Failed to provide the appropriate care and treatment following her admission to the ED on 2 October 2023
14. Miss M says the Trust discharged her mother home the same day with a diagnosis of constipation and a recommendation to take laxatives. She says when her mother went back to the ED on 7 October 2023 she was diagnosed with a perforated bowel and died 2 days later. Miss M says her mother’s perforated bowel should have been identified at this earlier attendance at the ED.
15. 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.’
16. The records indicate when she attended the ED on 2 October 2023 Mrs M described cramp like lower abdominal pain which had started 4 days earlier. The records of the ED triage assessment state Mrs M reported less bowel output than normal (small, hard stools) and a pain score of 6 out of 10. The records indicate the doctor performed a thorough examination of Mrs M and noted her abdomen was mildly distended (enlarged) but soft with no areas of tenderness.
17. The Trust recorded her clinical observations (respiratory rate, oxygen saturation levels, heart rate blood pressure, temperature etc) and noted they were all within the normal range. The Trust also completed a National Early Warning Score (NEWS2, a scoring tool used to identify critically unwell patients using clinical observations) which provided a score of 0, indicating she was at low risk of clinical deterioration. The Trust performed blood tests which, although highlighted slightly raised inflammatory markers (CRP of 25), provided no evidence of infection or perforated bowel.
18. The records indicate following the assessment and tests the doctor felt Mrs M’s symptoms were due to constipation and recommended she be discharged home, take laxatives, arrange a follow up consultation with her GP and come back to the ED if her symptoms worsened.
19. Our ED adviser said the information in the records supports the diagnosis of constipation reached by the Trust and the diagnosis is consistent with Mrs M’s recorded symptoms, her clinical condition at that time and the results of the examination and tests performed by the Trust. Our ED adviser said the records indicate Mrs M did not show any clinical signs of bowel perforation or sepsis during this attendance.
20. The NICE constipation guidance says:
‘The aim of management of faecal loading and/or impaction is to achieve complete disimpaction with minimal discomfort.
Following an assessment:
If there are hard stools, consider prescribing a high dose of an oral macrogol (a type of laxative). If there are soft stools, or ongoing hard stools after a few days of treatment with an oral macrogol, consider starting or adding an oral stimulant laxative.
A mini enema such as docusate (softener and weak stimulant) or sodium citrate (osmotic).
Reinforce advice on lifestyle measures such as increasing dietary fibre, fluid intake, and activity levels, to help maintain regular bowel movements and prevent recurrent faecal loading.
Consider the need for regular laxative use to maintain regular bowel movements, or the use of intermittent laxatives for episodes of faecal loading. Arrange to review the person every few days to assess the response to treatment, depending on clinical judgement.’
21. In their report to the coroner the Trust’s ED doctor said they treated Mrs M with intravenous (IV) fluids and paracetamol and performed an enema. However having reviewed the information in the records we have seen no evidence of this treatment being provided. The Trust’s account also contradicts the account provided to us by Miss M who was present with her mother throughout this attendance. Miss M says no treatment was provided to her mother at any time during this attendance.
22. Our ED adviser said IV fluids, paracetamol and an enema would be a reasonable treatment plan for a patient presenting with abdominal pain and constipation and such treatment would be consistent with the GMC and NICE constipation guidance. However there is no evidence in the records this treatment was provided by the Trust to Mrs M. There is no record of any of treatment written in the doctor’s assessment plan or in the treatment section of the ED notes in the records.
23. There is no evidence in the records to indicate Mrs M’s condition improved in the ED and no record of her being re-assessed or re-examined by the Trust following the diagnosis. In their report to the coroner the Trust’s ED doctor said Mrs M felt much better when she was discharged however there is no evidence in the records to support this.
24. We carefully considered Miss M’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 it was appropriate for the Trust to diagnose Mrs M with constipation. However, having made this diagnosis we think, in line with the GMC guidance and the NICE constipation guidance, the Trust should have provided treatment with pain relief medication, IV fluids and an enema before discharging Mrs M home. We found no evidence the Trust provided any of this treatment. We consider this to be a failing.
25. When considering the impact this failing had on Mrs M we have looked at her second attendance at the ED 5 days later. When Mrs M returned to the ED on 7 October 2023 the Trust performed a CT scan and identified a perforated diverticulitis. This occurs when small pouches known as diverticula form in weak spots in the wall of the intestine, a condition known as diverticulosis.
