The Trust failed to identify Mrs X was suffering from a bowel obstruction when she attended A&E on 10 May 2022
25. Mrs X’s concern about 10 May 2022 is that, if a CT scan (or some other investigations), had been done on that day, her bowel obstruction may have been identified sooner and the events of 11 May 2022 onwards avoided.
26. Mrs X arrived at A&E with a history of several days of vomiting, upon examination she appeared well but had a soft but tender feeling upper abdomen and reported having opened her bowels and having normal stools. A blood test showed raised inflammatory markers, raised white blood cell count (WCC), low sodium, but normal kidney function and electrolytes.
27. Upon arrival, her initial NEWS score (a system based on clinical observations indicating need for medical attention) was 7, indicating a medium to high risk. Mrs X was prescribed IV fluids and anti-vomiting medication. Following this therapy her NEWS score dropped to 2 (low risk). This indicates she responded well to treatment, and her clinical need had sufficiently lowered by the time of discharge to indicate this was safe to do so.
28. ‘RCEM Learning – Bowel Obstruction’ guidance sets out research from an observational study of patients with acute mechanical bowel obstruction. This reported that an absence of the passage of gas (90%) and/or faeces (80.6%) was the most common presenting symptom, with abdominal distension (65.3%) being the most common physical finding.
29. Mrs X had an absence of abdominal bloating, a soft abdomen, was still passing stool and had responded to therapy. In that event, we see it is reasonable not to have suspected a bowel obstruction and have ordered a CT scan on 10 May 2022. Our ED adviser noted that that the trigger for ordering a CT scan the day after was elevated blood markers not present in the previous day’s results. This was only reasonable to suspect once those clinical signs appeared. As such we see it would have been difficult to clinically justify ordering a scan any earlier.
30. Our ED adviser said that the Trust initially concluding Mrs X was likely to be suffering gastroenteritis (a stomach bug) was reasonable in the circumstances. They explained that ‘NICE CKS – hyponatraemia’ guidance outlines how vomiting and diarrhoea can result in dehydration, which in the absence of abnormal kidney function, would account for much of the initial blood test result. This along, with her raised WCC in her presentation, would be consistent with an infective cause as key indicators of a bowel blockage were absent.
31. Based on the available evidence on 10 May 2022, there appears to be nothing present which should have raised suspicion of a bowel obstruction during Mrs X’s first attendance. The telltale signs first appeared the next day. Our radiology adviser also confirmed the CT scan the next day definitively shows a bowel obstruction, probably caused by adhesions. They said there is no evidence of additional inflammation or malignancy, and this indicates a very recent blockage developing. We see this also supports the narrative of this being an acute emergency that only fully developed after Mrs X left hospital on 10 May 2022.
32. Our ED adviser did note that the inflammatory markers in the blood results may have presented an opportunity to keep Mrs X in and keep her under observation. We can therefore understand why she is unhappy this was not what happened. However, they were clear this is not a failing, as Mrs X’s acute deterioration occurred later, between leaving hospital on 10 May 2022 and returning the next day.
33. In their view, if Mrs X had been in hospital at the time this happened, it may not have altered the outcome for her, as the bowel obstruction and its consequences would have been no less likely to happen. Our ED adviser said it was not predictable that she would present with such a sharp deterioration the next day. Essentially, its presence (and so an opportunity to act) would not have been revealed any sooner. Taking this advice into consideration, we found it likely there was a sudden change in her condition, due to her bowel becoming fully obstructed, and it was not possible to anticipate or prevent this day before.
34. We can understand why Mrs X will have been concerned an earlier admission may have altered later events for her, especially since it may have been possible to justify keeping her in for observation overnight (though not expected). The Trust appears to have acted consistently with the available guidance, there was nothing initially missed which could have helped predict her bowel obstruction, and the clinical decisions appear reasonably supported.
35. We found no evidence to indicate Mrs X was suffering from a bowel obstruction on 10 May 2022. As such, there is no indication of the Trust missing one, or missing warning signs of an obstruction occurring in the near future.
The Trust failed to address and prevent the risk of sepsis then or when she reattended the next day
36. A key point in Mrs X’s complaint is that, on 11 May 2022, her lactate was 9, which is a red flag for suspecting sepsis (Lactate is a term for the concentration of lactic acid in the bloodstream). She says the Trust did not do enough to prevent sepsis.
