University Hospitals Birmingham NHS Foundation Trust

7. Mrs N complains about aspects of the care and treatment the Trust provided to her husband, Mr N, in 2022. Mrs N specifically complains the Trust:

• failed to investigate the cause of Mr N’s high white cell counts during his admissions in 2022 • discharged Mr N in November 2022 despite him suffering from a multiple sclerosis (MS) relapse • failed to complete skin assessments of Mr N’s feet in December 2022 • failed to investigate the functioning of Mr N’s bowels during his admissions in 2022 • failed to provide Mr N with a colonoscopy in 2022.

8. Both Mrs N and Mr N have been affected by the care and treatment the Trust has provided. Mrs N says by not having further investigations for her husband has left both and her husband in significant distress.

9. Mrs N says her husband has become weaker each time he was admitted to hospital, has vomited blood and clots, and has had increased seizure activity. Mrs N says her husband’s health has been compromised. She says the lack of skin assessment led to blistering and ulcers on his feet, which were not discovered until he was discharged.

10. Mrs N also believes Mr N’s MS relapse could have been caught sooner and caused less permanent damage. Instead, she says it was so big, Mr N required steroids, plasma exchange and additional treatment to begin his recovery.

11. Mrs N says the care provided to her husband was inadequate and she has lost trust in the system. She says she is fearful of Mr N returning to hospital due to the lack of care that was provided to him.

12. By bringing her complaint to us, Mrs N would like an apology from the Trust.

13. Mr N has diabetes and multiple sclerosis (MS). The Trust admitted Mr N in early March 2022 due to acidosis (excess acid in the body’s fluids) and high blood glucose. The Trust commenced a variable rate insulin drip.

14. The Trust completed an endoscopy which showed Mr N had severe oesophagitis secondary to gastroparesis. Oesophagitis is when the tube that connects the throat to the stomach becomes inflamed. Mr N was discharged approximately one week later.

15. The Trust also undertook a CT scan of Mr N’s bowel during an outpatient appointment, which showed there were no blockages. The scan showed there was a thickening low down in Mr N’s rectum.

16. Mr N attended the Trust in early June with a one-week history of vomiting, diarrhoea and abdominal pain. The Trust noted it was likely gastroenteritis (infection in the gut), and it gave Mr N anti-sickness tablets, and took a stool sample. The Trust discharged Mr N the next day.

17. Mrs N raised concerns about the diagnosis, and the doctor informed her Mr N likely had MS-related gastroparesis complicated gastroenteritis. Mrs N asked the Trust to expedite Mr N’s colonoscopy, and the Trust contacted the relevant department to request this.

18. The Trust admitted Mr N in early to mid-July with a one-day history of vomiting, diarrhoea and abdominal pain. Mrs N reported they were waiting for a colonoscopy, but this had not been followed up.

19. The day after his admittance a doctor reviewed Mr N and noted he had a possible upper GI bleed and poorly controlled diabetes. The Trust requested an endoscopy and referred Mr N to the diabetes team. The endoscopy report was available the same day which showed severe oesophagitis. The report said there was no evidence of an upper GI bleed and recommended treatment for Mr N to treat the oesophagitis.

20. Mr N reported he had a burning sensation is his stomach that was ‘like acid’. The Trust noted once Mr N’s pain had settled so did the vomiting and diarrhoea. Mrs N reported Mr N had been suffering with being sick for three years and that he was regularly constipated. The Trust noted Mrs N wanted Mr N to have a colonoscopy.

21. The Trust discharged Mr N the following day and noted it planned for Mr N’s colonoscopy to take place as an outpatient.

22. In mid-October the Trust requested an urgent colonoscopy due to Mr N’s worsening constipation. The Trust noted it had suspicions of cancer.

23. Mr N presented to the Trust by ambulance in November with abdominal pain. The ambulance handover noted Mr N reported a history of eight weeks of loose stool with episodes of vomiting.

