20. Mrs O’s key concern regarding her mother’s care is that, despite increasingly frequent episodes of severe symptoms and admissions to the Trust, her mother’s condition continued to deteriorate with ever more significant weight loss before her eventual bowel obstruction and death. She says the cause of this should have been suspected much sooner. She is concerned signs of mesenteric ischaemia were missed in the many investigations that were completed between the start of her mother’s symptoms and her eventual death.
21. Some specific points she raises are:
• the Trust considered her mother’s care as a series of separate care periods instead of as a whole, and failed to fully recognise missed opportunities to diagnose her • the Trust’s investigation identified two scans that showed narrowing of her mother’s mesenteric artery, and this was not recognised soon enough • she was advised by her mother’s surgeon that the MRI scan showed evidence of MI, yet this was not reported • despite the Trust’s investigation accepting that in hindsight her mother had symptoms of MI in August 2020, it would not agree to do a Serious Incident review.
22. When investigating, we look at what happened, and what should have happened. If there is a gap between these two things we consider if is any impact or injustice, and whether a Trust has done enough to put this right already. In the process of doing this we will address the specific concerns set out above. We have reviewed Mrs E’s care in chronological order and cover some key periods below before considering the overview of her care.
Care prior to August 2020 admission 23. Prior to the events complained about, Mrs E’s known clinical history included extensive vascular disease (poor circulation due to narrowed arteries), previous stroke, and having suffered irritable bowel syndrome (IBS) since the 1990’s.
24. More recently, in March 2020, Mrs E required a femoral bypass operation to restore blood flow to her right leg after the circulation failed. Records from this time confirm her weight at 67.9kg. She had lost a significant amount of weight by the time she was admitted to hospital from the ED in August 2020.
25. From June 2020 Mrs E began to suffer with abdominal pain, a loss of appetite, and nausea. The pain continued and Mrs E started to lose weight and suffer altered bowel habits, suffering constipation and diarrhoea. She sought the help of her GP, who initially thought her symptoms could be due to irritable bowel syndrome (IBS) which she had an established history of.
26. In July 2020, Mrs E’s pain was more severe. Her GP suspected that she had a bowel obstruction, and she went to the emergency department (ED). The Trust did an x-ray and concluded, as there was no blockage detected, she may have suffered a bowel blockage from constipation which had passed through. She was prescribed laxatives and discharged.
27. Mrs E had several attendances at the ED during August 2020. When her condition did not improve, she was admitted to hospital. At this time, she weighed around 55.2kg, a loss of around 12kg since March. Our gastroenterologist adviser said the first opportunity to suspect alternative causes of her symptoms was during this admission.
28. We see that it was not unreasonable prior to this point to have suspected IBS and/or constipation, as the cause. Mrs E did have a longstanding history of IBS, and this was consistent with her GP’s thinking.
August 2020 admission 29. The immediate main concern of the medical team at the time of Mrs E’s admission on 9 August 2020 was that she may have cancer. This is not unreasonable for a patient with symptoms including recent unexplained weight loss. A CT scan was ordered to look for signs of malignancy. The results were reassuring, showing no concerning signs of disease and the small bowel and colon were noted to look normal.
30. Our radiology adviser explained it is possible to identify a narrowing of the superior mesenteric artery (SMA) which supplies blood to the small and the first part of the large intestine, if looked for. However, the scan was not optimised for visualising blood supply. They also explained this would not be a feature that should be flagged up on such a scan.
31. They explained the person ordering the scan would have been fully aware of, and to some extent expect, problems with the blood supply to the bowel. This would not need a scan to bring it to their attention as it would be known already that Mrs E had extensive narrowing of arteries throughout her body through her past medical history. The reporting radiologist would not be aware of this unless specifically mentioned in the scan request.
32. Our radiologist adviser also explained that later scans establish that this narrowed artery was probably not a key factor in Mrs E’s later deterioration, or of particular use in making an MI diagnosis. We explain more on this later when considering impacts. We hope this is of some reassurance to Mrs O that this did not contribute to missing MI.