37. We can see this concern is reasonable as this is correct, and we note her medical records contain a Sepsis Trust checklist which highlights high lactate is a red flag (>6 is considered severe and a concern). We note Mrs X had, a lactate at discharge of 2.7 on 10 May 2022. This indicates there was no red flag for sepsis the prior day. Her lactate level increased later.
38. Mrs X had lactate of 9.1 on her initial blood results when attending A&E on 11 May 2023. This would be sufficient clinical information to suspect sepsis. High lactate is an indication that the body is not getting enough oxygen into the bloodstream, one cause of which can be sepsis, but there are other potential causes. What we would expect to happen in this situation is for the Trust to cover the risk of Mrs X having sepsis.
39. NICE NG51 and Sepsis Trust guidance sets out that, in the event that a patient is suspected to be suffering from sepsis, they should be given antibiotics and IV fluids within one hour of that concern arising. Mrs X was prescribed IV fluids and her first dose of antibiotics at 5.52pm. The medical records do not contain information on the exact time the result of high lactate was known about, so it is not possible for us to establish if the hour timeframe was met.
40. Importantly the notes from Mrs X’s bowel surgery, on 13 May 2022, state ‘no ischaemic bowel or intra-abdominal sepsis’. Ischaemia (loss of blood flow to the bowel) is another known cause of high lactate. If this was not present this suggests another cause, possibly sepsis, for the earlier high lactate. However, the note confirms there was no sign of sepsis by the time of the operation two days later. This is reassuring.
41. It was never confirmed that Mrs X had in fact suffered sepsis. Sepsis is an extreme bodily reaction to infection. There is an absence of any evidence of any infection from the obstruction that could lead to sepsis, but Mrs X does seem to have suffered hypovolemic shock, which can also lead to high lactate levels. This is a type of shock caused due to fluid imbalances, in this case caused by her bowel obstruction and vomiting leading to excessive dehydration.
42. From this we think, on balance of probability, that it is more likely than not that the intervention with IV fluids and antibiotics was timely and effective to address the cause of the high lactate levels. This had been swiftly addressed by the time of surgery with no lasting ill effects identified in the surgical notes.
43. We can understand why Mrs X may have been concerned about a delay in action increasing her risk of sepsis. What we found is that possibility was considered, and covered for, but her condition was more likely to have been due to septic shock from dehydration than sepsis. We found the Trust did what it should have to address and prevent the risk of sepsis upon Mrs X returning to A&E on 11 May 2022.
The Trust inappropriately sent her to a surgical ward instead of ICU, leading to her becoming critically unwell and needing to be placed on a ventilator
44. Mrs X says she was moved to Resuscitation upon arrival on 11 May 2022, and was reviewed by the Intensive Care Unit (ICU) but not accepted for moving there as the ICU claimed her high lactate was from dehydration. She says the Surgical Assessment Unit (SAU) would not accept her due to her unstable observations and high NEWS score, so she remained in Resuscitation overnight. She says she was only moved to the SAU at 4am on 12 May. Her concern is that her deterioration may have been avoidable if she had been in the right place for her needs.
45. Mrs X was moved on to the Trust’s Department of Critical Care from 11am on 12 May 2022. Her records prior to this show regular input from the Intensive Care Team and Critical care. The Trust’s information on its Critical Care services indicates the DCC provides level 2 and 3 care. Level 2 would be intensive care and high dependency care according to Intensive Care Society ‘Levels of care’ guidance.
46. Therefore, we see that each area Mrs X was cared for on could meet her needs. Each had access to critical care and intensive care resources prior to her surgery. Advising her that her high lactate was from dehydration would also be consistent with a patient who is showing signs of hypovolemic shock.
47. Mrs X deteriorated on 13 May 2022 and then was placed on a ventilator and taken to surgery shortly after. While we appreciate she may feel this may not have happened if she had been cared for in a different area, the sequence of events indicates this is not the case.
48. Mrs X was identified as having a bowel obstruction on 11 May from her CT scan. The exact cause of this was not clear from the scan but the working diagnosis was that this was probably due to adhesions from her prior hysterectomy surgery. However, it was not possible to definitively know this from a scan. There was a small possibility that another temporary cause, such as faecal blockage, was present and the obstruction may clear once she had been rehydrated with IV fluids and had received other treatment. A period of conservative management for at least 24 hours was planned to cover this eventuality. The only alternative would be major abdominal surgery.