24. The next day a doctor reviewed Mr N and noted he had coffee ground vomit and had been experiencing abdominal pains for approximately two days and had loose stools. The doctor noted Mr N did not have a fever, chest pain, shortness of breath or any urinary symptoms.

25. Later that day during the ward round, the Trust noted Mr N likely had gastroparesis and oesophagitis. It requested a review from a gastroenterologist and prescribed him anti-sickness and gastric medications.

26. Two days later the gastroenterologist reviewed Mr N. They noted Mr N reported his diarrhoea, and vomiting had stopped, and his abdominal pain was also resolved. The gastroenterologist noted on an endoscopy from July 2022 Mr N had significant oesophagitis. They requested a repeat scan which took place the following day.

27. At the time the results of Mr N’s endoscopy became available, the Trust informed him he had grade D oesophagitis. This is when the inflammation is severe and involves 75% or more of the oesophageal circumference. The Trust discharged Mr N the same day and arranged for a follow-up endoscopy to take place in eight weeks.

28. In a call with the Trust in early December Mrs N reported Ms N’s colonoscopy was arranged for 14 December. The colonoscopy was unable to go ahead on this date as the Trust had provided Mr N with iron tablets which affects the visibility required for the procedure.

White Blood Cells

33. Mrs N said Mr N’s white blood cells were raised on each of his admissions to the Trust and this is an indicator for infection. Mrs N said the Trust failed to investigate the cause of Mr N’s raised white blood cells, which she believes was caused by problems he was experiencing with his bowel.

34. Our adviser told us there is no specific guidance relating to what investigations should be undertaken following a raised white blood cell count. GMC guidance says doctors should promptly provide or arrange investigations where necessary.

35. We have reviewed Mr N’s medical records as part of our consideration of Mrs N’s complaint. The Trust’s blood report says a normal range for white blood cells is between 4.3 and 11.2 x 109/L.

36. From the records we can see the Trust recorded Mr N’s white blood cells were:

• 13.5 x 109/L on his admittance in March • 14 x 109/L on Mr N’s next admittance to the Trust in June • 33.6 x 109/L when he next presented to the Trust in July • 12.2 x 109/L following treatment for severe oesophagitis and gastroparesis • 16.59 x 109/L in November • 14.09 x 109/L in December.

37. Looking at the data above, Mr N’s white blood cell count was above the normal range on each of the occasions the Trust tested it. Our adviser explained Mr N had raised neutrophils, which are a subset of cells within white blood cells. Our adviser explained neutrophils are involved in fighting infection, but they rise for a number of reasons, including if someone is vomiting.

38. From the evidence we have seen, we have found the Trust has acted in line with GMC guidance. We can see in March, June, July and November the Trust noted Mr N had gastroparesis. This is a gut infection and could have been the source of Mr N’s raised white blood cells. We can see Mr N was taking medication for gastroparesis to treat the infection.

39. We find this is in line with GMC guidance which says doctors should provide prompt investigation where necessary. We can see the Trust identified Mr N’s infection, gastroparesis, and he was receiving treatment.

40. We understand Mrs N is concerned the Trust missed an infection in Mr N. Our adviser said there were no other signs of infection in Mr N during his admittances to the Trust. As there were no other signs of infection, there was no need for further investigation.

41. Based on this we have found no failings in the Trust’s management of Mr N’s raised white blood cells.

Bowel Function

42. Mrs N said the Trust failed to investigate Mr N’s bowels during his admissions in 2022. Mrs N said she told staff repeatedly that the problems were with Mr N’s stomach and bowels, and she was not listened to.

43. GMC guidance says doctors must promptly provide or arrange suitable investigations.

44. We can see the Trust performed a CT scan of Mr N’s bowel and this shows the Trust was investigating Mr N’s bowel symptoms. We can see the Trust reported there were no blockages that would be causing the constipation.

