16. When looking at whether there have been failings in the service provided, we consider what should have happened. We look at what did happen, and if this was different. If it was, we consider if it fell so far short of what should have happened to amount to a failing. If there was a failing, we look at what impact this had. If it caused a negative impact to the individual concerned, and the organisation has not done enough to put that right, we can make recommendations for it to take further action.
17. Mrs R complains about the treatment her mother received at the Trust between 1 March and 10 March 2021. She says the Trust did not address her mother’s symptoms appropriately and did not identify her mother’s bowel was blocked as quickly as it should have done.
18. The Trust said it found Mrs L had shortness of breath and blood tests showed she had an infection. The Trust says the chest X-ray showed she had pneumonia and it began a course of antibiotics to treat Mrs L accordingly. The Trust said it considered bowel obstruction was an unlikely diagnosis because Mrs L’s bowel was soft and not swollen, also sounds through a stethoscope suggested her bowel was normal.
A&E
19. We have seen from the records on 1 March 2021, Mrs L was taken by ambulance to A&E at the Trust. She was complaining of a four day history of abdominal pain, vomiting, not able to keep food down, being short of breath and constipation. The Trust recorded Mrs L’s primary problem was abdominal pain.
20. The Bowel Pain Study explains, clinicians must consider multiple diagnoses, especially those life-threatening conditions that require timely intervention to limit morbidity and mortality.
21. Best Practice guidance on small bowel obstruction explains, small bowel obstruction is a medical emergency which requires early diagnosis and intervention. Typically, small bowel obstruction presents with the combined symptoms of abdominal pain, bloating, vomiting, and constipation. Diagnosis is generally based upon clinical features and confirmed with a CT Scan. Patients who are treated in a timely manner have a very good prognosis. If untreated, bowel obstruction is often fatal.
22. The Bowel Pain Study adds, in abdominal examination, abdominal auscultation (listening to sounds) is of very limited diagnostic utility, and prolonged listening for bowel sounds is an ineffective use of time. It may reveal high pitched sounds in early small bowel obstruction or silence in bowel obstruction or abdominal catastrophe.
23. The records show the Trust ordered blood tests, examined Mrs L’s abdomen and listened to bowel sounds. The blood tests showed Mrs L’s C-reactive protein (CRP) was 211. CRP is a protein released into the blood which indicates infection or other inflammation. CRP increases proportionately with infection severity. Normal CRP for a woman of Mrs L’s age is less than 10.
24. Upon examination the Trust found crackles at the bottom of both lungs, minimal tenderness in her abdomen and normal bowel sounds. Based on this examination the Trust recorded a working diagnosis of COVID-19 and constipation.
25. A chest X-ray was completed. We have seen a doctor in A&E reviewed the X-ray at the time. The Trust recorded it identified small bowel loops from the X-ray but considered these were not consistent with an obstruction or perforation. A radiology report of the X-ray was not completed until 29 July 2021 after Mrs L’s death which confirmed multiple dilated loops of the small bowel which can be an indication of a bowel obstruction. The Trust have said this was an oversight and reporting should have taken place sooner.
26. The Trust diagnosed pneumonia and ruled out COVID-19. It began to treat her with antibiotics and moved her to a ward.
27. Our gastroenterologist adviser says the symptoms Mrs L presented with are typical of those of a patient with a small bowel obstruction. As set out in the Best Practice guidance on small bowel obstruction, small bowel obstruction presents with the combined symptoms of abdominal pain, bloating, vomiting, and constipation. All symptoms described by Mrs L on admission.
28. Best Practice guidance on small bowel obstruction states with symptoms of abdominal pain, vomiting, nausea and constipation, a CT scan of the abdomen and pelvis is key. NCEPOD report on Acute Bowel Obstruction states early recognition, further investigations and a CT scan is essential to identify obstructions.
29. When Mrs L’s X-ray was reported on, the findings identified moderately dilated small bowel loops. When the small bowel is obstructed it can lead to a build up of gas and fluids causing bowel loops, or segments of intestine, to expand in diameter. The Trust failed to consider Mrs L’s symptoms along with the small bowel loops identified in her X-ray and take action for further investigations. This is a missed opportunity to identify a bowel obstruction and is a failing.
30. We also note Mrs L spoke Turkish as her first language. Although the records show there seemed to be a language barrier, there is no record of an interpreter or support for Mrs L’s communication needs.
