Issue 1 -diagnosis and treatment of Sepsis
16. Before we decide if we should conduct a detailed investigation of a complaint, we look at whether there are signs the organisation has got something wrong. We do this by comparing what should have happened with what did happen. We have done this and have not found any indications that something has gone wrong.
17. Section 1.6.1 from the above NICE guideline says, ‘For adults, children and young people aged 12 years and over who have suspected sepsis and 1 or more high risk criteria:
• arrange for immediate review by the senior clinical decision maker to assess the person and think about alternative diagnoses to sepsis….
• give a broad-spectrum antimicrobial [an antibiotic used to treat a variety of infections] at the maximum recommended dose without delay (within 1 hour of identifying that they meet any high-risk criteria in an acute hospital setting)’.
18. Ms B said the Trust took too long to diagnose and start treating Mr A for sepsis.
19. In its initial response, the Trust said it admitted Mr A with symptoms of vomiting and diahorrea. It also said it made an initial diagnosis of sepsis with gastroenteritis and started treatment with antibiotics. The Trust in its final response said it could have given antibiotics sooner.
20. We can see from Mr A’s medical records that he arrived at the ED at 9.19pm. Clinicians’ initial impression was that Mr A had gastroenteritis with dehydration.
21. We can also see at this time clinicians at the Trust noted that his venous blood gas test indicated Mr A may have renal dysfunction (acute kidney injury or AKI, where kidneys suddenly stops working properly). A venous blood gas is a test which measures the level of oxygen and carbon dioxide in the blood. This test also measures pH (acidity) and bicarbonate levels. Low bicarbonate levels can indicate issues with the kidneys.
22. The Trust later confirmed this diagnosis with blood tests.
23. ED clinicians then referred Mr A to internal medicine (clinicians who specialise in prevention, diagnosis, and treatment of diseases) at 10.38pm after deciding he would need admission to hospital. Our adviser says this showed that the Trust acted within the NICE guidelines as staff referred Mr A to a senior decision maker for review. The senior decision maker in this instance being the internal medicine team.
24. The internal medical team began assessment at 10.44pm and prescribed and administered Co-amoxiclav (a broad-spectrum antibiotic used to treat a variety of infections) by 11.48pm.
25. We can see from Mr A’s records that at the point of ED triage, clinicians worked on the possibility of pre-renal AKI (a reduction in blood flow to the kidneys) likely caused by dehydration. Our adviser said that this working diagnosis was reasonable (based on the venous blood gases test) and that sepsis was not evident at this time.
26. Our adviser also said that as further information became available (notably blood test results) around the time of the internal medical team assessment, sepsis became a more likely diagnosis.
27. They said this was because the blood tests showed Mr A’s venous lactate (lactic acid) level was 2.2 mmol/L. Elevated lactate levels can indicate conditions such as sepsis. Our adviser explained this is the upper level of a normal lactate level but not elevated. A normal lactate level would be between 0.5 and 2.2 mmol per litre of blood. A mmol/L stands for millimoles per litre, a unit of measurement to define the concentration of a substance (in this case lactic acid) in the blood.
28. We can see in Mr A’s records that from the time of his presentation at the ED to clinicians administering antibiotics took approximately two and a half hours.
29. From internal clinicians beginning to assess him and sepsis becoming a likely diagnosis (10.44pm) to them administering Co-amoxiclav antibiotics (11.48pm) took approximately one hour.
30. Our adviser said that Mr A’s diagnosis was not clear when he presented at the ED and clinicians needed time to clarify this. They also said the Trust’s initial triage, referral and review timings were prompt and appropriately documented.
31. We acknowledge that the Trust said it could have prescribed antibiotics sooner. When we review a complaint to explore what should have happened, we use national guidelines to do this. The NICE guidelines we have referred to allows clinicians time to clarify a patient’s diagnosis.
32. As the Trust used the time allowed to determine the cause of Mr A’s symptoms, our adviser gave their view that clinicians at the Trust acted in line with the above section of the NICE guidelines as they prescribed antibiotics within approximately one hour of suspecting sepsis.