49. Due to this uncertainty, we can see it was a reasonable clinical decision to wait for a period to allow for the chance of avoiding surgery if possible. As it turned out, the obstruction was found to be due to adhesions later, but this could not have been known at the time, before surgical intervention.
50. The records show Mrs X was being prepped for surgery as early as 6.35am on 12 May 2022 according to anaesthesia records from that time. This shows that planning was in place for both eventualities. Her medical notes prior to being taken for surgery indicate all efforts were being made to manage her care conservatively, but that the team was ready to move her to theatre if this proved unavoidable.
51. Mrs X collapsing on 13 May, while undesirable, confirmed the Trust could wait no longer to see if the obstruction could resolve naturally. This now removed the concern of potentially operating on her only to find a cause that would render surgery unnecessary. Unfortunately, a bowel obstruction from adhesions would require surgical intervention so this (and therefore being placed on a ventilator) appears to have been inevitable, in hindsight. While Mrs X required ventilating earlier due to her collapse, she would have been ventilated shortly later anyway. The obstruction was never going to resolve naturally without surgical intervention, although that could not be known at that time.
52. In addition to this, our ED Adviser said the care in the lead up to Mrs X’s surgery was satisfactory and fully in line with NICE NG51 ‘Suspected sepsis: recognition, diagnosis and early management’ and CG174 ‘Intravenous fluid therapy in adults in hospital’ guidelines. This indicates her care was of a suitable standard irrespective of which ward or area she received care in the time leading up to her surgery.
53. We are unable to identify any alternative intervention that would have addressed the cause Mrs X of being acutely unwell. In short, her bowel was obstructed by scar tissues that needed to be physically separated, and while there initially was some hope of fixing this without major surgery as it was not possible to know this at first, this eventually had to be resorted to in order to prevent her death.
54. We found no evidence to suggest Mrs X could have avoided being placed on a ventilator or needing emergency surgery, but there was reasonable justification for waiting for a period before proceeding. Her underlying problem required surgery, and this was organised without delay once there was sufficient confidence this was the only remaining option.
The Trust failed to communicate effectively what was going on and communication was often contradictory from previous updates
55. GMC Good Medical Practice guidance on ‘Sharing Information with Patients’ and ‘Communicating with those Close to a Patient’
‘The exchange of information between medical professionals and patients is central to good decision making. You must give patients the information they want or need in a way they can understand. This includes information about: • their condition(s), likely progression, and any uncertainties about diagnosis and prognosis • the options for treating or managing the condition(s), including the option to take no action • the potential benefits, risks of harm, uncertainties about, and likelihood of success for each option.
‘You must be considerate and compassionate to those close to a patient and be sensitive and responsive in giving them support and information.’
56. There are extensive notes covering Mrs X’s care from her initial admission in May through to September 2022. This shows evidence of regular and accurate (in relation to the events we have established in this report) updating of Mrs X with daily discussion, and her family members at key points.
57. From these notes it is possible to see that there was some uncertainty about how Mrs X was progressing. Unfortunately, several times unanticipated complications interrupted her recovery and required intervention and a change of course. We appreciate clearer communication on what was happening on was sought by Mrs X and her family, and that there was reasonable effort made to keep them updated on developments. We also think it is fair to recognise that while communication can always be improved upon, the standard we should judge the Trust on is whether the key important information is shared at the appropriate times.
58. Generally, there is enough detail in the level of day-to-day communication documented to support it being in line with GMC Good Medical Practice guidance. What is recorded in the records of discussions is not inaccurate in relation to the facts of events as we see them. We recognise that the necessity for a conservative approach to care, and the many uncertainties on what would happen next, may have been perceived as indecisiveness. We note there were key updates from senior staff at certain points to try and address these concerns and clarify the situation.
59. Between 13 and 18 May 2022 following her initial surgery, the records show daily detailed updates provided on Mrs Xs progress to her family. Important updates are also documented following key events including her diagnosis of ulceration, dealing with her bleed, the diagnosis of her stricture, and the process of exploring the different options to resolve this later.
60. On 18 August 2022 a consultant surgeon spoke to Mrs X’s daughter in detail about her concerns regarding recent events relating to medication and care. The notes show she was updated on how the stricture was developing, the need to wait for MDT input and advice from Sheffield, and the possibility of surgery if other less invasive solutions had not worked given sufficient time.