26. Diverticulosis is a common condition and most people will develop some degree of diverticulosis as they get older. The likelihood increases with age and studies suggest it affects approximately 30% of individuals aged over 50 and 75% of individuals over 80. Constipation can be a symptom of diverticulosis, however some individuals can have no symptoms and may not know they have it.
27. Diverticulitis is when the diverticula become inflamed or infected and it can cause symptoms such as abdominal pain, fever, changes in bowel habits including constipation and perforated bowel. Perforated diverticulitis occurs when one or more diverticula become inflamed and rupture, creating a hole in the wall of the intestine allowing contents to leak into the abdominal cavity. This can lead to severe, life-threatening infection which requires urgent treatment.
28. In Mrs M’s case a section of her sigmoid colon (the lower part of the large intestine) was affected by diverticulitis which had caused a hole to appear in the wall of her intestine. The purpose of the surgery performed by the Trust on 8 October 2023 was to identify and remove that section of her intestine and it was successful in doing so.
29. It is not possible to say from the evidence precisely when the perforation happened or what caused it. It was not evident during the attendance on 2 October 2023 but it was evident during the attendance on 7 October 2023. During the 5 day period in between Mrs M was at home and there is no evidence we can review which would enable us to provide a view, even on balance of probabilities, when the perforation happened or what caused it.
30. Chronic constipation and the presence of hard stools may increase the pressure within the intestine. However a perforated bowel is a recognised complication of diverticulitis and the condition can cause the colon wall to rupture by itself due to the effect the infection or inflammation during a flare up has on weakening the bowel wall.
31. For this reason we cannot say, even on balance of probabilities that the failure to provide Mrs M with IV fluids, paracetamol and an enema caused her to suffer a perforated diverticulitis. We also cannot say, even on balance of probabilities that it would not have happened if the Trust had provided this treatment during her attendance at the ED on 2 October 2023.
32. Although we cannot say the treatment would have prevented Mrs M’s condition from deteriorating in the days that followed, we think it would have helped ease Mrs M’s symptoms at that time and provided her with some degree of comfort. We acknowledge that this leaves Miss M with doubt, which we cannot now resolve, about the impact any treatment may have had on her mother’s condition at this time. This in itself is an injustice.
Failed to diagnose her perforated bowel and arrange emergency surgery quickly enough following her admission to the ED on 7 October 2023
33. The records indicate Mrs M attended the ED for a second time at 3.52pm on 7 October 2023. She reported continuation of her constipation despite taking laxatives and she had experienced vomiting. The records indicate she had a high heart rate, rapid shallow breathing, a cough and she reported being in severe pain. The Trust completed a NEWS2 which provided a score of 7, indicating she was at high risk of sepsis and clinical deterioration.
34. The examination performed by the doctor identified crepitations (abnormal crackling sounds heard through a stethoscope) in both lungs and a distended abdomen. The records indicate the Trust performed an electrocardiogram (ECG, a test to record the electrical activity of the heart) blood tests and requested a chest x-ray. The Trust recorded a differential diagnosis (consideration of various potential conditions that may be causing a patient’s symptoms) of chest sepsis or subacute bowel obstruction (subacute meaning not sudden). The Trust provided treatment with IV fluids and antibiotics and referred Mrs M to the inpatient medical team for further management at 5.55pm.
35. The Trust performed the chest x-ray at 6.15pm and Mrs M was reviewed by the consultant physician in the inpatient medical team at 8.00pm. The records indicate the physician felt her symptoms were abdominal (they note absent bowel sounds) and required surgical intervention. The physician requested abdominal imaging and a review from the Trust’s surgical team. The Trust performed an abdominal x-ray at 8.15pm and Mrs M was reviewed by the surgical specialist registrar (SSR) at 9.06pm.
36. The records indicate the SSR felt the primary source of Mrs M sepsis infection was from her chest but a CT scan of her abdomen would be required to investigate whether it was linked to her abdominal symptoms. The abdominal CT scan was performed at 9.22pm and reviewed by the surgical team at 10.02pm. The CT scan identified a perforated diverticulitis in Mrs M’s sigmoid colon.
37. The Trust transferred Mrs M to theatre and carried out her pre-anaesthetic assessment at 11.30pm. The surgery to remove the affected area of her intestine commenced at 12.22am on 8 October 2023. Following surgery Mrs M was taken to the intensive care unit (ICU) but her condition continued to deteriorate due to sepsis and multi-organ failure. Mrs M sadly died on 9 October 2023.
