Levofloxacin prescription/ admission delays
14. Mr A says clinicians inappropriately gave his wife an antibiotic medication (levofloxacin) which has known side effects, and they did not inform him about this. He also says clinicians left his wife on a trolley for too long in A&E on 27 July 2022.
15. The Trust says the antibiotic prescription for Mrs A’s infective exacerbation of COPD (IECOPD) was appropriate and it explains other recommended antibiotics were contraindicated in Mrs A’s case. It explains the volume of patients attending A&E requiring medical team review and hospital admission on 27 July meant Mrs A remained on a trolley bed in A&E for longer than it would want.
16. NICE Guideline NG114 says the recommended oral antibiotics for IECOPD are amoxicillin, doxycycline, clarithromycin, co-amoxiclav, cotrimoxazole or levofloxacin.
17. The Trust’s antibiotic formulary for respiratory systems says the first line antibiotics for IECOPD are doxycycline and amoxycillin or clarithromycin if the patient Is allergic to penicillin. The second line antibiotic is co-amoxiclav. The formulary says ‘patients known to have recent carriage of resistant organisms …. may be prescribed levofloxacin 500mg orally daily as first line therapy if organism is known to be susceptible’.
18. Levofloxacin is a type of fluoroquinolone antibiotic medication, which are used to treat a range of serious bacterial infections. Tendon disorders can be an ‘uncommon’ side effect of fluoroquinolone antibiotics.
19. The NHS constitution says at least 95% of patients attending A&E should be admitted, transferred to another hospital or discharged within four hours.
20. The notes show Mrs A arrived in A&E on 27 July at approximately 4:51pm. A nurse completed triage at 5:33pm and noted her presenting complaint was shortness of breath. An A&E clinician later examined Mrs A at around 7:41pm. They noted she reported a two-week history of increased breathlessness and intermittent wheeze. She had completed a course of clarithromycin (antibiotics used to treat chest infections) a week previously but she was still very unwell and was unable to mobilise more than five to ten yards due to breathlessness. She had a national early warning score (NEWS) of eight, which indicated the risk of clinical deterioration was high. Following examination, the clinical impression was IECOPD. The A&E clinician prescribed intravenous (IV) levofloxacin at 7:56pm to treat this and referred her to the medical team.
21. A clinician from the medical team reviewed Mrs A at 6:20am the following morning. On examination, the clinician noted Mrs A appeared unwell, was breathless but not distressed, very frail and she had a wheeze. Blood tests showed she had a raised neutrophil count which is a subset of white blood cells that fight bacterial infections, and a raised c-reactive protein (CRP) which indicates inflammation, often due to infection. The plan was to continue levofloxacin and prednisolone. Prednisolone is a type of steroid medication which helps reduce inflammation.
22. During the ward round later that afternoon, the consultant changed the levofloxacin prescription to oral, but did not make significant changes to the treatment plan. The consultant noted they counselled Mrs A on the side effects of levofloxacin including the risks of Achilles tendonitis. Tendonitis is inflammation of a tendon which connect muscle to bone. The Achilles tendon connects the calf muscle to the heel bone.
23. Mrs A was transferred to the acute medical unit (AMU) at 11:42am, approximately 19 hours after she arrived in A&E. At 6:17pm, clinicians reviewed Mrs A and noted she was alert and responsive and there was no ankle/ lower leg oedema (swelling). Clinicians discharged her home with oral levofloxacin, and a plan for daily support from the COPD team at home. During home visits with the COPD team on 29 and 30 July, Mrs A reported ankle pain, and an out of hours GP reduced her levofloxacin dosage. On 1 August 2023, Mrs A went back to A&E with a high respiratory rate and suspected Achilles rupture. An Achilles tendon rupture is a full or partial tear of the Achilles tendon.
24. Clinicians decided to admit Mrs A to hospital for further assessment and treatment. She again experienced an extended period in A&E before she was admitted to AMU. An ultrasound scan later confirmed she had a full thickness tear of her Achilles tendon, and her foot was placed in plaster.