61. We recognise this update was during the absence of Mrs X’s original surgeon and following some inconsistent messaging due her daughter speaking to different doctors on what was happening. We accept the messaging was inconsistent for that period prior to this the update on 18 August, but not the extent that it failed to meet the GMC standard. The communication was not ideal but was sufficient to provide an accurate picture of where Mrs X’s progress was at each point, and the level of uncertainty. The need to monitor and proceed cautiously was explained.
62. In addition to this there is also evidence of email exchanges between Mrs X’s daughter and her consultant surgeon between 23 and 31 August, where the possible routes forward were further explained and, following the outcome of the local and regional MDT’s, the plan to finally resort to surgery and the reasons why this was the option of last resort explained.
63. The Trust’s complaint responses also provide further detail and explanation on Mrs X’s journey from first admission in May 2022 to her recovery post stricture surgery in September 2022. While we cannot say there is evidence to support the view that communication did fail to meet the minimum acceptable standard, this shows the Trust made all reasonable efforts to resolve any remaining confusion or uncertainty about events once a complaint was made.
64. We have taken account of how Mrs X’s progress was inconsistent and the approach to care was being adjusted on a daily basis. Her clinical picture was uncertain and marked by several unpredictable clinical complications. We see there were periods where it was necessary to wait, sometimes to see how she progressed, sometimes for test results or advice, or sometimes because it was not safe to repeat procedures too soon due to the risk of harm.
65. We can understand why Mrs X and her daughter may still be unhappy at the quality of communication during her care as it was a worrying and uncertain time. We found it would be unfair to consider any inconsistent or contradictory communication provided during that period to have breached the relevant standards.
The Trust failed to investigate the cause of abdominal pain whilst on the ward which turned out to be duodenal ulcers which later haemorrhaged and left her in critical condition.
66. Following Mrs X’s successful surgery to fix her obstruction, her bowels were unable to regain their normal functioning for some time after. This is an unfortunate but common complication of such major surgery. It slowed her recovery and increased the risk of other post-surgical complications. Once she left the DCC on 26 May 2022 the plan was to slowly build up her diet again. This is necessary after such surgery to prevent complications such as refeeding syndrome (a serious metabolic condition that can affect malnourished persons when they start to be fed again) or a bowel perforation.
67. By Mrs X’s account, the period in question spans 26 May (when she was stepped down to Ward care) to 5 June 2022 (when she suffered a bleed). She says doctors only noted pain once prior to the bleed. The Trust states that, in daily checks with Mrs X from different staff, she did not report any pain, but a doctor would have reviewed her if this had occurred. It also says pain would not be transitory if there was some significant cause. We note the pain Mrs X describes was a band of pain across her abdomen, particularly after eating, and not extreme and constant pain.
68. Mrs X’s daily clinical notes indicate daily ward checks were recorded where pain was queried. She reported ‘some discomfort’ on 28 May 2022 but the records show no evidence of her reporting pain or discomfort prior to this. There is a note made on 29 May 2022 of a discussion with her daughter. This details how she had revealed she had not been telling staff about being in pain. The note details her daughter’s concerns about this pain indicating serious problems occurring and missed opportunities to act.
69. Mrs X’s daughter said her mother reported pain most days. The available evidence does not support this. The records indicate she had not done this prior to 29 May 2022, and only started reporting some discomfort the day before. We see she then latterly started to report she was suffering pain after. On 30 May 2022 she subsequently reported ‘pain voiced 6/10’, on 31 May ‘pain 5/10 voiced’, and on 1 June ‘pain voiced 6/10’.
70. A CT scan was performed on 29 May 2022 in response to Mrs X’s increased discomfort. This confirmed some improvement in Mrs X’s bowel and no obstruction, but some indication of wall thickening in the duodenum (the first part of the small intestine after the stomach). On 1 June 2022 her feeding tube was removed, and Mrs X was able to tolerate some food. This progressed to some good progress over 3 and 4 June and our surgeon adviser said the medical records show nothing that could have suggested there would be an impending problem in this period.
71. Unfortunately, on 5 June 2022 she suffered a sudden and unexpected deterioration. Blood test results indicated a bleed, and the cause of this this was then confirmed as duodenal ulcers on 8 June 2022 by gastroscopy. The bleed was stopped by be the medical team’s intervention.
