16. We know how concerned Miss G is about the care her father received on 21 November. To fully address her concerns, we share our findings regarding the events as they occurred chronologically.
17. Early on the morning of 21 November, the pain management chart documents that Mr G complained of 0/3 pain on rest and 1/3 pain on movement. He had paracetamol at 6am and was receiving analgesia (pain relief) via epidural (given via a small needle, injected into the back near the spine).
18. Our nursing adviser confirms this was in line with various nursing expectations set out within The Code, and NICE CG138. NICE CG138 says if a patient is unable to manage their own pain relief, do not assume pain relief is adequate, ask them regularly about pain, assess this using a scale and provide pain relief and adjust as needed.
19. Mr G was seen at 8.59am by the critical care consultant and an SpR. At this clinical ward round, records note Mr G was alert, that he looked well and comfortable, and only reported a sore throat. The clinical impression was of an uncomplicated recovery, and it was noted he had been weaned off metaraminol, a drug given to manage his blood pressure (BP).
20. In line with GMC guidance, which says clinicians should examine the patient where necessary, Mr G was examined. Normal and stable findings on examination were noted.
21. Our surgical adviser confirms the documented plan was appropriate to the clinical circumstance. This took consideration of Mr G having recent major surgery, his clinical stability on examination, and aimed to continue his recovery. The plan included for nursing staff to monitor Mr G’s BP and provision for nurses to give metaraminol if needed, to keep his mean arterial BP (MAP) between a certain level.
22. The plan also included provision for pain relief via epidural and additional analgesia if needed, and the building-up Mr G’s JEJ feed (a jejunostomy or JEJ is a tube that had been inserted during surgery to allow direct feeding into the small intestine). Our surgical adviser confirms this was all clinically reasonable as a post-surgical plan for Mr G.
23. Records show nurses were monitoring Mr G’s vital signs – which included BP – appropriately, documenting observations every two hours alongside him having continual monitoring whilst in critical care. This was in line with NEWS guidance and the NMC Code, which respectively sets out the frequency of monitoring observations, and says nursing staff should accurately identify, observe and assess signs of normal or worsening physical health.
24. The physiotherapist saw Mr G at 12.15pm and in helping him to move from bed into a chair, his BP dropped. Our nursing adviser explains this is not an abnormal occurrence when getting a patient out of bed after some time. The physiotherapist helped Mr G back into bed and nursing staff gave metaraminol in response to the drop in BP. This was appropriate and in line with the surgical care plan. Our nursing adviser explains critical care nurses are trained at titrating the dose to ensure BP is where it needs to be, and records show they did this.
25. Mr G also reported some pain on coughing. The pain management chart shows his pain was being monitored in line with NICE CG138. It shows his pain had not worsened, that he again complained of 0/3 pain on rest and 1/3 pain on movement. Drug charts show a dose of paracetamol was given at midday. This monitoring and nursing response was in line with NEWS guidance, The Code, NICE CG138, and the surgical plan.
26. The pain management chart shows Mr G complained of an increased, 2/3 pain at rest, at 4pm. In response nursing staff gave an increased infusion via his epidural as well as oramorph (a morphine-based opioid pain reliever). This is evidence of appropriate monitoring and response, in line with guidance and the surgical plan.
27. A pain assessment is recorded at 5.15pm, noting Mr G reported a reduced, 1/3 pain at his abdomen which is described as: ‘aching, throbbing’. This reduction in pain suggests effectiveness in the previous nursing actions and the pain management plan. Whilst reduced, in response to its continued presence, nursing staff performed observations, noted that intravenous (IV) boluses (a bolus is a single, relatively large dose of medication or fluid) were being given and gave Mr G more oramorph. This again is evidence of appropriate monitoring and response in line with guidance and the surgical plan.
28. At 6pm, Mr G’s pain is documented as a 3/3, indicating severe pain. In response, nursing staff gave a bolus dose of analgesia via epidural, further paracetamol and a titrated IV morphine dose. This was another appropriate response to Mr G’s increased pain in line with guidance and the surgical plan.
29. When next assessed at 6.50pm Mr G’s pain was documented again as a 3/3. In response, nursing staff tested Mr G’s epidural, finding the left side was not working. Our nursing adviser explains this can easily happen, considering the small size of the needle that is used, that the patient can need slight repositioning to ensure both sides of the spinal area are receiving the necessary analgesia.
30. Records note nursing staff repositioned Mr G and gave him a 10ml epidural bolus and a 10mg dose of morphine, along with oxycodone (a different type of opioid analgesia) via his epidural. His BP had also dropped, and in response nursing staff put him back onto metaraminol. This was again appropriate and in line with guidance and the surgical plan.
31. As Mr G’s BP did not improve despite the appropriate actions, nurses requested surgical review. Our nursing adviser confirms this was appropriate escalation of care for clinical review, in line with NEWS guidance.
32. Following escalation, the surgical SpR attended at 7.30pm. In line with GMC guidance, the SpR examined Mr G, finding he had a distended abdomen with some guarding, no rebound tenderness and noting he was ‘not peritonitic’. The SpR also noted Mr G had not opened his bowels but had passed wind.
