Mid Cheshire Hospitals NHS Foundation Trust

6. Mrs B complains about the care and treatment provided by Mid Cheshire Hospitals NHS Foundation Trust (the Trust) to her husband, Mr B from 29 January to 3 February 2023. She says the Trust:

• Failed to provide the treatment he needed for his gallbladder infection after he was admitted

• Failed to act on his signs of deterioration

• Failed to identify that his condition had developed into sepsis and provide treatment for sepsis

7. Mrs B says there were clear indications and warning signs during his admission that her husband’s condition was deteriorating. She says the Trust failed to provide her husband with the treatment he needed to prevent his condition from worsening. She says her husband died because the Trust did not provide the care and treatment he needed.

8. Mr B died on 3 February 2023 and Mrs B says his death may have been prevented if the Trust had provided the appropriate treatment. She says the death of her husband and the circumstances under which he died caused her a great deal of distress and had a huge impact on her life which she still struggles with today.

9. Mrs B would like the Trust to acknowledge the failings and apologise. She would also like the Trust to put in place significant service improvements.

10. Mr B attended A&E at the Trust on 29 January 2023 due to abdominal pain. The Trust diagnosed cholecystitis (gallbladder infection) and admitted him to hospital. Mr B suffered vomiting which led to aspiration (stomach contents entering the lungs) and a cardiac arrest and sadly died in hospital on 3 February 2023.

Treatment for gallbladder infection

14. Mrs B says the Trust failed to provide her husband with the treatment he needed for his gallbladder infection after he was admitted to hospital.

15. The NICE gallbladder infection guidance states:

‘If acute cholecystitis is suspected, admit the person to hospital for:

• Confirmation of the diagnosis, including abdominal ultrasound and blood tests such as a white blood cell count, C-reactive protein (CRP, a protein released into the blood in response to inflammation in the body), and serum amylase.

• Monitoring (for example blood pressure, pulse, and urinary output).

• Treatment may include intravenous (IV) fluids, antibiotics, and analgesia.

• Surgical assessment for cholecystectomy.’

16. The AUGIS guidance also states, ‘patients with acute cholecystitis should be admitted to hospital to have fluid resuscitation (IV fluids), antibiotics and analgesia.’

17. The records indicate following his admission the Trust provided Mr B with pain relief medication and IV antibiotics. Our adviser said the initial treatment provided by the Trust for his gallbladder infection was appropriate and consistent with the NICE gallbladder infection guidance and the AUGIS guidance. Our adviser said the records also indicate Mr B was admitted to hospital in November 2022 with similar problems which settled following the same treatment.

18. When considering whether there was anything more the Trust could have done to treat Mr B’s gallbladder infection during this period, our adviser said the AUGIS guidance suggests surgery to remove the gallbladder be considered after 72 hours or if the patient is frail, a tube should be placed to drain the gallbladder (cholecystostomy). Our adviser said the records indicate Mr B’s condition improved with antibiotics and these additional measures were not required. The records show his white cell count and CRP improved after treatment which was a clear indication the antibiotics were working.

19. 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 no evidence the Trust failed to provide Mr B with the treatment he needed for his gallbladder infection after he was admitted to hospital.

Signs of deterioration

20. Mrs B says the Trust failed to act on her husband’s signs of deterioration. The GMC guidance 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 (including the symptoms and psychological, spiritual, social and cultural factors), their views and values; where necessary, examine the patient

• promptly provide or arrange suitable advice, investigations or treatment where necessary.’

21. The records indicate Mr B was improving clinically up until the evening of 3 February 2023. His blood tests were showing improvement and the records state he reported feeling well during the ward round on 2 February 2023. He became unwell at around 5pm on 3 February 2023 with a NEWS (National Early Warning Score, a system for scoring physiological parameters to identify acutely ill patients) score of 5, indicating he was at medium risk of clinical deterioration and required an urgent review. The doctor who reviewed Mr B noted that he had difficulty breathing, increased oxygen requirements and a swollen abdomen.

22. Our adviser said it is clear from the records Mr B was struggling with his breathing at this time, however the examination of his chest did not identify any signs of a chest infection. His abdomen was noted to be ‘grossly distended’ (swollen beyond its normal size) which our adviser says was likely causing compression on his chest and impeding his breathing. However the doctor who reviewed Mr B did not record any consideration of this as the possible cause of his breathing difficulty.

23. The records indicate the Trust took no further action for his swollen abdomen. The records indicate the Trust restarted IV treatment, arranged hourly observations and planned further blood tests and a chest X-ray.