72. Our surgeon adviser said some of Mrs X’s pain was likely to be partly from post-surgical oesophageal inflammation, a complication of her recent surgery and prolonged ileus. This would not be related to the issues in the duodenum where her ulcers developed, as the stomach separates these two parts of the digestive system. This indicates that pain would not necessarily have been an indicator to alert staff of ulcers. Our surgeon adviser also said that pain after eating would be expected during the healing process, so the described (and not reported) pain would not be a missed sign of ulceration and a quite common post-operative occurrence.
73. This is reassuring, as we recognise that Mrs X may have been concerned that she could have had a better outcome if she had reported her pain sooner. This does not appear to be the case for the following reasons.
74. Our surgeon adviser said that a gastroscopy would be required to confirm ulceration, but this is an invasive procedure, and such procedures would have had to be put on hold for a period after surgery. This is due to there being a high risk of harm to the patient. They explained that ulceration is a known complication that can occur following major surgery and the patient suffering a prolonged period before the bowel returns to normal functioning.
75. NICE CG141 1.7.1 states: ‘Offer acid-suppression therapy (H2-receptor antagonists or proton pump inhibitors) for primary prevention of upper gastrointestinal bleeding in acutely ill patients admitted to critical care.’ Proton pump inhibitors (PPI) are the primary form of treatment for the prevention and treatment of gastrointestinal ulcers as they supress the production of stomach acids which would irritate and hinder healing of the lining of intestines.
76. NICE CKS ‘Dyspepsia - proven peptic ulcer: Scenario: Management - proven peptic ulcer’ guidance also recommends full dose PPI medication for 6-8 weeks to promote healing.
77. Our surgeon adviser stressed that Mrs X had been placed on the correct treatment for treating/preventing duodenal ulcers (PPI) straight after surgery on 13 May 2022. This preventative treatment was started before it was safe to perform a gastroscopy, which is what identified ulceration after her bleed. They said her treatment and the timeline of investigations were appropriate given the frailty of Mrs X after the first operation and no standards were breached.
78. We see her treatment was in line with NICE guidance according to our adviser and that precautions to minimise the risk of ulcers were taken. Mrs X seems to have suffered ulceration despite this, possibly due to her prolonged ileus.
79. It would have been difficult to justify risking a gastroscopy prior to her bleed occurring, when she was progressing along her slow recovery. As she had been receiving correct treatment for several weeks already, earlier knowledge of ulceration would have had no impact on her clinical management or lessened the chances of her suffering this complication. As this was the case, we are unable to see what more could have been done to reduce the chance of this post operative complication occurring.
80. From the above we can conclude the Trust did not fail to investigate the cause of Mrs X’s pain while on the ward. It would only have been possible to act 29 May, as this was the earliest point of knowledge staff had of any pain despite daily checks. A CT scan was done in response to this new information on that day. This showed some inflammation (which alerted the team to the possibility of ulceration).
81. As such the scan result was reasonably reassuring on Mrs X’s general improvement, and the first real opportunity to be concerned about the possibility of ulcers. Nonetheless, we are unable to see what more the Trust could have done in response to that knowledge than was already being done.
82. We found the evidence does not indicate a failure to investigate Mrs X’s cause of pain on the Ward or any delay in identifying the cause and acting. There is some doubt that this was in fact pain from her ulcers but, nonetheless, timely investigations occurred on the day staff became aware of her pain.
83. We are unable to see how a different course of action could have been predicted or prevented her ulcers, or later events. Mrs X appears to have been unfortunate to have suffered this post operative complication rather than it being caused or worsened by any failure to act. We saw no evidence of any breach of guidance or standards in care.
The Trust discharged her without any follow up despite known haemorrhaged duodenal ulcers, which then progressed to a duodenal stricture and readmittance to hospital
84. The Trust accepts it did not arrange a follow up after the gastroscopy on 8 June 2022 which diagnosed with duodenum ulceration/inflammation on 8 June. It accepts this would be the usual practice to do and it explains that there was no recommendation for follow up on the Endoscopist’s report. It accepts that there should have been a follow up arranged for 6 to 8 weeks later, but it says she had several follow up procedures before that time and so she was suitably monitored.
85. Mrs X was discharged to rehab to continue PPI treatment intended to help heal her ulcers so we can understand why she was concerned that she would have left hospital with no plan to monitor her progress. In fact, as her recovery was prolonged and marked by several setbacks, she remained on high doses of PPI medication, which would have provided the maximum preventative conditions in her bowel for healing.