31. Our acute medicine adviser said a language barrier likely meant the Trust missed an opportunity for Mrs L to put added emphasis to her abdominal issues. This may have allowed her symptoms to be explored further. GMC Good Medical Practice tells us clinicians must take steps to meet patients’ language and communication needs, so they can support them to engage in meaningful dialogue and make informed decisions about their care.
32. There is no record of the Trust taking steps to meet Mrs L’s communication needs. This is a failing.
33. The records do show after admission on 1 March the Trust had a conversation with Mrs L’s daughter. She said her mother had not opened her bowels for two days and was unable to keep anything down. Our emergency medicine adviser tells us this information was indicative of a more serious problem such as a bowel obstruction and would usually require a surgical doctor to review the patient. We have not seen any action was taken.
34. GMC Good Medical Practice guidance says doctors must promptly provide or arrange suitable advice, investigations or treatment where necessary and refer a patient to another practitioner when this serves the patient’s needs.
35. We understand how important it is to have any symptoms taken seriously and fully considered. We recognise this can be even more important when there may be a language barrier. Best Practice guidance on small bowel obstruction says small bowel obstruction is a medical emergency which requires early diagnosis and intervention. On 1 March 2021, the Trust ruled out bowel obstruction caused Mrs L’s symptoms. It based its decision on a manual examination and listening which the Bowel Pain Study tells us offers little diagnostic benefit. The Trust also ruled out Mrs L had a bowel problem despite an X-ray indicating an abnormality.
36. We understand how distressing it can be when a patient cannot fully communicate their symptoms. We do not think the Trust provided support for Mrs L to communicate in line with GMC Good medical practice.
37. We recognise how important it is for all of a patient’s symptoms to be carefully considered. The Trust did not fully consider Mrs L’s symptoms in line with Best Practice guidance on small bowel obstruction, refer for a CT scan in line with NCEPOD report on Acute Bowel Obstruction or take steps to ensure she could effectively communicate her concerns. We consider the Trust failed to do enough to adequately rule out bowel obstruction caused Mrs L’s symptoms. We consider the impact of these failings later in the report.
Ward
38. Mrs L was moved from A&E to a ward for treatment of pneumonia and monitoring later in the day on 1 March.
39. On 2 March, the Trust recorded Mrs L’s chest was relatively clear with low oxygen requirement. Our gastroenterologist adviser tells us this suggests Mrs L’s pneumonia was improving.
40. The records show a vomiting episode was recorded on 2 March and anti sickness medication was administered. On 3 March, the records say Mrs L had further episodes of vomiting, was feeling constipated and had pain in her upper abdomen area. The records do not reflect any abdominal examination for this occasion. These entries show her abdominal symptoms continued during her admission.
41. On 3 March, Mrs L was documented as still having shortness of breath and a CT scan was arranged for the 4 March to rule out a blood clot. Because of a number of issues with Mrs L’s cannula, the CT scan was not completed and postponed for a later date.
42. The records dated 4 March show Mrs L’s CRP as 189 reduced from 211 when she was first admitted. This was likely an effect of the improvement in her pneumonia. However, her CRP was still greatly elevated over the normal CRP of less than 10. We see no CRP recorded on 5 and 6 March.
43. On 4 March, Mrs L is recorded as not having opened her bowels on that day and further episodes of vomiting were documented as well as abdominal pain. There is nothing in the records to show further assessment of her symptoms was carried out.
44. A CT scan was performed on 6 March. The records show she had a CT pulmonary angiogram which included some imaging of her upper abdomen. The findings were reported the following day on 7 March and found Mrs L had a small bowel obstruction.
45. An abdominal CT scan on 7 March confirmed the small bowel obstruction and showed Mrs L’s bowel had perforated. Blood test results showed Mrs L’s CRP had increased to 402. She had developed a fever. At this point the Trust changed her antibiotics from co-amoxiclav to Tazosin, an antibiotic which treats abdominal infections.
46. The records do not show information to suggest the infection was being caused by any other explanation apart from the bowel obstruction. The Trust changed its care plan for Mrs L on 7 March and began to treat her for sepsis in line with NICE Sepsis Guidance.
47. Following the results of the CT scan on 8 March, the Trust operated on Mrs L and found an abscess had blocked her bowel. The abscess had become infected and her bowel perforated causing waste and air to leak into her abdominal cavity. Following surgery, the Trust began to treat Mrs L on an appropriate Sepsis pathway. Mrs L developed sepsis and multi-organ failure. She sadly died on 10 March.
48. The Trust explained in its complaint response, based on its initial examination, it was satisfied there were no obviously abnormal findings to suggest bowel obstruction.