33. Following the scan result, consideration of the cause of Mrs E’s symptoms then returned to possible bowel conditions. Input was sought from the Trust’s gastroenterology team. While she waited for this her symptoms were treated, which she responded well to.
34. The Trust has explained to us that, due to pressures on services from the Covid pandemic at the time, it was not possible for the gastroenterology team to see Mrs E. It also explained that this adversely affected how quickly it could provide many of its services during 2020, including diagnostic testing and sharing results. We recognise this was not ideal but an unavoidable resourcing problem across the NHS at that time which led to delays in availability of specialist care. We have taken this into account in our consideration of later events.
35. As Mrs E’s condition improved, the Trust returned to a working diagnosis of IBS, or some other associated digestive condition, and discharged her home on 14 August with a referral to the Trust’s gastroenterology team to arrange a follow up in its outpatient clinic. The referral asked for consideration of whether a colonoscopy was needed to explore the possibility of other causes.
36. We see this was the right thing to do in the circumstances since it had not been possible for a gastroenterologist to see Mrs E yet, she was now fit to discharge, and a definitive diagnosis had not been made yet.
37. At this point Mrs E booked to see a gastroenterologist privately and was seen within the week. The consultant arranged a gastroscopy and colonoscopy with biopsy, completed on the NHS in October 2020, to look for signs of cancer or inflammatory bowel disease (IBD). These tests did not identify signs of either condition. We can understand why Mrs E took this step, as it would have been apparent to her the Trust was not able to get her seen as quickly. These events had also not occurred yet at the time of her admission.
38. Our gastroenterologist adviser noted Mrs E’s relevant clinical history and the BMJ Best Practice Ischaemic Heart Disease guidance. They said if a patient presents with significant vascular risk factors, abdominal pain, diarrhoea, and weight loss, and had a normal gastroscopy and colonoscopy, most gastroenterologists would question a diagnosis of MI. They consider opportunities to make a diagnosis started to be missed from August 2020. Specifically, they said a diagnosis could have been made in August 2020 but, in any case, should have been made earlier than it was eventually was.
39. They also qualified this by explaining MI is an uncommon and complex to diagnose condition which they would not expect an ED department to make, and we should not be critical of the ED team for not making an MI diagnosis during any of Mrs E’s attendances. We recognise that ED care is focused on acute emergency care and an ED team would, correctly, defer to more specialist knowledge for such a diagnosis.
40. When considering this, there are some other facts we took account of. Mrs E did not see a gastroenterologist in August 2020. Her first NHS gastroenterology appointment was in November 2020. She had not undergone a gastroscopy, colonoscopy, or had biopsies taken for testing yet during that admission.
41. The Trust’s responses state that MI is uncommon and would be a difficult diagnosis to make, as it can present with unspecific symptoms common to a number of other conditions and be hard to confirm. This is consistent with our advice on the condition. We note the doctor who treated Mrs E during her admission to hospital in August 2020 apologised for not suspecting MI the time and that they now consider that, in hindsight, they could have considered this as a possible cause.
42. They go on to explain that there are two types of scans which can confirm an MI diagnosis. These are both specialised, not available to ED departments, and would require a high suspicion of the condition to arrange first (our radiologist adviser confirmed this). The doctor accepted they failed to consider the possibility of MI and refer Mrs E on to the vascular and general surgical specialisms earlier (whom we assume could have ordered the scans in question).
43. At this point it is useful to explain how differential diagnosis helps to diagnose the cause of illness. A differential diagnosis is a list of conditions known to cause the symptoms a patient is suffering, and which may be causing them. A diagnosis is arrived at by process of elimination via tests/examinations/scans (usually focusing on most likely or serious causes first) until it is possible to confirm with clinical evidence presence of the underlying cause.