86. We note she was thoroughly monitored due to suffering setbacks in her recovery, rather because of any planned follow up. As such there does appear to be an indication of a failing on this point so we considered if there was any impact.
87. Mrs X was diagnosed as developing a duodenal stricture 17 July 2022, so we reviewed the care between her diagnosis of ulceration and then. Our Surgeon adviser said that the management of her ulceration in this period was in line with NICE CG141 ‘Acute upper gastrointestinal bleeding in over 16s: management’. They said that, on review of all the gastroscopy tests for this period, all the relevant guidelines were followed, including:
• ‘1.3.1 Offer endoscopy to unstable patients with severe acute upper gastrointestinal bleeding immediately after resuscitation.
• 1.3.2 Offer endoscopy within 24 hours of admission to all other patients with upper gastrointestinal bleeding.
• 1.4.4 Offer proton pump inhibitors to patients with non-variceal upper gastrointestinal bleeding and stigmata of recent haemorrhage shown at endoscopy.
• 1.6.2 Stop other non-steroidal anti-inflammatory drugs (including cyclooxygenase-2 [COX-2] inhibitors) during the acute phase in patients presenting with upper gastrointestinal bleeding.
• 1.7.1 Offer acid-suppression therapy (H2-receptor antagonists or proton pump inhibitors) for primary prevention of upper gastrointestinal bleeding in acutely ill patients admitted to critical care. If possible, use the oral form of the drug.'
88. Crucially, our surgeon adviser explained that a stricture, like the one Mrs X later developed, would happen as a consequence of successful healing of the ulcerated tissues. Scar tissue created during healing will often later shrink. This can constrict the affected bowel if enough of its circumference is affected. As such, a stricture is dependent on the how the patient’s anatomy evolves during the healing process. This is reassuring as, rather than this being an indication of poor care, it is evidence that management of Mrs X’s ulcers had been effective and her ongoing treatment to heal them was working.
89. There does appear to be a slight failing here in that a follow up would be usual practise, and this was not arranged before Mrs X was discharged. This omission has been explained, and reassurances provided that there were several follow up checks. As the care appears entirely in line with guidance and the ulcers progressed to stricture despite correct care, there is no evidence of any material impact.
90. We can understand why Mrs X may feel that, if not for events occurring which prompted intervention before the 6-8 week mark, she may not have had any follow up. We cannot assume a follow up would not have been arranged before that point in the absence of other prompts, but we recognise this caused her concern. The failing appears a minor oversight and the impact minimal since Mrs X received ample follow up monitoring.
91. We have seen nothing to indicate discharging Mrs X to continue her healing made the chance of her suffering a stricture more likely. The stricture was apparently the result of her specific healing process following her bleed and, as such, not a preventable condition.
92. We found the impact form this is limited to a loss of confidence and some worry. We think the responses the Trust provided to explain were enough to have resolved that concern in the course of the complaints process.
The Trust failed to provide continuity of care, decision making, or consultant and dietician review, over the next six weeks admission which she says led to her needing surgery as this led to the stricture not resolving.
She says that many actions would not have been done if not prompted by her daughter, who is a health professional and advocated for her.
93. We considered these two points together as they are closely linked. On 11 July 2022, Mrs X had been discharged home due to her condition improving and her being able to tolerate normal food and fluids. Also, her ulcers were healing well. Unfortunately, she then had to be readmitted three days later as she had started vomiting. The cause of this was then discovered to be that a stricture was developing. Fibres from the healing ulcers were contracting and this was closing off her duodenum and preventing food exiting her stomach to the small intestine.
94. Mrs X raised a number of concerns with the Trust about her care during the period after her stricture was diagnosed on 17 July 2022. She eventually underwent further surgery to resolve this on 15 September 2022. Her overarching concern about this period is that poor care and delays resulted in a worse outcome for her, specifically needing surgery which she feels could have been avoided or done sooner.
95. The Trust’s response to this effectively states that Mrs X’s stricture was a rare complication, and she eventually needed surgery due to it unfortunately not responding to treatment, rather than it being due to a lack of effective decision making. It indicates her dietary intake needed to be cautiously increased due to her condition and this meant it would take longer to get Mrs X nutritionally optimised for surgery. It also indicates that medical management of the stricture had to be tried first, so surgery was not possible to plan for initially.
