Surgery to remove his tumour
14. Mrs B says the Trust missed the opportunity to operate and remove the tumour. She says the Trust placed her husband on the surgery ward and planned the surgery but never carried it out.
15. Both our surgeon and physician advisers said there is no evidence in the records to indicate there was an opportunity during this admission where the Trust could have performed surgery to remove Mr B’s tumour. Both our surgeon and physician advisers said there was no point during this admission where Mr B was fit enough to withstand surgery.
16. The GMC guidance 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 (including the symptoms and psychological, spiritual, social and cultural factors), their views and values; where necessary, examine the patient
b. promptly provide or arrange suitable advice, investigations or treatment where necessary.’
17. The records indicate Mr B had a history of serious comorbidities (medical conditions that coexist alongside a patient’s primary diagnosis and affect their health and treatment options) including anaemia (low level of red blood cells), atrial fibrillation (irregular heart rate) a cardiac pacemaker, pulmonary hypertension (high blood pressure in the lungs), chronic obstructive pulmonary disease (COPD, a progressive lung disease that limits airflow through the lungs), diabetes, kidney impairment and heart failure.
18. Our physician adviser said the records show that very early in his admission Mr B’s risk of death from surgery was very high. His P-Possum score (Physiological and Operative Severity Score for the enUmeration of Mortality - a tool used to calculate the risk of a patient dying during surgery) indicates he had a potential risk of death from surgery of 65.9% and a risk of morbidity (becoming unwell because of the surgery) of 97% which would mean surgery was not appropriate. The records indicate Mr B’s condition deteriorated whilst in hospital which would have further increased his risk of death from surgery.
19. The records indicate Mr B was reviewed by the Trust’s gastroenterology doctors on 18 September 2023 and they concluded he was not well enough to withstand a colonoscopy (a procedure that allows doctors to examine the inside of the colon using a flexible tube with a camera). The records also indicate Mr B had been referred by his GP for tests a year earlier and been deemed not fit for investigations or surgery at that time.
20. Our surgeon adviser said the records indicate Mr B was still frail and high risk for surgery despite the medical treatment provided by the Trust to try and optimise his condition. Our physician adviser said the evidence in the records supports the view that on balance of probabilities, Mr B would have been unable to survive such major surgery had it been attempted and it would have been more likely than not to have resulted in his death.
21. We carefully considered Mrs B’s complaint and the supporting information she has provided. We also considered the information in the records, the guidance and the advice we have received. We found the Trust’s decision not to perform surgery to remove his tumour can be supported by the evidence in the records and was in line with the GMC guidance. We found no evidence to indicate the Trust missed an opportunity to perform surgery and remove Mr B’s tumour during this admission.
Treatment provided in to prevent his condition from deteriorating
22. Mrs B says the Trust failed to provide her husband with the treatment he needed to prevent his condition from deteriorating. She says he was in hospital for 8 weeks and never became well enough for surgery.
23. In addition to his main cancer diagnosis, Mr B had a number of significant medical problems which the Trust treated during his admission. The Trust diagnosed Mr B with a urinary tract infection and pneumonia and provided treatment with antibiotics for both of these conditions. The Trust also performed a blood transfusion to treat his anaemia.
24. Mr B developed E.coli bacteraemia (bacteria in the blood) around 18 October 2023, which after seeking advice from its microbiology team, the Trust treated with antibiotics. The Trust performed a CT scan on 23 October 2023 which identified a possible perforation in Mr B’s bowel which the Trust also treated with antibiotics. Our physician adviser said the investigations carried out and the treatment provided by the Trust was appropriate for each of these specific conditions and consistent with the GMC guidance.
25. The records indicate the Trust also provided Mr B with physiotherapy. He was first seen by the Trust’s physiotherapist on 16 September 2023 and the records indicate they carried out a comprehensive assessment of his needs. Due to his very frail condition he needed assistance from one person to move from a sitting to standing position and assistance from two people to move to his armchair.
