thinning of her bones. This is a condition that affects many older people. They said doctors gave her appropriate treatment for this pain. They investigated the pain by arranging an X-ray and prescribed pain medication. The doctors followed Good Medical Practice in this respect because they adequately assessed her and arranged the investigations and treatments for the back pain that were necessary.
21. We have considered the impact of the failing relating to clinicians not recording Mrs A’s performance status on 9 March 2022. If her performance status had been satisfactory doctors would have continued with the planned treatment. But there is a possibility her performance status would have prompted doctors to cancel or delay the planned cycle of chemotherapy.
22. If the chemotherapy had not gone ahead then Mrs A may not have experienced some of the symptoms she had over the following weeks, such as diarrhoea or sepsis. The Oncology Adviser said it was their opinion that Mrs A would still have died around the same time even if the chemotherapy had not gone ahead. Many of the issues she later developed were due to the cancer rather than the treatment. So, she would have experienced these issues even if the treatment had been delayed. We cannot say she would have survived her illness or lived longer if her performance status resulted in the chemotherapy being delayed or cancelled.
23. We find the doctors did not follow the Manual for Cancer Services by not recording Mrs A’s performance status. This means we do not know whether her fourth cycle of chemotherapy should have been delayed. Based on the clinical advice we have received we do not consider this failing contributed to Mrs A’s death. But there is a possibility some of the distressing symptoms she experienced, and the distress for her family, could have been avoided.
24. Miss A and her family are left not knowing whether the chemotherapy should have gone ahead and if some of the symptoms Mrs A experienced in the Hospital could have been avoided. This is an ongoing injustice for them.
Aspiration
25. Miss A says her mother had signs of aspiration for more than two days before doctors prescribed antibiotics on 10 April 2022. She says these signs included hallucinations and a low temperature.
26. Aspiration pneumonia is a condition caused by fluid, food or vomit leaking into the chest from the stomach or mouth. This causes a bacterial infection in the lungs. It is most common in older people who are less able to swallow. The symptoms are the same as other types of pneumonia. These include coughing, high temperature and feelings of breathlessness.
27. The Medical Adviser told us there were no specific guidelines about aspiration pneumonia at the time of Mrs A’s admission to the Hospital. But there were general guidelines about diagnosing and managing pneumonia. Doctors would also be expected to follow Good Medical Practice as explained above.
28. The Prescribing Guideline explains how healthcare professional should prescribe antibiotics for hospital acquired pneumonia. It says they should start antibiotics as soon as possible after diagnosing pneumonia and certainly within four hours, or within one hour if the person has suspected sepsis.
29. The records show that by 7 April 2022 doctors suspected a bowel obstruction was the cause of Mrs A’s problems. The Medical Adviser told us it was right for doctors to focus on that. The possible causes of an obstruction would have been chemotherapy, the cancer itself and the medication Mrs A was taking. Doctors appear to have assessed her appropriately and their plan was to treat episodes of vomiting. They were clearly trying to prevent her from inhaling vomit because she was ‘nil by mouth’ and had a tube in place to remove any stomach contents. She then had an abdominal CT scan which showed areas of faecal loading, but no bowel obstruction.
30. The Medical Adviser told us any of Mrs A’s ongoing issues could have caused hallucinations. There is only one reference to low temperature in the early hours of 9 April 2022. However, other observations were normal and were not in keeping with any significant infection such as pneumonia. There is no evidence that doctors missed signs of pneumonia.
31. At 1.16am on 10 April 2022 a junior doctor reviewed Mrs A’s CT scan result. They discussed it with a more senior doctor and noted the scan showed possible signs of pneumonia. The doctors decided Mrs A should have antibiotics. The antibiotics started at 7.09am. This was almost six hours later. This was outside of the four hours recommended in the Prescribing Guideline.
32. Clinicians use a system called NEWS (National Early Warning Score) when monitoring patients in hospital. This aims to improve the detection of and response to clinical deterioration in patients with acute illness. It is based on a simple scoring system where scores are allocated to specific physiological measurements (breathing rate, levels of oxygen in the blood, blood pressure, pulse, consciousness and temperature). The NEWS tells clinicians how they should respond when the total score is between specific values. Only scores of five and above indicate that a person needs urgent attention.
33. For the early part of Mrs A’s admission her NEWS was at three or below. This did not suggest she had any signs of a serious infection. It was only at 4.50am on 10 April 2022 when her NEWS increased to five. The Medical Adviser said this would usually be the trigger for starting antibiotics.
34. The Medical Adviser said the junior doctor probably made the right decision to recommend antibiotics at 1.16am. But they do not consider the delay in providing the medication was a significant failing. This is because Mrs A’s NEWS did not indicate a significant deterioration in her health until 4.50am.