25. As set out in NICE guidelines above, the recommended oral antibiotics for IECOPD are amoxicillin (which Mrs. A could not have due to penicillin allergy), doxycycline (which she could not tolerate), clarithromycin (which she had the week before but was unsuccessful), co-amoxiclav (also a penicillin, so not used because of her allergy), cotrimoxazole, or levofloxacin.
26. Our A&E adviser says because Mrs A had a high early warning score on arrival to ED, it was appropriate to start her on alternative antibiotics considering she had already taken clarithromycin and still had worsening symptoms. Our physician adviser tells us the antibiotic management largely adhered to NICE and local guidelines. Whilst co-trimoxazole can be used as an alternative to levofloxacin according to NICE guidance, it is not listed in the local antibiotic formulary for IECOPD. We recognise tendon issues can be a side effect of levofloxacin, and we are very sorry that Mrs A went on to develop Achilles tendon rupture after taking this medication. Given there were issues which prevented the prescription of other antibiotics recommended in the guidance, we consider the levofloxacin prescription was appropriate to treat Mrs A’s infection.
27. In line with paragraphs 32 and 33 of GMC Good Medical Practice guidance, doctors should give patients information they need to know and be considerate of people close to the patient. The GMC’s guidance on decision-making and consent says the patient should be at the centre of decision-making. Involvement of those close to the patient is mentioned in principle six which only applies if the patient lacks capacity.
28. We can see from the notes, the consultant discussed the side effects of levofloxacin with Mrs A on the morning of 29 August, including Achilles tendonitis. We consider this meets the GMC standard. There is no mention of Mrs A being confused in the notes or any indication she lacked capacity to make her own decisions. We appreciate it would have been very upsetting for Mr A to feel like he was left out of decision making regarding his wife’s medication and we are sorry for any additional distress he experienced. While it is considerate to share information with family members, it is not mandatory if the patient has capacity, and we therefore cannot see there was a requirement for clinicians to discuss the levofloxacin prescription or the risks with Mr A beforehand.
29. As above, the NHS constitution says at least 95% of patients attending A&E should be admitted, transferred to another hospital or discharged within four hours. Unfortunately, there are system wide pressures being faced by A&E departments across the country which the Royal College of Emergency Medicine and other royal colleges have acknowledged, and therefore this target is not always achievable. We can see Mrs A waited for approximately 19 hours before being admitted the medical ward. The Trust has recognised the delay and explained there was a high volume of patients attending A&E at that time and it has apologised for the lengthy wait.
30. Our A&E adviser tells us whilst Mrs A’s prolonged trolley time in A&E was not ideal, clinicians commenced appropriate treatment for her IECOPD (nebulisers and antibiotics) in line with NICE guidelines. We appreciate the delays would have been very distressing, given Mrs A was so unwell, and we are truly sorry they had to experience this. Given this is a nationally recognised issue and there is no indication Mrs A’s care and treatment was impacted by her extended time in A&E, we do not consider this was an indication of service failure.
Mobilising:
31. Mr A says staff did not assist his wife with mobilising during her hospital admission and this caused her to fall.
32. Paragraph 4 of the NMC ‘the code’ guidance says nurses must ‘act in the best interests of people at all times’.
33. The nursing notes show Mrs A was bed bound on admission as she was strictly non weight bearing due to her ruptured Achilles tendon. On 7 August, nurses noted Mrs A had reduced mobility and required assistance of one person to mobilise due to the plaster cast on her right leg. This continued until at least the 9 August, when nurses documented Mrs A was still unable to weight bear on her right leg. As a result of this, our nursing adviser tells us it would have been very difficult to mobilise her during this period.