96. In relation to specific concerns raised we see the following. Mrs X complained about delays prescribing Sucralfate, a medication which can coat the lining of the intestine to aid healing by protecting it from gastric juices, and steroids (to promote easing of the stricture), and a lack of dietician input. The Trust accepted and apologised for delays providing these medications. It did not agree Mrs X’s dietary intake had been poorly handled.
97. The Trust confirmed that the gastroscopy that diagnosed Mrs X’s stricture on 17 July 2022 did recommend starting Mrs X on Sucralfate. It accepted providing this was delayed by junior doctors seeking confirmation to do this from Mrs X’s surgeon. This was sought via routine channels instead of directly, which lost time. This, and the surgeon’s absence (apparently due to leave or possibly also a covid infection) delayed her receiving this medication for several days. However, we are unable to identify any significant impact this had on her overall recovery as her ulcers continued to heal steadily.
98. The Trust also confirmed that the Gastroenterology team had suggested Mrs X may benefit from steroids after her stricture had not eased with time and continuation of PPI medication, sucralfate, and cautious dietary management. While steroids can help ease a stricture of this type, they can also increase the risk of bleeding from ulcers. We can see why some caution over this decision was necessary.
99. Nonetheless, the Trust accepts it also delayed starting Mrs X on steroids and apologised for this. We note Mrs X’s gastroscopy on 16 August 2022 included the recommendations ‘Parent team to decide about next management plan as no improvement in the stricture. ?Trial of steroids ?Surgery’. We see this indicates a suggestion that the treating team consider its options, and a query on whether a trial of steroids would be beneficial or if surgery was needed.
100. Mrs X’s daughter raised the delay in review with a consultant surgeon two days later, who apologised for this not being picked up straight away. Again, we have been unable to identify any impact from this short delay in considering a steroid trial. The stricture ultimately did not respond to any conservative treatment.
101. In relation to concerns about a lack of dietary management, our review of the clinical notes shows evidence of multiple dietitian reviews on a regular basis throughout July, August and September 2022. We also recognise that Mrs X’s recovery needed to be managed on a day-to-day basis. We are not seeing indications of a lack of dietician review and while Mrs X appears to have suffered occasional setbacks, the management of her dietary intake does not appear to have affected her rate of recovery.
102. We recognise a key concern for Mrs X was whether she could have been optimised for surgery sooner, or surgery avoided altogether. We therefore looked at what the overall management of this period was and sought advice from our surgeon adviser.
103. From 17 July 2022 when the stricture was identified, the treatment plan was to manage conservatively with PPI medication, cautious dietary build-up, and sucralfate. The plan was to initially see if the stricture could resolve naturally if possible. This would require time. Unfortunately, a repeat gastroscopy on 16 August 2022 confirmed the stricture was not improving and other options needed to be considered. A review on 18 August 2022 referred her to the local MDT and ordered another CT scan.
104. The MDT was held on 23 August 2022 noted the CT scan showed no malignancy but the results from biopsies taken earlier were still pending to confirm (later these did confirm no signs of cancer). It also confirmed the cause of the stricture was considered to be due to fibrosis (healing tissues contracting) and that this would require surgery, and Mrs X’s case was referred to the regional MDT at Sheffield for expert advice on which surgical option to take.
105. The regional MDT was held on 31 August 2022 and advised that bypass surgery would be the only remaining option for Mrs X, as the stricture was not settling naturally, could not be stretched safely without risk of further injury, and stenting (bracing the affected section of bowel with a tube to keep it open) would not resolve the underlying problem of restricted flow. The plan then was to prepare Mrs X for surgery in mid-September, which is when she did undergo surgery to bypass the affected section of her bowel.
106. Based on this we see there was a coherent care approach for the period consisting of needing to wait to see if conservative management of the new condition could resolve it without having to resort to surgery, only for this to become the only option once all other less invasive ones had been tried and eliminated.
107. Our surgeon adviser said that the medical team responded appropriately to Mrs X’s changing clinical situation. They noted that some of her pain after eating was likely to have been from inflammation in her oesophagus due to her prolonged recovery and unrelated to the development of a stricture.
108. As explained earlier in this report our adviser said the stricture was a consequence of the ulcer healing process laying down fibrous tissues which later contracted, but her care was in line with NICE CG141 and CKS guidelines as set out in paragraphs 75, 76 and 87.
