Administering of general anaesthetic 14. Mrs B explains her mother should not have been administered with a general anaesthetic before having surgery. She explains this is because there are more risks associated in an elderly patient having a general anaesthetic. She says she was told her mother would have been sedated with a spinal block.
15. The Trust says it carried out a thorough anaesthetic evaluation, and a spinal block would have been the first choice if Mrs V could have tolerated it. It says it gave general anaesthetic in Mrs V’s best interests.
16. We have carefully considered if the decision to administer general anaesthetic was appropriate and in line with guidance. The hip fracture guidance is applicable here, it explains patients should be offered spinal or general anaesthesia after the risks and benefits are discussed.
17. The consent for anaesthesia guidance is also applicable and sets out information about the anaesthesia process. It says information about anaesthesia and its associated risks should be provided to patients as early as possible.
18. The records show the anaesthetist contacted Mrs B on 7 July to discuss her mother’s surgery and anaesthetic process. The anaesthetist explained there are two possible ways to anaesthetise, either a general anaesthetic or spinal block. The anaesthetist advised if Mrs V could tolerate it, their plan would be for a spinal anaesthetic with sedation.
19. The anaesthetist documented there is a risk of failure of a spinal block, then the other option is general anaesthetic. The anaesthetist documented Mrs B understood these risks and had no further questions.
20. A plan was then made for spinal and sedation if Mrs V tolerated it, and if not a general anaesthetic. This plan was discussed and agreed to, with the associated risks explained.
21. We recognise Mrs V then went on to require a general anaesthetic. This was appropriate management, as it was in line with the initial plan set out that had been discussed, communicated and agreed with family. In the clinical situation it was reasonable and in Mrs V’s best interests to have a general anaesthetic. This decision was in line with the above guidance.
22. We are mindful Mrs B has serious concerns that this was used, and any impact this may have had on Mrs V’s prognosis. Our anaesthetist adviser has provided some more information about this to give Mrs B some reassurance about this decision.
23. Our anaesthetist adviser explains statistics and research shows there is no evidence that any one option is better than the other for patients such as Mrs V in this clinical context. From a safety perspective, there is no significant clinical difference in the two options.
24. Our anaesthetist adviser says a spinal block also presents its own clinical challenges. Mrs V also had some cardiac issues, therefore the option of general anaesthetic would have given the anaesthetist more control and may have been a safer option as a result. There are various research papers that would support this, and a significant number of anaesthetists would have opted for a general anaesthetic in this clinical scenario.
25. Research from the association of anaesthetists was unable to demonstrate clinically relevant differences between modes of anaesthesia. It explains in a study of hip fracture patients to asses the effects on outcome of general and spinal anaesthesia, there were no significant difference between the groups in risk factors, length of hospital stay or mortality rates.
26. The BMJ research says hip fracture surgery is associated with high in-hospital and 30-day mortality rates and serious adverse patient outcomes. Evidence from randomised controlled trials regarding effectiveness of spinal versus general anaesthesia on patient-centred outcomes after hip fracture surgery is sparse.
27. The British Journal of Anaesthesia also sets out there were no differences between spinal and general anaesthetic in hip fracture surgery.
28. When a patient presents with a hip or thigh fracture, it can be very difficult to position them for a spinal anaesthetic, as the patient needs to either sit up or turn on to their side. This can be very painful for a patient, in an already painful state. Our anaesthetist adviser would suggest there is not necessarily a right or wrong way here, and it is reasonable to conclude this decision was in Mrs V’s best interests.
29. The evidence also supports that the anaesthetic process went well. Our anaesthetic adviser explains it cannot see any evidence to support this would link or have had an impact on the outcome or situation. We are mindful the clinical picture went on to develop so we understand why Mrs B would have concerns. We hope this information is helpful and can offer Mrs B some assurance about the decision making.
Delays and in investigating and treating Mrs V’s abdominal pain 30. We recognise Mrs B has serious concerns the Trust caused delays in investigating and treating her mother’s abdominal pain. She specifically has concerns about the time taken to carry out blood tests and radiology imaging. We have sought advice from surgical and radiology consultants, who have very carefully considered these issues below. We will address this chronologically, in order of events.
31. As set out above, Mrs V underwent emergency surgery on 7 July following a fall. Our surgical adviser explains from a surgical perspective, the evidence supports the surgery went to plan and there is no suggestion of any issues during surgery.
32. GMC guidance says when treating patients, doctors should adequately assess a patient’s condition and promptly arrange suitable advice, investigation or treatment where necessary.
33. Mrs V went onto a surgical ward post-surgery for monitoring. Our surgical adviser explains based on her condition, she should have had a blood test at this point. This is because this is routine practice following a surgical procedure. We have found a failing here, which we will consider later in the report.