33. To explain these medical terms, abdominal distension is a noticeable swelling of the abdomen, often caused by the accumulation of gas, fluid or other substances, leading to discomfort or pain. Abdominal guarding is the involuntary tensing of the abdominal muscles to protect inflamed or injured organs from pain when palpated (felt or pressed with fingers).
34. Rebound tenderness is a clinical sign indicating pain or discomfort upon the release of pressure on the abdomen, such as when removing fingers after pressing the area. ‘Not peritonitic’ means there are no signs of peritonitis, an inflammation of the peritoneum, the tissue lining the inner wall of the abdomen and covering the abdominal organs. Peritonitis is often caused by infection which can occur when something inside the abdomen leaks or breaks, exposing the peritoneum to irritating or infected body fluids.
35. Our surgical adviser explains the SpR’s documented findings suggested that Mr G’s intestinal function was as expected at that point following surgery. These findings on examination did not indicate that bowel ischaemia was present or developing.
36. The SpR documented a plan comprising three parts: for nursing staff to take an arterial blood gas sample (ABG), to give further analgesia to assist with Mr G’s pain, and for: ‘Review at night’.
37. Our surgical adviser confirms the documented plan was appropriate to the clinical circumstances. An ABG would test for lactate. Lactate, otherwise known as lactic acid, is a substance the body produces mainly by breaking down glucose typically on exertion or exercise. If lactate levels are raised in a patient in Mr G’s condition, this can therefore indicate a concern requiring further investigation.
38. Analgesia provision within the plan was appropriate in attempts to meet Mr G’s fluctuating pain needs. Whilst his pain was continuing and at times increased, our surgical adviser explains this was not immediately concerning considering Mr G’s recent major surgery and in the absence of any other concerning factors.
39. Our surgical adviser says a ‘review at night’ was also a reasonable part of the plan. This enabled planned surgical oversight after some hours, to consider ABG results once returned, the effect of any further analgesia and allow for examination again at that later time. We cannot see that any at night surgical review took place, and we identify this as a failing. We go on to explore this later in our report, after continuing to share our decision on the chronology of the events that followed.
40. Records suggest Mr G’s pain reduced following the interventions taken when the epidural was repositioned and after SpR advice for further analgesia. This reduction in pain again suggests effectiveness in the previous nursing actions and the management plan.
41. Mr G reported a 2/3 pain on rest at 8.30pm and at 1.30am. Records show nursing staff documented the administration of epidural analgesia on each occasion, observations continued to be performed and recorded two-hourly, and Mr G remained on a continual monitoring device. Our nursing adviser confirms these actions in response to his reported pain and in continuing to monitor Mr G were in line with guidance and the surgical and SpR’s plan.
42. At 1.50am it is documented Mr G is in ‘++’ pain, which aligns with the pain chart noting this remained a 2/3. On this occasion, appropriately, nursing staff documented an increased infusion given via the epidural, in line with guidance and the surgical and SpR’s plan.
43. Also in line with the SpR’s plan, nursing staff performed an ABG. Results returned at 3.49am as normal. Mr G’s observations recorded at 2am, 4am, 6am were also normal. Our nursing adviser says for any indication of Mr G becoming unwell, it would reasonably be seen in observations showing some abnormalities. Instead, observations through the night showed his vital signs were stable and his blood gases were also stable.
44. He had a recent major surgery which had been performed successfully without complication and appeared to be recovering well. Aside from his unresolving pain, our nursing adviser explains nothing else was demonstrating signs of a deteriorating patient or anything concerning to warrant further nursing intervention or need for escalation of care.
45. At 5.09am, nurses documented Mr G’s pain had increased to a 3/3 and having made doctors aware. Our nursing adviser confirms it was appropriate nurses escalated to clinicians as by this point, Mr G’s pain had remained high for some time and had now increased, despite him receiving analgesia under an appropriate pain management plan. This circumstance was appropriate to require a clinical review, and records show such escalation occurred, in line with NEWS guidance.
46. Notes of the clinical review are recorded at 7.48am. Another ABG was taken and on review, the doctor recorded that Mr G’s lactate had now risen and his base excess was negative (another measure in blood to indicate an acid-base disturbance), to levels considered abnormal. Examination was performed in line with GMC guidance, finding his distended abdomen was now firm and he was delirious, indicated by a GCS of 13.
47. The Glasgow Coma Scale or GCS a clinical tool used to assess a person’s level of consciousness based on their response in three areas: eye, verbal and motor responses. The highest score is 15, indicating a person is fully awake and aware, with the lowest score of 3 indicating a deep coma.
48. These changed clinical circumstances raised concern, and the doctor recorded speaking with the surgical SpR who had seen Mr G the previous evening and asking a consultant general surgeon to review. A nursing entry at 9am documents that this review had taken place, and Mr G was planned for a CT scan. The scan was taken at 10.09am, Mr G was reviewed at 10.30am when it was noted he was now peritonitic, and he was returned to theatre within the hour.