49. We have seen on 1 March, Mrs L presented to the Trust complaining of a four-day history of abdominal pain, vomiting, could not keep food down and was constipated. Best Practice guidance on small bowel obstruction explains, such symptoms are consistent with bowel obstruction. We have also seen her abdominal symptoms continued without further assessment during her admission until she had a CT scan in 6 March. With this in mind, we consider it was likely Mrs L’s bowel was obstructed at the time she presented to the Trust. We consider the Trust did not do enough to explore all of her symptoms and there was a missed opportunity to diagnosis the obstruction earlier. This is a failing.
50. Mrs R has raised concerns about how her mother was encouraged to eat during the admission. The records document Mrs L was encouraged to eat at regular meal times during her admission.
51. NCEPOD Acute Bowel Obstruction advises clinicians to undertake, record and act on nutritional screening. The records for Mrs L’s nutritional intake during her admission were not adequately captured. They show her appetite was poor and her oral intake was documented as low but the Trust continued to encourage Mrs L to eat.
52. The records also document the Trust administered an enema to Mrs L on 3 March. Our gastroenterologist adviser tells us enemas would not have made the obstruction worse or caused the perforation but explains patients with bowel obstruction should be nil by mouth as feeding can increase the risk of perforation.
53. Having a delayed diagnosis during her admission meant that she was inappropriately encouraged to eat when she should have been nil by mouth. We consider the impact of this below.
Impact
54. Mrs R says because of the Trust’s actions it failed to identify her mother’s bowel was blocked. She says this meant the Trust continued to feed her mother and administer her with enemas which caused pressure around the blockage. The actions caused her mother significant increasing pain and discomfort and led to her bowel perforating. Mrs R says the actions caused her mother’s premature death. This has caused her and the family distress and question whether things could have been different which has affected their grieving.
55. We can see from the evidence, Mrs L was admitted on 1 March 2021 displaying symptoms of a bowel obstruction. This was not identified by the Trust until 7 March.
56. We think had the Trust fully investigated her bowel issues at an earlier opportunity, it is likely her bowel would not have developed an infection, perforated, led to sepsis and subsequent death.
57. NICE Sepsis Guidance explains, Sepsis is a person’s overwhelming whole-body immune response to an infection or an injury to the body. Sepsis occurs unpredictably and can progress rapidly to septic shock. Once this happens, multiple organs—lungs, kidneys, liver—can quickly fail, and the patient can die.
58. Treatment Study summaries show several studies on sepsis and septic shock which show the delayed administration of antibiotics is associated with detrimental outcomes.
59. Mrs L may have developed sepsis from either her unavoidable pneumonia or her undiagnosed bowel problems. We looked closely at Mrs L’s medical records to see what they told us about her infections and sepsis.
60. Whilst pneumonia had potential to lead to sepsis for Mrs L, her temperature remained normal, and CRP was reducing. The records suggest she was recovering from pneumonia. We see no reason why she would not have continued to improve had infection not occurred elsewhere.
61. On 7 March 2021 Mrs L’s temperature raised, and her CRP was 402. She had developed a bowel infection which the Trust began to treat with antibiotics suitable for abdominal infections.
62. When the Trust operated on Mrs L, it found an abscess causing her bowel blockage had become infected. This in turn caused her bowel to perforate, and waste to leak into her abdominal cavity.
63. We consider had the Trust carried out a CT scan following the initial X-ray which identified dilated loops it would have found and treated Mrs L’s blocked bowel around 2 March 2021 and it would likely have prevented her bowel from developing infection. This in turn would have prevented Mrs L’s bowel from perforating, her developing sepsis, and would have prevented her subsequent death.
64. Failing to fully investigate her symptoms delayed the Trust diagnosing and treating her bowel obstruction by around five days. In this time, she developed an abdominal infection which led to her bowel perforating, and she developed sepsis. Despite it changing Mrs L’s treatment to a sepsis pathway, the Trust was unable to prevent her deteriorating, her organs began to fail, and she died.
65. We consider, had the failing not occurred, it is likely Mrs L would not have developed an abdominal infection and sepsis, and she would likely have survived. We consider the failings led to the avoidable death of Mrs L. We understand how devastating it will be for the family to learn this and for them to imagine how things could have been different.
66. We can also link the continued encouraging Mrs L to eat would have likely caused her further distress and discomfort at what was already a challenging time.
67. We understand how difficult this time has been for Mrs R and her family and recognise the distress caused by the failures identified above. We recognise the death of a parent can have a profound effect on someone especially when things could have gone differently. We make recommendations below.