34. We acknowledge it is unclear at various points in the records exactly what time some actions took place or were typed up in retrospect. This is why we may refer to ‘around’ for some timings and acknowledge this is not always clear in the records, as Mrs B has rightly told us.
35. Whilst on the surgical ward, the records then suggest Mrs V was complaining of abdominal pain in the early hours of 9 July, around 12.48am, and the doctor was notified. A bladder scan and ECG were arranged, and it is noted Mrs V became tachycardic.
36. The doctor came to review Mrs V promptly, around 1.17am. The doctor advised it was unlikely this was cardiac pain based on the ECG results and wanted to rule out evidence of any bowel obstruction. The doctor discussed this with the surgical team, who also advised to carry out a CT of the abdomen.
37. At the time of events in July 2023, there were no national turnaround times for reporting scans in imaging. Despite this there were well recognised ‘unofficial’ reporting turnaround targets which hospitals tried to meet. Shortly after the events in question, in August 2023 NHSE produced the diagnostic reporting turnaround time guidance.
38. We therefore make reference to the NHS England diagnostic imaging reporting turnaround times which state that for an urgent inpatient scan a report should be issued within 12 hours of the scan, and within four hours post-acquisition of images for acutely unwell patients.
39. The CT scan took place quickly overnight. Our radiology adviser explains the timings of the CT scan above were reasonable and prompt in the clinical context of taking place overnight.
40. The surgical doctor then informally reviewed the scan around 3.29am. They are not a radiologist and so would have been looking for something obvious appropriate to their level of experience. The surgical registrar noted ‘abnormal dilation of bowel loops’, with a plan for a nasogastric tube, for Mrs V to be nil by mouth and to await the formal report. The scan was then sent to the overnight outsourced on-call reporting service.
41. Outsourcing services are used within hospitals across the country to provide 24 hour a day consultant radiologist reporting, as most hospitals do not have enough radiologists to meet the work demand both during the day and overnight.
42. The report was done by a consultant radiologist, finalised at 5.40am and sent back to the Trust. Following this, the doctor reviewed the report and Mrs V again at 5.49am.
43. The doctor recorded she appeared comfortable, her abdomen was mildly distended, and the CT findings were considered. The CT report ruled out evidence of any bowel obstruction and advised there was a large build-up of faeces. A plan was made for Mrs V to have laxatives and enemas as a result. There was an assessment of Mrs V’s history and condition, with suitable advice and treatment arranged as set out in the GMC guidance. Our surgical adviser explains this plan and follow up was appropriate management based on the CT findings and in in line with the above GMC guidance.
44. Our surgical adviser explains whilst the plan and follow up suggested was appropriate, there was a further opportunity to carry out a blood test overnight, or at this point of review. This was a second missed opportunity, and we consider this to be a failing. We will go on to consider the impact of this later in the report.
45. Our radiologist adviser explains the reporting turnaround for the CT scan was within three hours, and therefore from a radiological perspective, this was appropriate management in line with the NHSE guidance and the clinical urgency.
46. The RCR standards set out the essential steps for understanding and analysing radiology images, and for reporting on them. Our radiology adviser has carefully considered the CT scan. The radiologists’ report was thorough and reported on in line with the above standards.
47. Our radiology adviser confirms the findings of the scan were normal and did not show a bowel obstruction. It showed Mrs V had a long redundant loop of sigmoid colon, which is very common in elderly people and is harmless. It was not twisted at the time of the scan, and no cause for the abdominal pain was identified. There is no indication anything was missed on the imaging at this stage.
48. We recognise the events went on to develop the following day. At 9.13am, Mrs V’s NEWS was recorded to be zero. At 9.50am it was one, as her heart rate was 106.
49. The NEWS tool was developed by the RCP to improve the detection and response to clinical deterioration in adult patients. It has a scoring system looking at key physiological measurements, with trigger points indicating when a patient needs a clinical review. A score of one to four is classed as ‘low clinical risk’. Mrs V’s observations at that time would therefore prompt the need for repeat observations at a minimum of four to six hours.
50. The next entry in the medical records shows Mrs V was seen by a doctor on the ward round at 10.20am. There is no reference to the events from the night before, and it refers to Mrs V having constipation. There is a reference to Mrs V needing post operative bloods at this review, which we cannot see took place here. We think this is a third opportunity for a blood test to have been carried out.
51. The next entry is when the emergency call went out between 2pm and 2.30pm, due to Mrs V’s collapse. We recognise the family say this was around 2.30pm. It was noted Mrs V had unrecordable sats and tachypnoea (rapid breathing).
52. We acknowledge the family’s view that the records and timings are difficult to follow, and it is not always clear what happened when. We therefore accept the families account of when this happened.
53. The records suggest a chest X-ray was taken around 2.43pm. Our radiology adviser explains at this stage, a gas filled loop of bowel can be seen on the chest X-ray under the left diaphragm. This was not present on the previous CT scan and suggests that something had occurred within the abdomen after the CT scan took place.