26. The records indicate the Trust provided this support and additional physiotherapy care during his admission which resulted in a small degree of benefit. The records indicate on 18 September 2023 Mr B had difficulty standing. The records show after a few days he was able to walk a very short distance using a Zimmer frame with the assistance of one person. Despite this care, we acknowledge Mr B remained very frail and required support throughout this admission.
27. The NICE nutrition guidance states:
‘Nutrition support should be considered in people at risk of malnutrition who, as defined by any of the following:
• have eaten little or nothing for more than 5 days and/or are likely to eat little or nothing for the next 5 days or longer • have a poor absorptive capacity, and/or have high nutrient losses and/or have increased nutritional needs from causes such as catabolism.
Healthcare professionals should consider using oral, enteral or parenteral nutrition support, alone or in combination, for people who are either malnourished or at risk of malnutrition.’
28. Mr B was admitted to the Trust on 16 September 2023 and was first reviewed by a dietician on 19 October 2023. The records of his nutritional intake prior to the dietician review mainly concentrate on the consistency of his dietary intake (i.e. normal diet and fluids, not thickened fluids or pureed food) rather than the amount of food he was eating during his meals.
29. The dietician identified Mr B had lost a lot of weight, from a reported previous weight of 73kg, to a measured weight of 71.65kg on 23 September 2023, down to 65.3kg on 14 October 2023. This is a significant weight loss of at least 6kg during his admission before a dietician review was carried out.
30. Mr B’s food charts indicate he often refused meals and he was noted by the dietician during the review to be eating a maximum of one quarter of his meal portions. The dietician recommended nutritional supplements and for the red tray system to be used (where patients get their meals on a red tray to indicate to staff they are at nutritional risk and need help/accurate recording of their food intake). The records indicate Mr B’s weight continued to fall despite this and his weight was recorded as 64.1kg on 21 October 2023.
31. Our physician adviser said nutrition is of critical importance in such cases of acute illness. In Mr B’s case the Trust did not arrange a dietician review until 33 days after he was admitted despite his significant weight loss and evidence of inadequate dietary intake.
32. We think Mr B should have been reviewed by a dietician much sooner than 19 October 2023. The records provide evidence his oral intake was insufficient from admission and we think to meet the criteria in the NICE nutrition guidance the Trust should have referred him for a dietician review within a week of his admission at the latest.
33. Our physician adviser said it is very difficult to say what impact the poor nutritional care had on Mr B’s condition due to the severity of his illness. Unfortunately, Mr B’s death was not something that could have been prevented as he was never fit for any of the curative treatment options such as surgery or chemotherapy. However better nutritional care may have provided Mr B with some degree of comfort during this period and may have increased his energy levels and lessened his weight loss.
34. We carefully considered Mrs B’s complaint and the supporting information she has provided. We also considered the information in the records, the guidance and the advice we have received. We think there was a delay in the Trust acting on Mr B’s poor oral intake and weight loss. We think the Trust should have referred him for a dietician review sooner in accordance with the NICE nutrition guidance.
35. We acknowledge the Trust was treating Mr B for numerous conditions during this time, however it is clear from the information in the records he was at risk of malnutrition from the outset and the indications of poor oral intake and weight loss were evident sooner and not appropriately acted upon. We think this is a failing.
36. Despite the failings in his nutritional care, we have not seen any evidence to indicate this was a contributory factor in Mr B’s death and we have not seen any evidence to indicate his death could have been prevented. We have not identified failings in any other areas of care and treatment provided to Mr B by the Trust whilst it was attempting to optimise his condition for surgery.
Plans to discharge Mr B and treat him as an outpatient
37. Mrs B says the Trust failed to follow through with its plans to discharge her husband and treat him as an outpatient. She said they were told several times, during several meetings he would be discharged home but he never was.
38. Our physician adviser said there is no evidence in the records to support the view that it was safe to discharge Mr B home at any point during this admission as he was very frail from the outset and experienced difficulty walking and repositioning himself without assistance at times during the admission. The records indicate the Trust’s physiotherapy and occupational therapy team recommended not to discharge him home due to the high risk of him suffering a fall. Despite regular physiotherapy input during his admission, Mr B’s mobility continued to deteriorate.