38. Our ED adviser said Mrs M was promptly assessed on arrival in ED and IV fluids and antibiotics were administered within 100 minutes of her arrival. It is clear from the records that the Trust identified Mrs M was significantly unwell from the outset with symptoms and signs of sepsis. Our ED adviser said it can be difficult to establish the source of sepsis in such instances, particularly when a patient has pre-existing co-morbidities (existing medical conditions that coexist alongside a primary diagnosis) and a combination of symptoms (in Mrs M’s case, her abdominal symptoms along with her chest symptoms, lung crepitations, cough and rapid, shallow breathing).
39. The records indicate the cause of Mrs M’s deterioration was initially attributed by the Trust to chest sepsis rather than bowel perforation and for this reason the ED doctor referred her to the medical team first rather than the surgical team. Following a review the physician in the medical team referred Mrs M to the surgical team who managed her investigations and care from that point on.
40. Our ED adviser said as Mrs M was noted during her triage and medical assessment to be experiencing severe abdominal pain with associated vomiting and distended abdomen, it would have been appropriate, and in line with the GMC guidance, to refer her directly to the surgical team rather than the medical team. Referring her to the medical team first is likely to have caused a delay in her assessment by the surgical team of approximately 1-2 hours.
41. Our ED adviser said due to Mrs M’s symptoms and the differential diagnosis of bowel obstruction, it would have been appropriate and in line with the GMC guidance for the Trust’s initial investigations to have included an abdominal x-ray or abdominal CT scan. Our ED adviser said an earlier abdominal x-ray, performed at the time of the initial chest x-ray, would have prompted an earlier referral to the surgical team.
42. Our physician adviser agreed with our ED adviser and said it is clear in the records when she was first assessed in the ED that Mrs M was unwell and with abdominal problems. Our physician adviser said they accept that her clinical picture was complicated by her chest symptoms, which may have been thought to be the main problem and drawn attention away from her abdominal problem.
43. However her abdominal symptoms (severe abdominal pain, persistent vomiting, no bowel opening for more than a week), her abdominal signs (distended abdomen, absence of bowel sounds), her NEWS2 score of 7 and the results of her blood tests (raised lactate in her venous blood gas) would have made it appropriate and in line with the GMC guidance for the Trust to arrange an urgent CT scan of her abdomen.
44. The records show the Trust scored Mrs M as 7 when completing her NEWS2 during her triage in the ED. The RCP NEWS2 guidance states if a patient scores 7 or above the Trust should consider transferring them to a level 2 or 3 facility such as ICU or a Higher Dependency Unit. The records provide no evidence to indicate the Trust considered transferring Mrs M’s care to a level 2 or 3 facility and she is only transferred to the ICU after her surgery. Our physician adviser said it would have been in line with the RCP NEWS2 guidance for the Trust to consider transferring Mrs M to ICU or a higher dependency unit earlier.
45. The NICE perforated diverticulitis guidance says:
‘Management of bowel perforations
Offer either laparoscopic lavage or resectional surgery to people with diverticular perforation with generalised peritonitis after discussing the risks and benefits of the 2 options with them (see table 3). If faecal peritonitis is identified intraoperatively, proceed to resectional surgery.’
46. The emergency surgery guidance recommends surgery as soon as possible and sets an estimate for surgery to start within 2 hours of the decision to operate being made. The NCEPOD guidance gives the following advice for surgery deemed urgent:
‘URGENT – Intervention for acute onset or clinical deterioration of potentially life-threatening conditions, for those conditions that may threaten the survival of limb or organ, for fixation of many fractures and for relief of pain or other distressing symptoms. Normally within hours of decision to operate.’
47. Our surgeon adviser said once the diagnosis of bowel perforation was made at 10.02pm the surgery was organised very quickly in line with the emergency surgery guidance and the NCEPOD guidance. The records indicate Mrs M was in the surgical department for anaesthesia at 11.30pm and in the operating theatre shortly after midnight.
48. Our surgeon adviser said due to the perforation of her diverticulitis, the only treatment options available to Mrs M were surgery to remove the affected area of her intestine or conservative treatments such as pain relief, antibiotics and treatment to keep her as comfortable as possible. Surgery for a perforated bowel in a high risk patient such as Mrs M carries a high risk of mortality and the records indicate the consultant surgeon had a ‘frank’ discussion with Mrs M and her relatives about the risks, in line with the NICE perforated diverticulitis guidance, before confirming the surgery could go ahead.
