February 2022 discharge
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 here.
17. GMC ‘Good medical practice’ says when doctors provide clinical care, they must prescribe drugs or treatment only when they have adequate knowledge of the patient’s health. They must also be satisfied that the drugs or treatment serve the patient’s needs.
18. Mrs W attended the ED on the 24 February with a painful knee and difficulty in walking. She underwent a clinical examination which confirmed a reduced range of active movement, her passive movement had not reduced. This means Mrs W was not able to move her joint independently as well as before, but it did move well using an outside force.
19. Our adviser explained some of Mrs W’s blood tests were abnormal and showed evidence of inflammation in terms of a raised white cell count and C-reactive protein (CRP, an infection marker). Her serum urate, which causes crystals to form in joints when levels are high, was below the level NICE NG219 advises is helpful in the diagnosis of gout.
20. The doctors wanted to confirm a diagnosis of gout or pseudogout (chondrocalcinosis) and rule out an infective cause by aspirating Mrs W’s knee joint. This was in line with NICE NG219 but Mrs W declined this. The team gave her treatment to cover for gout or pseudogout and arranged for a review three days later in order to try and aspirate her knee at that time.
21. The X-ray performed at the time confirmed the diagnosis of chondrocalcinosis or pseudogout (the presence of calcium crystals in the joint). Mrs W was therefore given the correct treatment, in line with the guidance set out above.
22. Our adviser said it appears the Trust went above and beyond to persuade Mrs W to have the aspiration done and arrange for appropriate follow-up. There was no indication at this time of any systemic infection or respiratory issues. We have seen no indication of a failing here.
March 2022 discharge
23. Mrs W attended the Emergency Department on two occasions in March. She was discharged on the first occasion and admitted on the second.
24. On 3 March Mrs W arrived in the ED complaining of shortness of breath, accompanied by a dry cough and temperature. She had also vomited once and her observations showed she had a slight oxygen requirement. The Trust carried out a chest X-ray which was interpreted as showing right sided consolidation and an effusion.
25. Given Mrs W’s history, this finding was interpreted as a lower respiratory chest infection and the Trust started her on intravenous antibiotics. Mrs W appears to have been referred to the medical registrar initially due to the oxygen requirement she had. This was subsequently weaned down and so the medical and ED team advised that she could go home on oral antibiotics.
26. The official report of Mrs W’s chest X-ray, four days later, advised the heart was enlarged compared to that in 2023 and she had bilateral pleural effusions, worse on the right side. This was suspected to be due to heart failure or infection and correlation with inflammatory markers was advised.
27. While there is no evidence from the notes that any further action was taken based on this report, the Trust told us the inpatient medical team had interpreted the findings at the time. We hope it helps Mr W to know a chest X-ray did take place.
28. NICE NG138 says people with community-acquired pneumonia should be offered an antibiotic, taking account of the severity. The guidance says this should be based on clinical judgement and guided by the CURB 65 score. This is used in hospital to assess 30day mortality risk in adults with pneumonia. Anyone scoring 3 or more requires urgent admission.
29. The CURB65 score is calculated by giving one point for each of the following prognostic features: (confusion, urea more than 7 mmol/litre, respiratory rate 30/minute or more, low systolic [less than 90 mmHg] or diastolic [60 mmHg or less] blood pressure, age 65 or more). A score of 0 or 1 means low risk, 2 is intermediate risk, 3 to 5 is high risk.
30. Contrary to the guidance, there is no evidence the Trust calculated this score. Using the Trust’s records, our adviser said Mrs W’s respiratory rate was not elevated and her blood pressure was not low. She was under 65, so her maximum CURB65 score was therefore probably 2. This means that she could have been discharged with follow-up.
31. We recognise, given Mrs W’s score of 2, the Trust could have considered further investigations including blood and sputum cultures, and pneumococcal urine antigen test. We understand there was no guidance in place at the time recommending this. We are therefore not critical of the Trust for considering or arranging these investigations.
32. Before we decide if we should conduct a detailed investigation of a complaint, we look at whether there are signs the events complained about had a negative effect which the organisation has not put right. Having done so we cannot link the events complained about with the negative impact Mr W has claimed.
33. We recognise it is possible that Mrs W may have benefitted from an inpatient admission or close outpatient follow-up with further microbiological investigations. However, these investigations appear to have been done at the time of her admission on 19 March. Our adviser noted it is therefore unlikely that this would have changed any outcome for Mrs W.
34. Our adviser explained the Trust’s working diagnosis during the later admission was of pulmonary oedema and infection. Mrs W was treated on Bipap, a non-invasive form of ventilation, to help with her breathing. She was also given intravenous furosemide, which is a diuretic designed to reduce the fluid present in the lungs.
35. The Trust carried out a chest X-ray which confirmed the diagnosis of pulmonary oedema and infection. Mrs W responded to the treatment well in the ED, and her oxygen requirement dropped. With this in mind, we have decided not to look into this part of the complaint further. This is not intended to detract from what was clearly a challenging time for Mrs W’s family.
April 2022 pneumonia
36. Mrs W’s final attendance on 4 April was due to worsening shortness of breath over a few days and increasing oedema to the legs. Mrs W’s observations were relatively normal apart from an elevated blood pressure. The Trust treated her for pulmonary oedema and administered furosemide.
37. The assessing doctor documented that they wanted to rule out infection. This was in line with GMC ‘Good medical practice’ which says doctors must adequately assess patients and promptly provide or arrange investigations or treatment, where necessary.
38. The Trust performed a chest X-ray and interpreted this as showing an improved picture. There was a reduction in the pleural effusion (a collection of fluid next to the lung) but with vascular prominence (where the blood vessels appear more enlarged than normal).
39. Mrs W’s blood pressure reduced following the furosemide and the Trust documented that she was keen to go home. The Trust arrange follow-up for her in four days in its Same Day Emergency Care service (SDEC). No change was made to her furosemide dosing.
40. It is not clear if the Trust based its decision not to repeat blood tests and not to give antibiotics on the blood results at the time. The official report of the chest X-ray said it showed florid pulmonary oedema and possibly infection.
41. Our adviser said the Trust’s arrangement of follow-up care would have allowed for review of Mrs W’s investigations and current treatment. This may have allowed for a change in medication and commencement of antibiotics, depending on the results.
42. GMC ‘Good medical practice’ says doctors must respect a patient’s right to reach decisions about their treatment and care.
43. We are unable to say something went wrong on this occasion, or that any of the care we have looked at led to Mrs W’s deterioration. We note the April attendance was nearly two months before Mrs W’s death.
44. Overall, we have seen no reason to justify investigating the complaint further. We hope our investigation reassures Mr W about the care his mother received.