109. Our surgeon adviser said there were probable delays along the course of Mrs X’s admission but while it would be easy to pick out minor weaknesses in her medical management, this should be considered in the context of her complex clinical picture. They explain that Mrs X had a condition with a known mortality risk, and she required a lot of medical professionals to be involved in her care.
110. We see seeking input from the local and regional MDT’s was in line with GMC Good Medical Practice - Providing Good Clinical Care 7 (g & h) which says: ‘consult colleagues or seek advice from your supervising clinician, where appropriate, refer a patient to another suitably qualified practitioner when this serves their needs.’
111. They felt the Trust managed a complex problem in an acceptable way with a good result, and that it would have been unavoidable that this led to a very traumatic and emotional time for her and her relatives.
112. We recognise that Mrs X’s daughter feels that some things would not have happened if not for her intervention and advocating for her mother. We are able to see that in some instances, such as the delays in starting medication, she did bring issues to the attention of staff, and this may have helped minimise further delay. After carefully reviewing the clinical notes, which are extensive, we can see ample evidence of her doing this, but also lots of notes where staff tried to explain the need for a cautious approach which would take time.
113. There is little in the records we have seen to indicate Mrs X’s care was not, on the whole, being managed correctly on a day-to-day basis. Clearly there was a limit to the pace of progress, mainly due to post operative complications which necessitated a number of interventions. She needed conservative management to promote a healing process which would be inevitably quite drawn-out, and these complications required extending her time in hospital multiple times.
114. In our view, the trajectory of her care looks to have been driven by these clinical issues and not a lack of urgency in addressing them. It would not be possible to disprove the concern that some things would not have been done if not for the pressure exerted by Mrs X’s daughter. As such, we can understand the underlying reason for this aspect of the complaint. We can also appreciate that if her daughter had not done this, her care would have progressed much along the same lines. Essentially, events were being driven by the complexities of Mrs X’s healing process more than any other factor.
115. In relation to the management of the stricture, our surgeon adviser explained that after an emergency operation, it is very difficult to re-operate within the first three months. This is due to residual inflammation remaining after major surgery. The longer the wait before attempting surgery, the easier the operation can become. As such, there is a balance between dealing with a patients ongoing symptoms, and also needing to allow the internal abdomen to heal after a first operation to allow the patient to be well enough to tolerate another.
116. We note Mrs X underwent major abdominal surgery on 13 May 2022, and then additional interventions on 5 June 2022, when she suffered a major bleed from an artery in her duodenum due to it becoming ulcerated following her ileus. These procedures would have made attempting surgery to bypass the stricture more difficult and a long pause necessary before any attempt to operate again.
117. We note Mrs X’s surgeon explained on 31 August 2022, in emails to her daughter following the Sheffield MDT, that the plan was to now attempt this operation. Considering our surgeon adviser’s advice about needing to wait at least three months to manage the risks operate, we note the Trust waited just over this timespan after the her major bleed by arranging her operation for 15 September 2022.
118. We therefore see that the Trust needed to wait at least this long before intervening with surgery in order to optimise the chances of success. As such, the surgery was arranged at the appropriate point and the time prior to committing to surgery was appropriately used to explore alternative possibilities and build up Mrs X’s diet and resilience cautiously.
119. We did not see evidence Mrs X was made to wait any longer than necessary for her operation, as it was vital to try and avoid her needing two major abdominal surgeries in one year, if at all possible. Unfortunately, her stricture did eventually require an operation to resolve after all, but only after other options had been considered and ruled out.
120. We found there is evidence of continuity of care, with appropriate decision making, oversight and review, in the period following the diagnosis of Mrs X’s stricture and her second operation. Again, the stricture did not occur due to mismanaged ulceration, or fail to resolve due to poor management.
121. The available evidence indicates these complications happened despite providing correct care, and the long wait before resorting to surgery was partly due to needing to give all other possible ways to resolve it a chance to work, and partly due to having to wait a significant amount of time before the final option of surgery was safe to attempt.
122. Taken as a whole, we found there is not a basis of evidence to support the view that Mrs X’s initial bowel obstruction, and the long recovery or series of complications that followed its initial treatment, were due to any failing in care. We can understand why she would have suspected this as she experienced many setbacks and uncertainties in her journey to recovering from her initial illness. We hope the contents of this report clarifies there was a need to carefully manage her recovery over an extended time period.