49. The purpose of the surgery was to identify and remove the section of intestine that had perforated. Our surgeon adviser said this was entirely appropriate for Mrs M’s condition and consistent with the GMC and NICE perforated diverticulitis guidance. The records indicate the surgery was completed appropriately and was effective in removing the cause of the perforation and infection.
50. Our surgeon adviser said there is no evidence in the records to indicate Mrs M would not have died had the surgery been performed earlier during this admission. Our surgeon adviser said, on balance of probabilities, due to the severity and nature of her condition at this time, surgery earlier on this admission is unlikely to have made a difference to her outcome.
51. We carefully considered Miss M’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 acknowledge how upsetting this incident was for Miss M and her family.
52. We found the Trust did not act in line with the GMC guidance when considering Mrs M’s abdominal problems. We also found the Trust failed to consider referring Mrs M to the ICU or higher dependency unit during this admission.
53. The failings led to a delay of between 1 to 2 hours in the Trust referring Mrs M to the surgical department, diagnosing her perforated bowel and arranging her surgery. We found the surgery was completed appropriately and in a reasonable timeframe once the diagnosis was made. We found the surgery successfully removed the affected section of Mrs M’s intestine.
54. We do not think the failing led to the impact claimed by Miss M. We found no evidence to indicate Mrs M’s outcome would have been different had the failings not occurred and the surgery performed 1 or 2 hours earlier. However we think the Trust missed an opportunity to provide Mrs M with the treatment she needed sooner during this attendance.
Failed to diagnose sepsis and provide treatment quickly enough following her admission to the ED on 7 October 2023
55. The sepsis screening tool recommends screening be completed if sepsis is suspected.
Mrs M attended the ED at 3.52pm on 7 October 2023 and the records indicate the Trust completed the sepsis screening tool at 4.20pm, less than 30 minutes after her arrival.
56. The screening tool says once an assessment is started and the patient is found to have a NEWS2 score of 7 or above, the medical team should record the patient as high risk and start ‘Sepsis Six’ which are six specific actions that need to be done. The six actions are:
• Inform senior clinician • Give oxygen if required • Send bloods including cultures • Give IV antibiotics • Give IV fluids • Monitor
57. Our physician adviser said the records support the view the Trust suspected sepsis from the outset due to Mrs M’s symptoms. Sepsis is one of the conditions referenced in the Trust’s differential diagnosis in the ED at the beginning of this attendance. The records indicate the Trust identified Mrs M as high risk and performed investigations and provided care consistent with the GMC guidance and the sepsis screening tool.
58. The sepsis screening tool states the actions in the ‘Sepsis Six’ should be completed within an hour. However the records indicate, although completed fairly promptly, the Trust did not complete all of these actions within the hour. Initial antibiotic treatment was provided at 5.55pm and additional treatment for sepsis was provided at 6.43pm. Our physician adviser said while aiming to achieving these actions within an hour would be the ideal, and possible in some medical settings such as an inpatient ward or ICU, it is very challenging and often difficult to achieve in a busy ED environment such as in this case.
59. In its complaint response the Trust has acknowledged it did not complete all the actions within the recommended hour. The Trust said:
‘It was a complex presentation, and it is often difficult to reach accurate diagnosis on first assessment. While there were some delays in initiating IV antibiotics for sepsis, of an hour, and taking her to theatre, in hindsight unfortunately it would not have changed the outcome’.
60. Our physician adviser there is no evidence in the records to indicate there was any additional care and treatment the Trust could have provided to Mrs M which may have prevented her condition from deteriorating. There is no evidence in the records to indicate completing the actions from the ‘Sepsis Six’ quicker would have made any difference to Mrs M’s condition or her outcome.
61. We carefully considered Miss M’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 acknowledge how upsetting this incident was for Miss M and her family.
62. We found the Trust acted in line with the GMC guidance and the sepsis screening tool when assessing Mrs M for sepsis and providing treatment. We acknowledge the Trust carried out the ‘Sepsis Six’ actions outside the recommended hour and the Trust has recognised this. We do not consider this to be a failing that has led to an injustice for Mrs M. We found no evidence the length of time taken to diagnose and treat sepsis was unreasonable or detrimental to Mrs M’s condition.
63. The records support the view the Trust considered sepsis as a diagnosis from the outset, performed the appropriate tests and provided the appropriate treatment in a reasonable timeframe. For this reason we think the Trust acted in line with the GMC guidance and identified the symptoms and signs of sepsis and provided treatment in a reasonable timeframe.