49. We know how concerned Miss G is, having raised concern about the escalation of her father’s care and of delays in her father’s treatment from 21 November. We hope our earlier explanations show that Mr G was receiving appropriate treatment without delay throughout 21 November and during the night, given by nursing staff in line with the surgical plans.
50. Our surgical adviser confirms the plans made on the morning and evening of 21 November were appropriate for Mr G’s clinical circumstances and needs on each occasion. Our nursing adviser further confirms that nursing staff acted accordingly and escalated Mr G’s care on the two occasions that escalation was warranted, in line with NEWS guidance.
51. Our surgical adviser explains there is no guidance that prescribes the number or frequency of clinical/surgical reviews in these circumstances. We have also explained that nursing input was frequent and appropriate, and there was nothing documented to warrant any overnight escalation of care. That said, it is our view Mr G should have been reviewed again by the surgical team during the night because this formed a part of the SpR’s documented plan.
52. Yet, from the evidence we have seen and carefully considered, we do not find anything to suggest this would have resulted in any changed approach to Mr G’s management and treatment plan or had any material impact on the very sad course of events.
53. Had Mr G been reviewed at night, it would be reasonable to expect this would have involved an examination in line with GMC guidance. In considering records of the nursing checks that were completed through the night, it is likely Mr G’s abdomen on examination would have remained tender, and he would have reported pain. This would not have been new information to have warranted any additional or alternative management or treatment.
54. From the nursing checks that did take place, we know Mr G’s observations taken at 2am, 4am and 6am were normal, at 3.49am his blood gas results were normal, and his blood pressure remained reasonably stable throughout. It is likely any surgical review of these observations during the night would have also resulted in normal findings. This would not have warranted any additional or alternative management or treatment.
55. Our surgical adviser says it is possible the nighttime surgical reviewer may have requested a repeat blood test. They explain this is not a stipulation in guidance and would have been a decision made on clinical judgement. We are therefore not critical that repeat blood testing was not taken, as this was not clinically indicated or a requirement in line with guidance.
56. Even had blood testing been done, considering the normal ABG results recorded at 3.49am, there is no clinical indication any repeat bloods that may have been taken during the night would have reported anything other than normal results. This would not have resulted in any changed approach to Mr G’s management or treatment plan.
57. Our surgical adviser says it is possible the nighttime surgical reviewer may have considered the need for CT. They explain this is also not a stipulation in guidance and would have been a decision made on clinical judgement. We are again not critical that a CT scan was not considered or requested sooner, as this was not clinically indicated or a requirement in line with guidance.
58. Even had earlier CT been requested, we cannot know what it would have shown or if it would have warranted earlier surgical exploration. It may not have resulted in any changed approach to Mr G’s management or treatment plan. Even if it had done so, this would only have brought the course of events as they happened forward by just a few hours.
59. Our surgical adviser says requesting CT then taking Mr G back to theatre after the 7.48am clinical review was the appropriate course of action, considering the changed clinical findings at that time. Sadly, at the point the ischaemia was seen in surgery, it was widespread with considerable death of tissue and without any apparent cause. A surgical journal study found that patients of Mr G’s age had a 68 to 90% risk of death from bowel ischaemia of his same type.
60. Considering the extent of damage seen in theatre, Mr G’s bowel ischaemia was sadly acute, and rapidly progressing. Our surgical adviser explains this is not reversible, especially when there is no apparent cause found, as was the case for Mr G even at post-mortem.
61. Miss G has come to us with the view that due to failings in her father’s care there was a missed opportunity to identify his developing bowel ischaemia and give him earlier treatment, which could have prevented his death. Very sadly, we cannot link this view with the failing we identify.
62. We can say a nighttime surgical review should have taken place in line with the plan. We can say it is unlikely it would have changed Mr G’s management or the course of events. We cannot say this should have resulted in an earlier CT scan and earlier surgery, but even had that been the case, our surgical adviser says it is unlikely a difference of these few hours would have had any material impact to the finding of ischaemia, to any extent it would have changed the very sad, eventual outcome.
In conclusion 63. We find evidence to show Mr G was receiving appropriate treatment without delay throughout 21 November and during the night, and that nursing staff responded and escalated his care when appropriate. We do not find any time when Mr G’s condition warranted further clinical escalation, but because the earlier SpR review noted a plan for nighttime surgical review, we consider it a failing this was not done.
64. We have explained from the evidence we have seen, an additional nighttime surgical review would not have had any impact on the appropriate management plan and treatment Mr G continued to receive. When his clinical circumstances changed later that morning, we find appropriate nursing escalation to clinicians, and the appropriate clinical course of events proceeded.
65. Our Principles for Remedy say where poor service or maladministration has led to injustice or hardship, the organisation responsible should take steps to put things right. In this case the failing we have identified has not led to any injustice or hardship and for this reason we do not propose any further action or recommendation for the Trust.
66. We know how much her father’s death and the circumstances of it have affected Miss G. We hope our report can provide her assurance and has fully explained the reasons for our views.