45. Our adviser said a colonoscopy was likely requested around this time to check for incidental findings such as polyps in the thickened area. Polyps are small tissue growths that can grow in various parts of the body such as the rectum. We have found the Trust acted in line with GMC guidance which says doctors must arrange suitable investigations.

46. In July the Trust queried whether Mr N had gastroenteritis. We can see the Trust examined Mr N and performed a digital rectal examination. It noted this was normal and there was no blood in Mr N’s rectum.

47. Our adviser said Mr N had an established diagnosis of gastroparesis and therefore no major tests would be required as the Trust was managing his symptoms. We can see in July the Trust provided Mr N with medication for gastroparesis and it also performed an endoscopy to determine the cause of his symptoms.

48. We can see Trust noted Mr N had severe oesophagitis and commenced treatment for this before discharging him home. We can see the Trust did perform investigations into the source of Mr N’s bowel problems and provided treatment for this. We find this is in line with GMC guidance.

49. We can also see the Trust requested an urgent colonoscopy in October due to Mr N’s constipation. In November we can see the Trust admitted Mr N and recorded it was likely gastroparesis and provided treatment for this. The Trust also requested a review from a gastroenterologist.

50. We can see following this review, the Trust performed an endoscopy and reported Mr N’s oesophagitis had worsened. We think this demonstrates the Trust was looking into and treating Mr N’s bowel symptoms in line with GMC guidance which says to promptly provide or arrange investigations.

51. We can see Mr N presented to the Trust in December with symptoms of an MS relapse. We can see on his admittance Mr N reported he had opened his bowel three days previously and that he was not experiencing any abdominal pain or diarrhoea. We have not seen any evidence Mr N reported any symptoms relating to his bowel during this admittance.

52. We have found the Trust has acted in line with GMC guidance. We can see Mr N presented with symptoms of an MS relapse and the Trust began investigations into this. We have found this is in line with GMC guidance which says to arrange investigations only where necessary. As Mr N was not displaying bowel symptoms, investigations into his bowel would not have been deemed clinically necessary during this admittance.

53. We are satisfied the Trust did investigate the cause of Mr N’s bowel issues when he presented with bowel symptoms, in line with GMC guidance. We understand Mrs N has told us she feels the Trust were not listening to her when she was raising concerns about Mr N’s bowels. We hope this provides reassurance to Mrs N that the Trust had not dismissed her concerns.

54. We have found no failings in the investigations performed by the Trust into Mr N’s bowel.

Colonoscopy

55. Mrs N said the Trust refused to do a colonoscopy as it felt Mr N’s diabetes was not managed well enough. Mrs N said in April 2022, she managed to arrange a face-to-face appointment with the colonoscopy team. Mrs N said during the appointment the Trust agreed to perform a colonoscopy, because of the negative effect it was having on Mr N’s day-to-day life, but this was not completed.

56. GMC guidance says doctors must adequately assess the patient’s condition, taking account of their history and promptly provide or arrange suitable investigations. GMC guidance says doctors must promptly provide or arrange suitable advice and treatment where necessary. The NHS colonoscopy guide says patients should stop taking iron tablets seven days before a colonoscopy.

57. We can see the Trust attempted to bring Mr N’s colonoscopy forward in June at Mrs N’s request. We can see in July the Trust queried whether Mr N had an upper GI bleed and requested an endoscopy to investigate this. The Trust said the colorectal team requested a colonoscopy in October 2022.

58. We think this test was appropriate at this time, considering Mr N’s symptoms. We can see the endoscopy showed severe oesophagitis which the Trust provided treatment for. From the evidence we have seen, we have found the Trust has acted in line with GMC guidance as it arranged suitable investigations considering Mr N’s symptoms.