54. The clinical team then arranged for urgent bloods and a further CT scan. At this point in time, Mrs V had a lactate of 10, which suggests the possibility of ischemic bowel. Mrs V was then given antibiotics covering potential infection or sepsis, fluids, and anticoagulation in case of any clotting. This is appropriate management in line with the GMC guidance.
55. The request for a CT scan appears to have been made around 3.07pm. Our radiology adviser explains there is normally a large list of urgent inpatient and emergency department CT requests on the radiology system each day in any hospital. It can be a challenge to prioritise them according to clinical need, although if the department is alerted to a very unwell patient, scan appointments can be adjusted as needed.
56. The records show between around 3pm and 3.20pm the prognosis was very poor, with Mrs V approaching end of life. Mrs V’s lactate of 10 was very high, indicating serious illness. Our surgical adviser explains an ischemic bowel was very sadly an unsurvivable event and there would not have been any treatment available.
57. The only available treatment would have been surgery, which Mrs V would not have survived or been a suitable candidate for. She was on full active treatment, and there is nothing further the Trust could have offered at this point. A second CT scan would not have altered management. Based on this, our adviser questions if it was appropriate to plan and arrange for the second CT scan in line with the GMC professional standards. These say the benefits of a treatment must be weighed against the burdens and risks for the patient.
58. Mrs V then attended for the scan around 4.59pm and sadly deteriorated at the scanner. The decision was made that Mrs V was end of life, and there was a plan to keep her comfortable. The scan did not go ahead and she sadly died that evening.
59. Our radiology adviser explains this was a reasonable time period for an urgent CT to be requested and planned to be carried out, in line with the NHSE guidance. From a radiological perspective, our radiology adviser explains the Trust arranged the appropriate scans at the appropriate times, and in line with reasonable timeframes. There is no indication anything was missed or there were any opportunities for earlier treatment, and this was in line with the above imaging guidance.
60. Regarding Mrs V’s surgical management, to summarise, we have identified a failing as we have seen multiple opportunities where we think the Trust should have carried out a blood test for Mrs V. We recognise the repeated opportunities may be difficult for Mrs B to learn about and we are mindful of this. We will now go on to carefully consider the impact of this.
61. As set out above, our surgical adviser explains bloods are routine after surgery and should have taken place post-surgery. There was then a further opportunity to have bloods overnight when Mrs V expressed pain and had her CT scan, and on the ward round following morning. There was a missed opportunity to understand more about the full clinical picture for Mrs V. It is possible blood tests could have given more information about Mrs V’s potentially deteriorating condition, for example if she had a raised white cell count or lactate alongside abdominal pain.
62. Our surgical adviser explains if these blood tests had taken place, this would not have altered the treatment or management that was available. This could not have been avoided, and very sadly an ischemic bowel is not a survivable event in a patient of that age group or with comorbidities. This is because Mrs V would not have survived the surgery.
63. She was on the maximum treatment that was available to her, and there very sadly were no further treatment options. Whilst we acknowledge this, we also recognise if the blood tests had taken place, there was a chance they would have been alerted to Mrs V’s condition sooner.
64. With this information about Mrs V’s condition available sooner, there may have been the opportunity to have discussions with Mrs V and her family about their wishes sooner, and possibly make different decisions around her care, such as keeping her comfortable. If her deterioration had been identified at an earlier point, there may have been the opportunity to discuss if it was proportionate to try to take Mrs V to the scanner again in light of the clinical picture, and the distress of this situation at the scanner may have possibly been avoided.
65. As set out above, our adviser explains Mrs V would not have been a candidate for surgery, due to her frailty and comorbidities. An ischemic bowel is an unsurviable event in these clinical circumstances. Even if she had a second CT scan, this sadly would not have changed the management. The risk of death with an ischemic bowel is between 68 and 90%. A lactate of 10 is an indication of something fairly catastrophic happening. Her lactate was very high, indicating the seriousness of her illness and providing further clinical evidence to support our view.
66. Overall, we cannot say this would have changed the clinical outcome but recognise the opportunity to make better informed decisions. We acknowledge it is possible a decision could have been made to keep Mrs V comfortable sooner. Mrs B is left not knowing if different arrangements could have been put in place for her mother at the end of her life, which is distressing in itself. There was a missed opportunity for dignity at end of life. It is understandable this caused the family distress and suffering, at what was already an incredibly difficult time for them. We are mindful of this, and the experience they went through.
67. We have looked to see what the Trust has done so far to recognise this. We acknowledge that the Trust’s serious incident report acknowledges that from a surgical perspective, Mrs V should have had full bloods post-surgery. We are pleased to see the Trust has accepted this. We think the Trust needs to acknowledge this, and recognise the impact on Mrs B and her family, and explain how it will stop this happening again in the future. We therefore recommend the Trust takes action.