34. Later in her admission, nurses noted Mrs A became very short of breath on minimal exertion, and was unable to mobilise any significant distance. This is also reflected in the therapy notes, which say Mrs A’s oxygen saturation dropped low on minimal exertion. On 15 August, a therapist noted Mrs A was able to mobilise with a frame but required regular rests due to shortness of breath. There are multiple nursing entries to say Mrs A was assisted to the toilet and from the bed to a chair by nursing staff and a wheelchair was used where appropriate.
35. Mrs A unfortunately tripped and fell when she tried to get up from the toilet on 24 August. There is no indication from the notes Mrs A had asked for assistance before trying to get up. Following the fall, the doctor noted Mrs A was ‘aware to call for help before going to the toilet etc.’
36. From the information in the nursing notes, we consider Mrs A was helped to mobilise appropriately where possible throughout her admission; however, this was very limited at times due to the constraints of her clinical condition. Clinicians referred Mrs A to the therapy team in a timely manner and they saw her regularly throughout her admission. We are very sorry to hear Mr A’s concerns about this and appreciate it would have very distressing. From the evidence we have reviewed, we consider the nursing team acted in Mrs A’s best interests, in line with NMC guidance. Given this, we do not uphold this part of the complaint.
Nutrition:
37. Mr A says the Trust failed to provide his wife with appropriate nutrition during her hospital admission from 1- 31 August, and this contributed to her overall weakness and clinical deterioration. The Trust says the nursing team documented Mrs A’s appetite was very poor and she would often decline diet and fluids, despite encouragement and verbal prompting.
38. NICE guidance on nutrition support for adults says:
1.2.1 Screening for malnutrition and the risk of malnutrition should be carried out by healthcare professionals with appropriate skills and training.
1.2.2 All hospital inpatients on admission and all outpatients at their first clinic appointment should be screened. Screening should be repeated weekly for inpatients and when there is clinical concern for outpatients.
1.2.6 Screening should assess body mass index (BMI) and percentage unintentional weight loss and should also consider the time over which nutrient intake has been unintentionally reduced and/or the likelihood of future impaired nutrient intake. The Malnutrition Universal Screening Tool (MUST), for example, may be used to do this. BMI is weight in kilograms divided by height in metres squared.
1.3.1 Nutrition support should be considered in people who are malnourished, as defined by any of the following: • a BMI of less than 18.5 kg/m2 • unintentional weight loss greater than 10% within the last 3 to 6 months • a BMI of less than 20 kg/m2 and unintentional weight loss greater than 5% within the last 3 to 6 months.
39. The notes show nursing staff completed a malnutrition universal screening tool (MUST) assessment for Mrs A on admission in line with paragraph one of the NICE guidance. A MUST assessment is a five-step screening tool used to calculate the risk of malnutrition in adults.
40. Mrs A’s initial MUST assessment on 2 August indicated she was at risk of malnutrition and nursing staff referred her for dietician review within seven days.
41. From the notes, we can see the dietician first reviewed Mrs A on 8 August. They noted she had not been eating very well and was keen to try nutritional supplements. They prescribed ensure compact nutritional supplements. Nursing staff completed weekly MUST assessments from 2 August to 31 August but there is no evidence they completed Mrs A’s food charts consistently during her admission. This means they could not accurately monitor her intake as required by the NICE guidance.
42. The dietician team again reviewed Mrs A on 18 August and noted she had poor oral intake and poor appetite. They noted although Mrs A’s weight was low, it had remained stable since admission and therefore she was likely to be meeting established nutritional requirements. Mrs A’s weight was the same on 1 August and 18 August at 35.5 kg. The plan going forward was to continue with the nutritional supplements and for her to have additional snacks/ food from home as she did not like the hospital food.
43. As noted above, there was a lack of consistent recording of Mrs A’s food intake. This was not in line with guidance, and we consider this is a failing. Our nursing adviser explains on the balance of probabilities, this likely had little impact on Mrs A as while she was not eating very much, her weight remained unchanged. Whilst the failing did not have an overall impact on Mrs A’s condition, we appreciate it would have caused distress. We therefore partly uphold this part of the complaint.