59. We can see on 7 December whilst Mr N was an inpatient, a member of the support team was looking at Mr N’s repeat medications. We can see they documented Mrs N told them ferrous sulfate was not given to Mr N when he was last discharged. The Trust documented Mr and Mrs N were waiting to hear back from the GP about Mr N taking this. Ferrous sulfate is an iron supplement used to treat iron deficient anaemia. Approximately 35 minutes later we can see a different member of the support team documented the ferrous sulfate had been restarted.

60. We can see a week later the Trust conducted a colonoscopy and in the procedure notes documented, ‘colonoscopy abandoned as patient has not stopped iron tablet’. We think this is referring to the ferrous sulfate medication restarted by the Trust on 7 December.

61. We can see in a doctor’s note they said the colonoscopy was unable to take place and that iron tablets should be stopped seven days prior to a colonoscopy. At 2.40pm we can see the Trust requested another colonoscopy and stopped Mr N’s iron tablets.

62. In late December we can see the doctor contacted the colonoscopy team. The colonoscopy team advised it would review their request the following week and an assessment of Mr N may be required prior to the appointment being booked. We can see this request also said Mr N did not have diabetes. We can see the Trust submitted a new urgent request for a colonoscopy.

63. We can see the Trust informed Mr and Mrs N the colonoscopy would take place at an outpatient appointment and Mr N was discharged the next day. We can see this was arranged to take place in January 2023.

64. In the procedure notes we can see the clinician documented the request was initially for a colonoscopy, but this had been changed to a sigmoidoscopy. A sigmoidoscopy is a procedure where a long thin flexible tube is inserted into the bottom with a small camera attached at the end to look at the rectum and lower parts of the large intestine. They noted this was due to the CT scan that was completed in March 2022 showing thickening of Mr N’s rectum.

65. The clinician noted that Mr and Mrs N both wanted a full colonoscopy, and it attempted to undertake one, but it was unsuccessful. The clinician noted visualisation was poor but confirmed the rectum appeared normal.

66. Mrs N has complained that the Trust refused to do a colonoscopy as it felt Mr N’s diabetes was not well managed. We have seen no evidence to show this was the case.

67. Mrs N also complained that having agreed to undertake the colonoscopy in April 2022, the Trust failed to complete this. Our adviser said a colonoscopy was not really needed as only the lower part of Mr N’s rectum needed examining. We appreciate it must have been frustrating for Mr and Mrs N when the colonoscopy in December was unable to go ahead, given how long they had been waiting for this.

68. From the evidence we have seen, we have found the Trust has not acted in line with GMC guidance. We can see the Trust commenced Mr N on iron tablets on 7 December, approximately seven days prior to his scheduled colonoscopy. The NHS colonoscopy guide says iron tablets should be stopped seven days prior to a colonoscopy.

69. We have found this is not in line with GMC guidance which says doctors must provide suitable advice and treatment. We think starting Mr N on iron tablets, seven days before his colonoscopy, was not appropriate treatment. We will consider the impact of the failings we have identified below.

70. We acknowledge the further frustration caused by the second attempt at the colonoscopy not being able to go ahead in January 2023. We do not think this was due to any failing by the Trust.

71. Mrs N said the Trust providing iron tablets a week before Mr N’s colonoscopy sabotaged the procedure. Mrs N said this made her angry and upset as she had fought hard for the colonoscopy. Mrs N said Mr N was not prescribed iron tablets at home, and it is confusing why he was given them whilst an inpatient as he was not anaemic.

72. We recognise the Trust giving Mr N iron tablets for seven days prior to his colonoscopy would have caused anger, upset and confusion to both Mr and Mrs N. We recognise it would have been incredibly frustrating for the colonoscopy to be unable to go ahead for this reason, specifically as Mrs N had been advocating for the colonoscopy for some time.

73. Mrs N said the Trust’s failure to complete a colonoscopy compromised Mr N’s quality of life. She said this was frustrating and stressful as she was having to contact the Trust to arrange the colonoscopy. Mrs N said it was distressing for both her and Mr N.