39. We acknowledge both Mr and Mrs B wanted him to be discharged home and treated as an outpatient, and that the Trust discussed this with them on several occasions during the admission. However the records indicate discharging Mr B home posed significant risks to him that had to be fully considered and resolved before it could be carried out. Sadly, from the information we have seen so far it seems he was never in suitable condition to be discharged home.
40. We carefully considered Mrs B’s complaint and the supporting information she has provided. We also considered the information in the records and the advice we have received. We found the Trust’s decision not to discharge Mr B home was appropriate and consistent with the GMC guidance. We accept the Trust discussed the possibility of discharging him with Mr and Mrs B at points during the admission. However we found no evidence to indicate the Trust missed an opportunity when it was safe to discharge Mr B home and treat him as an outpatient instead.
Decision to stop treatment with blood thinning medication
41. Mrs B says the Trust inappropriately decided to stop treatment with blood thinning medication. She says the Trust told her this was because the medication loses its effectiveness, however Mrs B disputes this reason. The Trust complaint response says the medication was stopped do the effect it could have on the bleeding in Mr B’s bowel. Mrs B says the decision to stop treatment with blood thinning medication caused her husband’s condition to worsen.
42. On admission to hospital Mr B was already very anaemic and his bowel motions were reported as ‘black and very smelly’. Our physician adviser said this is a symptom of bleeding in the bowel. This symptom continued throughout his admission which supports the view that Mr B was experiencing ongoing bleeding in his bowel. The records indicate the Trust stopped the blood thinning medication to prevent the worsening of the bleeding.
43. The purpose of blood thinning medication is to prevent the blood from forming clots and it is given to people at a high risk of clots to reduce their chances of developing serious conditions such as strokes and heart attacks. Preventing blood from clotting poses the risk of a patient bleeding too easily or excessively. Our Physician adviser said the use of blood thinning medication should not be used when a patient is actively bleeding, as Mr B was during this admission, due to the risk of the bleeding becoming worse or more difficult to stop.
44. We carefully considered Mrs B’s complaint and the supporting information she has provided. We also considered the information in the records and the advice we have received. We think the decision to stop treatment with blood thinning medication was appropriate and consistent with the GMC guidance. We found no evidence to indicate this decision contributed to the deterioration in Mr B’s condition.
Treatment with lorazepam (Ativan) medication
45. Mrs B says the Trust treated her husband with lorazepam (Ativan) medication which was inappropriate as he had COPD and other risk factors. She says they didn’t check its interactions with his regular medications and as a result it directly caused his condition to deteriorate.
46. The BNF guidance recommends lorazepam as a short-term treatment for anxiety. It states:
‘Indications and dose for lorazepam
Short-term use in anxiety Adult 1–4 mg daily in divided doses.
Elderly 0.5–2 mg daily in divided doses.’
47. Mr B was regularly seen by the Trust’s mental health liaison team during the admission. The records indicate as a result of his illness he had displayed agitation and needed periods of 1 to 1 supervision to ensure his safety. The mental health liaison team discussed his agitation with the consultant psychiatrist on 1 November 2023 who recommended treatment with 0.25mg of lorazepam medication twice a day.
48. The records indicate this medication was kept under close review by both the medical and mental health liaison team and the mental health liaison nurse reviewed Mr B again on 4 November 2023. The records indicate the Trust understood how this medication may impact Mr B’s physical health and the medical team monitored Mr B for any signs of adverse side effects such as drowsiness or low oxygen saturation levels.
49. Our physician adviser said 0.25mg is such a low dose that it would support the view that the consultant psychiatrist was being extra cautious with Mr B’s treatment. Our physician adviser said the records indicate there is no other medication being provided by the Trust to Mr B during this admission that would have rendered this cautious dose of lorazepam to be inappropriate.
50. We carefully considered Mrs B’s complaint and the supporting information she has provided. We also considered the information in the records, the guidance and the advice we have received. We think the decision to treat Mr B with a low dose of lorazepam medication to help ease his symptoms of agitation was appropriate and consistent with the GMC guidance and the BNF guidance. We found no evidence to indicate this treatment was detrimental to Mr B or contributed to the deterioration in his condition.