24. Our adviser said given his combination of breathing difficulty and swollen abdomen the Trust should have arranged an abdominal X-ray or CT scan at this point to diagnose the cause of the swelling. Our adviser said it was most likely being caused by ileus (where the intestine cannot push food and waste out of the body) or gastric dilatation (enlargement of the stomach due to excessive accumulation of gas or fluid) and a scan would have informed the clinical team and allowed it to consider treatment.

25. The records indicate a few hours later, at around 10pm on 3 February 2023, Mr B suffered vomiting which led to aspiration and a cardiac arrest. Despite resuscitation attempts from the clinical team Mr B sadly died a few minutes later.

26. Our adviser said there is no evidence we can point to that would enable us to say Mr B’s outcome would have been different even if the Trust attempted treatment to reduce his swollen abdomen earlier on 3 February 2023. Treatment would require a nasogastric tube to be inserted into his stomach and this treatment does not completely remove the possibility of aspiration and in some cases the act of inserting a tube can cause it. However given the circumstances of Mr B’s deterioration earlier that day it would have been consistent with the GMC guidance for the Trust to investigate his swollen abdomen and consider treatment to reduce it.

27. 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 did not act in line with the GMC guidance after it identified Mr B’s swollen abdomen on 3 February 2023. We think it would have been consistent with the GMC guidance for the Trust to perform a scan of Mr B’s abdomen and consider treatment to reduce the swelling.

28. We think this was a missed opportunity for the Trust to arrange further tests which may have led to additional treatment. We cannot say whether any additional treatment would have been successful in reducing Mr B’s swollen abdomen or that it would have prevented his aspiration later that evening. However this earlier missed opportunity to investigate and treat his swollen abdomen has led to doubt about the impact any additional treatment may have had at that time.

Sepsis

29. Mrs B says the Trust failed to identify that her husband’s condition had developed into sepsis. She also says the Trust failed to provide him with any treatment for sepsis.

30. Our adviser said there is no evidence in the records to indicate Mr B had sepsis during this admission. The records indicate he had a gallbladder infection which was being treated by the Trust with antibiotic medication. Up until 3 February 2023 his NEWS scores provided no indication he was at risk of deterioration, his condition was stable and his blood tests showed his gallbladder infection was improving. Sadly he suffered a sudden, unexpected deterioration on 3 February 2023 which caused him to aspirate, which in turn caused him to suffer a cardiac arrest from which he did not recover.

31. 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 no evidence that Mr B developed sepsis during this admission and for this reason we do not think the Trust failed to identify or treat sepsis.

1. We have decided to partly uphold Mrs B’s complaint. We acknowledge how upsetting these events were and that they continue to cause her considerable distress.

2. We found the Trust provided appropriate treatment for Mr B’s gallbladder infection.

3. We found the Trust missed an opportunity to arrange further tests after it identified Mr B’s swollen abdomen on 3 February 2023. We think a scan of his abdomen at this time may have led to additional treatment to reduce the swelling. We cannot say whether any additional treatment would have been successful or that it would have prevented his death later that evening. However we think this earlier missed opportunity has led to doubt about the impact any additional treatment may have had at that time.

4. We found no evidence Mr B developed sepsis and for this reason we do not think the Trust failed to identify and treat sepsis.

5. In relation to the failings we have identified in the lack of investigation and treatment for Mr B’s swollen abdomen on 3 February 2023, we will ask the Trust to act by providing an apology to Mrs B and an explanation of improvements.

32. We make recommendations in line with our Principles for Remedy which say public bodies should acknowledge failures, apologise, make amends, and use the opportunity to improve their services. In considering our recommendations, we have referred to the NHS Complaint Standards. These standards state that where poor service or maladministration has led to injustice or hardship, the organisation responsible should take steps to put things right.

33. The NHS Complaint Standards also say that public organisations should seek continuous improvement and should use the lessons learnt from complaints to ensure that maladministration or poor service is not repeated.

Recommendation 1

34. We recommend that within one month of the date of this report the Trust write to  Mrs B to acknowledge and apologise for the impact the failure to act on her husband’s swollen abdomen had. We think the Trust should also apologise for the doubt that now remains about the benefit any additional treatment may have had on Mr B’s condition at that time.

Recommendation 2

35. We recommend that within three months of the date of this report the Trust produce an action plan setting out the steps it will take (or the steps it has already taken) to reduce the risk of similar failings happening again in future. This action plan should be shared with us, Mrs B and the Care Quality Commission.