74. We cannot say Mr N’s quality of life was compromised by the Trust not arranging a colonoscopy in a timely manner. This is because the colonoscopy was requested to look for incidental findings in the lower part of Mr N’s rectum. It was not requested to diagnose or investigate Mr N’s bowel symptoms, or affect his treatment, but to rule out further findings.

75. We have set out our recommendations to address this below.

MS Relapse

76. Mrs N said she informed the Trust Mr N was suffering from an MS relapse on his admittance in November 2022. She said he was vomiting blood, had left sided weakness and a loss of balance.

77. Mrs N also said in December 2022 the Trust carried out a brain scan which confirmed Mr N had had an MS relapse. The Trust said it could not identify a delay in its administration of steroids for Mr N’s MS relapse.

78. NICE guidance on MS says before diagnosing a relapse of MS, clinicians should:

• rule out infection – particularly urinary tract and respiratory infections and • discriminate between the relapse and fluctuations in the disease or progression of this

79. From the evidence we have seen, we have found the Trust has acted in line with NICE guidance on MS. We can see the day after his admittance, the Trust considered Mr N’s symptoms and noted that he was not suffering with chest pain, shortness of breath or urinary symptoms. We think this demonstrated the Trust explored and ruled out respiratory and urinary infections in line with NICE guidance on MS.

80. We can see the guidance also says to discriminate between the relapse and fluctuations in the disease. Our adviser said Mr N did not display any symptoms that were neurological in origin which would have indicated a relapse. We can see during this admittance Mr N’s presenting concerns were abdominal pain, vomiting and loose stools.

81. We have found the Trust has acted in line with NICE guidance on MS in its decision not to diagnose Mr N with an MS relapse during his November admission.

82. We understand why Mrs N is concerned the Trust missed her husband’s MS relapse, particularly as this was diagnosed a month later. We can see when Mr N returned to the Trust on 6 December his presenting condition was different to that of his condition and symptoms in November.

83. We can see on 6 December, the day of his admittance, Mr N was reviewed by a doctor. The doctor noted Mr N had left leg weakness, puffiness to his eyes and swelling and redness to his elbow. We can see Mrs N reported Mr N had woken up the previous day with sudden onset left leg weakness.

84. We can see on examination the doctor noted Mr N’s left leg was flaccid and scored two out of five in power, in comparison to scoring five on his right leg. We can see the doctor queried whether this was a relapse of Mr N’s MS.

85. We think Mr N’s symptoms during his December admittance differs vastly to that of his presenting condition in November and therefore were investigated and treated differently by the Trust. We can also see during a call with Mr N’s MS nurse on 5 December, Mrs N reported Mr N had been displaying left sided weakness for two days. We can see Mrs N also reported she later called an ambulance and Mr N was admitted to the Trust.

86. We are satisfied the Trust did not miss the symptoms of an MS relapse in November 2022. Based on Mr N’s reported symptoms we have found the Trust has acted in line with NICE guidance on MS in its consideration of Mr N’s condition.

87. We recognise this is not the decision Mrs N was hoping for, especially as she told us she believes there may have been less permanent damage required if the Trist had identified his relapse. We do not underestimate how difficult this time was for both Mr and Mr N. We hope our decision provides reassurance to Mrs N that Mr N was not discharged in November whilst suffering from an MS relapse.

Skin Assessments

88. Mrs N said Mr N was discharged in December 2022, and she discovered he had developed ulcers on his feet during his admission. Mrs N said her husband was a wheelchair user and diabetic and the Trust should have completed skin assessments of his feet. The Trust said there was no reference to Mr N’s feet becoming ulcerated or blistered during his admission.

89. NICE guidance on pressure ulcers says patients being admitted to hospital should have a pressure ulcer risk assessment completed using a validated scale, such as the Waterlow scale.