33. From the evidence we have reviewed, including the clinical advice we have received, we have not found a failing regarding this aspect of Mr A’s care. We will therefore not take any further action on it.
34. We acknowledge this was a very difficult time for Mr A and Ms B. We understand that not knowing initially what was causing his symptoms would have been very worrying for them both.
Issue 2 – DNACPR
35. Section 131 of the above GMC guideline says, ‘a judgement about the likely success of CPR [cardiopulmonary resuscitation, an emergency procedure performed when someone’s breathing or heartbeat has stopped] or in restarting breathing and circulation and its benefits, burdens and risks should be made as early as possible.
36. Ms B said the Trust placed a DNACPR too soon for Mr A.
37. The Trust said, ‘DNACPR discussions occurred following appropriate senior medical assessment… It was clearly explained to Ms [B] that Mr [A’s] condition was deteriorating, and that CPR would not be appropriate due to the burdens outweighing any likely benefit.’
38. We can see from Mr A’s medical records that clinicians placed a DNACPR for Mr A the day after his admission to hospital. We can also see that later that day a clinician updated Ms B by telephone about Mr A’s clinical condition and that he ‘might not survive this admission’.
39. We know this would have been very upsetting for Ms B to hear this news.
40. At 5pm on the same day a nurse wrote they had explained to Ms B that Mr A was ‘currently on DNACPR’ but that he was also, ‘on active treatment’.
41. After approximately one week in hospital, we can see a clinician recorded that the ‘DNACPR was not informed/agreed by family’. This was after a conversation with Ms B.
42. We see a day after this conversation, the consultant team formally documented a DNACPR decision. We can also see Mr A was informed of the decision.
43. Section 131 of the above GMC guideline says clinicians should make a decision about the likely success of CPR as early as possible. We can also see the Trust did this the day after clinicians admitted Mr A to hospital.
44. Our adviser gave their opinion that the DNACPR was clinically justified and clinicians at the Trust therefore acted within the above section of the GMC guideline.
45. As such we have not found the Trust did anything wrong in its decision to place a DNACPR and we will take no further action on this issue.
Issue 3 – side room
46. Section 40 of the GMC guideline says, ‘The benefits of a treatment that may prolong life, improve a patient’s condition, or manage their symptoms must be weighed against the burdens and risks for that patient, before you can reach a view about whether it could be in their interests.
47. For example, it may not be in a patient’s interests to provide potentially life prolonging but burdensome treatment in the last days of their life when the focus of care is changing from active treatment to managing the patient’s symptoms and keeping them comfortable.’
48. Ms B says clinicians should have moved Mr A to the intensive care unit (the ICU) when his clinical condition deteriorated. By placing Mr A in a side room, she believes he did not receive the correct level of care.
49. The Trust said, ‘the decision was made by the multidisciplinary team to preserve his dignity and privacy’ and ‘he was checked regularly by staff’. It also said, ‘the burden of invasive and distressing treatments on ITU [or ICU] would outweigh any potential benefit.’
50. We can see from Mr A’s medical record that although he received on-going medical care, for example antibiotics, he showed a pattern of clinical decline which our adviser said is associated with dying.
51. We can see Mr A had pneumonia, renal failure, worsening liver function and started to experience rectal bleeding.
52. Our adviser said these symptoms are consistent with multiple organ failure or impairment. They also said that the appropriate senior clinicians assessed Mr A and correctly concluded that ICU would not offer benefit to him.
53. Our adviser gave their view that the decision to continue with ward-based care was in line with GMC end-of-life guidance.
54. From the evidence we have seen, we have not found a failing regarding the Trust’s decision to continue to care for Mr A in a side room. We can also see this decision was both appropriate and compassionate.
55. As we can see that clinicians at the Trust acted in line with GMC guidelines, we will therefore take no further action on this complaint issue.
