21. The NICE guidance explains it aims to improve care for people with suspected or diagnosed cancer by prompting best practice on the organisation of haematological cancer services.
22. The guidance explains Trusts need to provide inpatient isolation facilities, consisting of single occupancy rooms with their own bathroom, for haematological patients who are at risk of being neutropenic for more than seven days. It says there should be designated area for outpatient care that reasonably protects the patient from transmission of infectious agents and provides, as necessary, for patient isolation.
23. GMC guidance says in providing a good standard of practice and care, doctors should promptly provide or arrange suitable advice, investigations, or treatment where necessary.
24. Patients frequently need to be taken to other areas of the hospital as not everything can be done on the ward. Our haematology adviser said if a patient is clinically well, it is reasonable to take them off the ward, if necessary. It is a balance of the risk of taking patients away from an isolation room against the benefit of the reason for going off the ward.
Hearing test on 10 October 2022
25. The BSA guidelines recommend a maximum level of background noise for hearing tests. We can see that ordinarily this means such tests will be done in an audiology booth or a quiet clinic area.
26. Our ENT adviser said these tests can be and are done on a ward if necessary, depending on the circumstances of the patient. Although it is not ideal when there is background noise, there should be consideration of the risk to the patient against the benefit of taking them off the ward for the test.
27. By this time Mrs R had improved clinically since her admission. Her National Early Warning Score (NEWS, a scoring system to identify and respond to patients at risk of deteriorating in healthcare settings) was low, she was stable, and her blood test results were not concerning. Our haematology adviser said Mrs R appeared clinically well enough to go off the ward for necessary assessments or investigations.
28. Our ENT adviser said although a hearing test is routine for a patient with middle ear effusions, it is not urgent if they are also seriously ill and immunocompromised.
29. Despite being clinically stable, as an AML patient Mrs R would not have a fully functioning immune system. As the immune system is impaired, caution is still necessary due to being vulnerable to infections.
30. We can see Mrs R’s potential hearing loss was only a minor part of the bigger clinical picture at that time. Our ENT adviser said even if the test had identified significant hearing loss, she would not have received any intervention for this as she was seriously ill. The focus would, understandably, have been on treating her life threatening condition.
31. Therefore, although GMC guidance outlines the need to provide prompt investigations where necessary, we do not consider a hearing test was necessary or a priority at the time given Mrs R’s AML. The test could have been done in her isolation room. By taking Mrs R off the ward to do this test, the Trust did not consider the risk against the limited benefit of doing so at that time.
32. This is a failing, and we have considered the impact of this later in the report.
24 October 2022
33. At this time, Mrs R was showing signs of infection which needed investigation. Our haematology adviser said it is standard practice for a patient with a fever at this stage of treatment to have a chest X-ray to screen for infection.
34. A chest X-ray would assist in identifying the source and extent of infection, to then allow for targeted and best treatment.
35. Portable chest X-rays are used when a patient is too poorly or not stable enough to be taken to radiology. However, the quality of them is quite poor compared to standard X-rays. The images are of lower quality and clinical information is lost. There are also risks to other patients and staff when bringing radiation on to a ward.
36. Our haematology adviser said although Mrs R had a temperature, her observations were not alarming. They said she was clinically well enough to leave the ward for this investigation.
37. We consider the Trust acted in line with the GMC guidance to promptly provide necessary investigations when it took Mrs R from the ward for this chest X-ray. Doing so ensured they would have good quality images to allow staff to treat a potentially life-threatening infection. There was a clear benefit here when considering the risk.
38. We have not found a failing in relation this.
Complaint about infection control outside of the ward
39. Although the NICE guidance does not specify what measures should be put in place, it is clear there is a need to protect haematology patients from the risk of infection, including when they are visiting outpatient clinics. Although Mrs R was an inpatient, she was visiting an area of the hospital primarily used for outpatients.
40. We have not seen any Trust policies specifically for infection control in haematology patients. The only relevant policy the Trust has provided relates to infection prevention and control for COVID-19.
41. This says face masks are required in specific areas only, which includes those settings caring for clinically extremely vulnerable patients which includes haematology.
42. It says mask wearing by staff should be considered in clinical settings where patients are at high risk of infection due to being immunocompromised. In such settings, patients and visitors may be encouraged to wear a facemask.
43. Mrs B has told us about her sister’s concern and distress at being in the ENT clinic. She said people in the waiting room were not wearing masks and young children with runny noses were approaching her and touching her legs.
44. She also told us that when going to radiology, her sister was not given a face mask and had to wheel herself across the room to get one of these. We can appreciate how anxious she must have been at these times.
45. In line with the NICE guidance, we would expect the Trust to have taken steps to protect an immunocompromised inpatient being taken to other areas of the hospital.
46. We are pleased the Trust has acknowledged and apologised that staff did not offer Mrs R a face mask when leaving the ward on 24 October. However, we do not consider a face mask is sufficient to meet the NICE guidance.
47. Although the NICE guidance is not prescriptive about what steps should be taken, our adviser explained it could include things such as minimising time waiting in other areas, informing departments in advance of vulnerability, if possible, keeping them away from other patients.
48. We have not seen any evidence from the records or from the Trust directly that it took any steps, or considered doing so, to protect Mrs R from the risk of infection when leaving her isolation room on 10 and 24 October. This is not in line with the NICE guidance and is a failing.
Impact of the failings
49. Mrs R first showed signs of infection on 19 October. This means she cannot have caught the infection in radiology on 24 October.
50. Despite various tests, doctors were not able to confirm the source of Mrs R’s infection. They treated her for a fungal infection following discussions and input from microbiology.
51. Our haematology adviser said a fungal infection was the most likely type of infection considering the clinical picture and X-ray findings. It is common in this situation not to have proof of a fungal infection because it is hard to grow and cannot always be seen on some tests.
52. A fungal infection is not something caught from another person. It is caught environmentally, such as from damp or mould. Spores are commonly found in the air, and we breathe them in and out constantly.
53. There is no defined incubation period for a fungal infection and therefore it is impossible to say when Mrs R first contracted the fungal spores. However, as she first showed signs of infection before going to radiology, we know she cannot have contracted them there.
54. As there is no defined incubation period it is possible Mrs R caught the infection when she left isolation on 10 October to go to ENT. However, it is also possible she caught it before admission to hospital or on the isolation ward. Our haematology adviser said it is not possible to say which is more likely.
55. This means we are unable to say the failings we have seen led to Mrs R developing the infection from which she sadly died. However, we cannot entirely rule it out. We consider the failings were a missed opportunity to protect her when she was at risk.
56. Knowing this has had an emotional impact on Mrs B and the family. She told us how she and the whole family, including Mrs R’s teenage sons, had severely restricted visiting Mrs R in hospital in the hope of protecting her from infection. They sadly did not see Mrs R much before she died.
57. We do not doubt the distress it has caused them knowing they took these steps, yet the Trust failed to take adequate steps to protect Mrs R from infection.
58. We have made recommendation below for the Trust to take action to put this right.