90. From the records we can see Mr N was admitted to the Trust on 6 December with left sided weakness and swelling to his elbow. On 7 December we can see the Trust completed a diabetes foot assessment and noted Mr N did not have any current ulcers or pressure sores on his feet.

91. We can see the Trust also completed a weekly Waterlow chart which is a risk assessment for pressure ulcers. We can see on 7 December the Trust noted Mr N’s Waterlow score was 11. A score of between 10 and 14 would mean the patient is at risk of developing a pressure ulcer. We can see this was repeated on 14 December where Mr N had a Waterlow score of 12 and again on 21 December when Mr N’s Waterlow score was 11.

92. We can see the Trust also completed the skin inspection and assessment tool (SIAT) on 7 December and recorded Mr N’s skin was intact. We can see the SIAT says if a patient scores 10 or more on the Waterlow chart then daily skin inspections should be commenced. We can see the Trust performed skin inspections from 11 December to 18 December and 21 December to 23 December and noted Mr N’s skin was intact.

93. From the evidence we have seen, we have found the Trust has acted in line with NICE guidance on pressure ulcers. We can see the Trust completed a weekly Waterlow assessment and a diabetes foot assessment on his admittance to the Trust. This is in line with NICE guidance on pressure ulcers which says to use a validated scale, such as the Waterlow scale, to assess the risk for pressure ulcers.

94. We can also see based on the Waterlow score the Trust completed daily skin assessments of Mr N. The exceptions to this are 19 and 20 December and 24 December prior to Mr N’s discharge. Whilst we recognise the Trust did not check Mr N’s skin every day, his skin was checked on 23 December, the day before his discharge, and it was noted his skin including his feet, was intact.

95. We understand our decision will be upsetting to both Mr and Mrs N. As explained above, we have seen evidence the Trust completed skin assessments almost daily throughout Mr N’s December admittance. We acknowledge Mrs N has told us the Trust not completing skin assessments caused Mr N to develop blisters and ulcers on his feet. We recognise this would have been distressing for them both.

96. We have not seen any evidence the Trust was not completing skin assessments of Mr N’s feet in line with NICE guidance on pressure ulcers during his December admittance.

1. Mrs N has complained to us about the care her husband, Mr N, received from the Trust. We do not underestimate the difficult time both Mr and Mrs N have been through, and we recognise this has been emotional and distressing time.

2. Based on the evidence, we have found the Trust did not fail to investigate Mr N’s elevated white blood cells or his bowel symptoms. We have found the Trust acted in line with the relevant guidance.

3. We have found the Trust discharged Mr N in November 2022 in line with relevant guidance. We have not seen any evidence he was suffering from an MS relapse at the time.

4. We have also found the Trust completed regular skin assessments and we have not seen any evidence anything went wrong here. We understand the above events were distressing for Mrs N, and that our decision may also be upsetting for her.

5. We have found the Trust failed to act in line with relevant guidance when providing iron tablets to Mr N in the seven days prior to his colonoscopy. We have found this caused anger, upset, confusion and frustration to Mr and Mrs N.

6. For the above failing we consider the Trust should take action to put things right. We recommend the Trust acknowledge the failings we have found and apologise for the impacts we have identified.

97. In summary, we have found the Trust failed to act in line with relevant guidance when providing iron tablets to Mr N in the seven days prior to his colonoscopy. We have found this caused anger, upset, confusion and frustration.

98. 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. The Principles say we aim to ensure the public body puts the complainant back in the position they would have been in had nothing gone wrong. If that is not possible, the public body should compensate them appropriately.

99. Our Principles for Remedy are reflected in the NHS Complaints Standards which say organisations should offer fair remedies to put things right and identify learning and use it to improve services.

100. In line with this we recommend the Trust write to Mrs N within one month of our final report to acknowledge the failings that occurred. We also recommend the Trust apologise for the impact these failings had on Mr and Mrs N, as set out above. We would ask the Trust to send us a copy of this letter.