56. We are very sorry that Mr A experienced these symptoms and know it will be difficult for Ms B to relive these final days of his life.
Issue 4 – removal of fluids
57. Before we decide if we should conduct a detailed investigation of a complaint, we look at whether there are signs the event complained about had a negative effect which the organisation has not put right. Having done so we have not found any indication that these issues had a negative clinical impact on Mr A. We would also not be able to link this to a long-term impact on Ms B.
58. The following sections of the GMC guidelines say:
‘113. Providing nutrition and hydration by tube or drip may provide symptom relief or prolong or improve the quality of the patient’s life; but they may also present problems. The current evidence about the benefits, burdens, and risks of these techniques as patients approach the end of life is not clear-cut. This can lead to concerns that patients who are unconscious or semi-conscious may be experiencing distressing symptoms and complications, or otherwise be suffering either because their needs for nutrition or hydration are not being met or because attempts to meet their perceived needs for nutrition or hydration may be causing them avoidable suffering.
114. Nutrition and hydration provided by tube or drip are regarded in law as medical treatment and should be treated in the same way as other medical interventions. Nonetheless, some people see nutrition and hydration, whether taken orally or by tube or drip, as part of basic nurture for the patient that should almost always be provided. For this reason, it is especially important that you listen to and consider the views of the patient and of those close to them (including their cultural and religious views) and explain the issues to be considered, including the benefits, burdens, and risks of providing clinically assisted nutrition and hydration.
You should make sure that patients, those close to them and the healthcare team understand that, when clinically assisted nutrition or hydration would be of overall benefit, it will always be offered; and that if a decision is taken not to provide clinically assisted nutrition or hydration, the patient will continue to receive high-quality care, with any symptoms addressed.
115. If disagreement arises between you and the patient (or those close to a patient who lacks capacity), or you and other members of the healthcare team, or between the team and those close to the patient, about whether clinically assisted nutrition or hydration should be provided, you should seek resolution following the guidance in paragraphs 47 - 49.’
59. Ms B says clinicians removed Mr A’s fluids for several hours during one day of his hospital admission.
60. The Trust acknowledged a clinician’s instruction on the previous day was to continue slow intravenous fluid for Mr A.
61. The above sections of the guidelines say that providing nutrition or hydration in the form of IV fluids or a drip may be of benefit, but the evidence is not clear. It also says any decision not to provide this should be discussed with a patient or those close to them.
62. We can see from Mr A’s medical records that in early June, clinicians at the Trust prescribed slow IV fluids (intravenous fluids, liquids injected into a vein to prevent or treat dehydration).
63. Our adviser said clinicians would have prescribed this because Mr A could not drink, had evolving sepsis and at this time a diagnosis of chronic kidney disease (CKD, a type of kidney disease).
64. We can see Ms B discussed this issue with a clinician at the Trust as she had noted his fluids had stopped.
65. Mr A’s records show that fluids were interrupted for several hours in early June. We have not found any evidence that clinicians made a decision to stop IV fluids. Our adviser said that the interruption was likely to be a handover failure between staff changing shifts and not a conscious clinical decision to remove the fluids.
66. As the Trust did not plan to stop Mr A’s IV fluids, our adviser gave their view that clinicians did not act within sections 113 to 115 of the above guideline and is therefore an indicated failing in Mr A’s care.
67. As we can see indications clinicians at the Trust did not act within the above GMC guideline we the reviewed the impact this may have had on Mr A.
68. Ms B says as a result, Mr A may have died sooner than he should have.
69. We can see from Mr A’s medical records that he was receiving slow maintenance fluids, which are a gentle, continuous drip of fluid given through a vein to keep the body hydrated when a person can't drink enough.
70. The records show Mr A had extra fluid in his body (mainly in his abdomen and around his lungs) as a result of his low protein state. Our adviser said this low protein state was a natural consequence at this stage in his life.
71. Our adviser explained that the estimated amount of missed fluid was not clinically significant, as he had developing multiple organ failure. They said this would not have affected his outcome.