35. We find the doctors followed Good Medical Practice and the Prescribing Guideline in relation to how they recognised and treated Mrs A’s aspiration pneumonia. It was not ideal that it took almost six hours to prescribe medication on the morning of 10 April 2022, but we do not consider this fell below the standard required.
Constipation and diarrhoea
36. Miss A complains that doctors did not properly investigate her mother’s constipation and diarrhoea. She recalled that her mother had feculent vomiting (this is when a blockage in the bowels means that someone starts to vomit faeces) from 7 April 2022 onwards. She believes this happened because of her mother’s untreated constipation.
37. The CKS on Constipation explains that constipation is typically when someone has bowel movements less than three times a week with additional symptoms such as abdominal pain or bloating. Clinicians are advised to look for ‘red flag’ symptoms that might indicate a serious underlying cause. These ‘red flag’ symptoms include bloody stools, weight loss and abdominal pain. Clinicians are also advised to identify any underlying causes of constipation and to advise stopping any medication that may be causing or contributing to symptoms.
38. The CKS on Diarrhoea explains that diarrhoea is the passage of three or more loose or liquid stools per day. Acute diarrhoea is usually caused by a bacterial or viral infection. Clinicians are advised to consider ‘red flag’ symptoms that might indicate a serious underlying cause. The CKS explains a range of different approaches for different causes of diarrhoea. This includes diarrhoea associated with chemotherapy.
39. Doctors should also have followed Good Medical Practice when managing Mrs A’s constipation and diarrhoea.
40. The clinical records show Mrs A had diarrhoea when she first arrived at the Hospital. Doctors arranged tests to try and find whether there was an underlying cause. They diagnosed colitis (inflammation of part of the bowel) caused by her chemotherapy. By 19 March 2022 doctors noted Mrs A’s diarrhoea had stopped. She had been feeling nauseous and occasionally vomited, so doctors gave her anti-sickness medication.
41. Mrs A continued to have loose stools over the following days. Stool sample tests showed no signs of infection. Doctors prescribed medication to try and control the diarrhoea and abdominal pain. While she continued having loose stools following the treatment these were infrequent.
42. The Medical Adviser told us there is no evidence Mrs A had any infection that was causing diarrhoea. There is no reason to suggest that the diagnosis of chemotherapy related colitis was incorrect. Doctors carried out appropriate assessments and investigations. They excluded ‘red flag’ symptoms and provided treatment in line with the CKS on Diarrhoea.
43. On 8 April 2022 a junior doctor reviewed Mrs A. They noted she filled three bowls with vomit of what they described as feculent material. The doctor placed a tube in Mrs A’s stomach and noted this stopped her vomiting. They also gave her anti-sickness medication and contacted the palliative care team for further support. Mrs A said she was worried because she had not opened her bowels for a few days. The palliative care team recommended using a syringe driver to include anti-sickness medication. It was also decided she should be ‘nil by mouth.’
44. The clinical records also contain a stool chart. This shows no evidence of constipation up until 3 April 2022 with Mrs A having daily bowel movements up to that point. From 3 April she did not have any bowel movements. However, by 8 April 2022 this would not necessarily have been considered constipation because only five days had passed.
45. On 9 April 2022 doctors arranged for a CT scan to see if there were any signs of a bowel obstruction. The CT scan showed no evidence of a bowel obstruction. It showed there was faecal impaction. The Medical Adviser said this would not usually lead to vomiting. The faeces were at the beginning of the large bowel and in the rectum, so repeated enemas would not have been effective. In addition, oral laxatives would have been ineffective because they would have to have been delivered by the tube and not absorb well enough.
46. The Medical Adviser noted it was a junior doctor who described the vomit to be feculent. They said this very unlikely based on the results of clinical tests that followed. They said it is more likely to have been vomit associated with gastric stasis (alteration of stomach contents that have failed to drain from the stomach) and possibly the presence of old blood associated with the known stomach cancer. Mrs A’s NEWS score remained stable after the vomiting episode on 8 April 2022 and there is no suspicion of aspiration happening at that time.
47. The Medical Adviser said the appropriate management for Mrs A following her deterioration on 8 April 2022 would have been to control her vomiting using a drainage tube and anti-sickness medication using a syringe driver. This was a priority over investigating her constipation. For faecal impaction doctors should have stopped medication that could have been causing this and provided her with intravenous fluids. The records show doctors used a drainage tube, stopped medication and gave intravenous fluids. They provided a good standard of care in line with Good Medical Practice.
48. We find the doctors followed the relevant standards when responding to Mrs A’s diarrhoea, constipation and vomiting. These standards were Good Medical Practice, the CKS on Constipation and the CKS on Diarrhoea. We appreciate how distressing it must have been for Miss A and her family to witness these events. We cannot see any evidence to suggest there were any failings by clinicians in terms of how they responded to these symptoms.