72. We hope Ms B is reassured that Mr A not receiving fluids for several hours did not have any clinical impact on him.
73. Ms B also told us she experienced significant distress as a result of all the issues she raised and now has PTSD. We are sorry this is her experience.
74. We think this would have been distressing for Ms B to witness Mr A not receiving the IV fluids. We also know his death and the days leading to it would have been very upsetting for her. We understand that losing a loved one is a very difficult time.
75. We acknowledge that not giving Mr A the fluids he should have had was a potential failing.
76. We do not think we would be able to link this individual issue to Ms B’s PTSD diagnosis or to significant long-term distress.
77. This is because we have seen the Trust corrected this within several hours. Any impact on Ms B would therefore be of short duration.
78. We know the last stage of Mr A’s life was a very difficult time for both him and Ms B. We do not think at the detailed investigation stage we would be able to link a clinical diagnosis of PTSD to this specific complaint issue. This is because it would not be possible for us to determine if Mr A’s death itself caused the PTSD and long-term significant distress Ms B experiences, or him not receiving fluids for several hours.
79. Considering the available evidence and advice received, our view is that there are indications clinicians failed to act in line with the above GMC guidance.
80. We do not however consider this indicated failing is linked to the claimed impact on Mr A as it did not affect his clinical outcome. We also do not think we would be able to link a PTSD diagnosis or significant distress for a lasting period of time to this complaint issue at the detailed investigation stage.
81. As we cannot link the indicated failing to the claimed impact on Mr A or on Ms B, we cannot take this issue forward to a detailed investigation. We will therefore take no further action on it.
Issue 5 – communication
82. Our principles say, ‘Public administration should be transparent and information should be handled as openly as the law allows. Public bodies should give people information and, appropriate advice that is clear, accurate, complete, relevant, and timely’.
83. Ms B says the Trust did not communicate with her about the severity of Mr A’s clinical condition.
84. The Trust said the medical team regularly updated Ms B throughout Mr A’s hospital stay. It said staff discussed his poor prognosis on admission and of the potential outcome for his condition to be terminal.
85. Our principles say that staff should give people information and advice that is clear.
86. We can see from Mr A’s medical records that on the day of his admission, clinicians spoke with Ms B to gain Mr A’s recent history of feeling unwell.
87. On the day after Mr A’s admission, we can see that clinicians spoke with Mrs B and told her, ‘He might not survive this admission due to advanced frailty/co-morbidities [different health conditions which are present at the same time], worsening CKD and sepsis’. The clinician recorded that Ms B, ‘understood the management plan and happy with update’.
88. We can also see from Mr A’s medical records that on the same day Ms B spoke with staff at the hospital as she was not happy with the ‘palliative approach’. We can also see a staff member told her this approach was ‘to make sure that if he did not respond to treatment, he will be given comfort and free from pain’. In addition, the same clinician also told her Mr A was ‘currently on active treatment’ which included antibiotics.
89. We can also see several days later a clinician recorded, ‘seen NOK [next of kin, Ms B]. Informed about the diagnosis, which she is aware, thinks pt [patient] is looking better’.
90. The day after this, we can see from Mr A’s medical records that a clinician wrote that they spoke ‘to NOK and explained once again that pt has pneumonia and on antibiotics and also showed X-ray. Infection markers going down but it also affecting his kidneys. Also informed that his prognosis is poor’.
91. After reviewing the evidence, we can see that from very early stages in Mr A’s admission, staff regularly discussed his condition, the severity of it and that his prognosis was poor with Ms B.
92. We can see that the information was clear and given regularly to Ms B as Mr A’s clinical condition evolved.
93. As such we can see clinicians at the Trust acted in line with our principles and have found no indications of failings in staff communication with Ms B about the severity of Mr A’s clinical condition.
94. We know Mr A’s death will continue to have an on-going impact on Ms B and we are very sorry for her loss. We hope our investigation has answered some of the concerns she may have had surrounding the care and treatment he received in his final days.