44. We see the Trust did identify a missed opportunity for an earlier diagnosis here, by including MI as a differential diagnosis, along with the course of action which would have potentially led to an MI diagnosis. Our advice indicates it would be unjust to overly criticise a generalist doctor for failing to consider MI in the list of differential diagnoses at that time. We also know that Mrs E’s symptoms were common to multiple causes and a referral to a specialist in gastroenterology was pending to help narrow this down.
45. GMC Good Medical Practice, Domain 1: Knowledge, skills and performance - Apply knowledge and experience to practice states doctors should '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'.
46. Investigations up to this point, including the CT scan, did not reveal any signs of cancer or other conditions, which was reassuring. This did not completely rule out those possibilities but did suggest there was no immediate acute emergency that needed addressing. The doctor then ensured Mrs E was referred on to a suitable specialist to consider further investigations into the cause of her symptoms. We therefore see that the doctor acted in line with GMC standard of care.
47. These mitigating factors should be taken into account. It is commendable that the doctor has reflected on their clinical practise and recognised where they could have done better. We cannot say the Trust should have had a strong suspicion of MI during that admission. There were other possibilities to explore and rule out first. The diagnostic process was ongoing with no indication there would not be time to complete those investigations.
48. Our current view is the care up to this point was of a reasonable standard and in line with GMC standards. While it may have been possible to start suspecting MI at this earlier point, we do not think the Trust should have been expected to as a minimum standard of care. We cannot say this was a failing for that reason, but it can be considered an individual shortcoming, as recognised by the doctor in question.
49. The Trust, and its doctor, has addressed this in a responsible and proportionate manner so we are unable to identify anything more that could, or should, be done to learn from that missed opportunity. We recognise that Mrs O will have concerns about the impact of this on her mother, which we will address later in this report.
Care post August 2020 admission 50. Mrs E had her NHS gastroenterology follow up appointment on 6 November 2020. This happened to be with the same consultant who had provided her private care, and who had arranged her further investigations to narrow down the possible cause of her ongoing symptoms.
51. At the time of her appointment, Mrs E had by now undergone her gastroscopy and colonoscopy on 21 September, which again showed no signs of cancer, but did reveal some bowel inflammation. Biopsies had also been taken to test for IBD, which was now the main suspected differential diagnosis due to the presence of blood markers (faecal calprotectin) associated with IBD. However, in the November appointment, the gastroenterologist explained the biopsy results had not indicated IBD.
52. Due to the continued lack of a clear cause, the consultant planned an MRI as a further test to investigate the possibility of small bowel Crohn’s disease (a specific type of IBD). This was completed on 11 December. The results showed no signs of this. Mrs E chased up the results on 22 December 2020. Once aware she opted to see her consultant on a private basis on 30 December 2020 (as the NHS was unable to see her before 29 January 2021). It was only once the MRI results were considered by the consultant on that day that MI enters consideration.
53. We should not be critical of the length of the period after 6 November till the next review of Mrs E at the end of December. We accept this was a consequence of the pressures on NHS services during Covid times. It took time to arrange the scan and report on it. We see there was nothing in the scan results which would have prompted immediate review as the results showed no issues suggesting an acute problem. Due to this, we recognise there was no practical opportunity for the consultant to review Mrs E again sooner.
54. In the Trust’s responses, the consultant explained they had spared no effort in their attempts to make a diagnosis. This is inconsistent with our adviser’s viewpoint. They highlight that, following normal gastroscopy and colonoscopy results, and based on Mrs E’s clinical history and multiple risk factors alone, most gastroenterologists would question a diagnosis of MI. They noted there is no obvious consideration, or diagnosis of, MI in any of the Trust’s records.
55. The biopsy results were still outstanding following tests in September 2020. By the time of the 6 November outpatient discussions the results were known to the consultant, and showed no evidence of IBD. We recognise there is some argument to support the view that, prior to this, it was reasonable to consider IBD as the most likely cause and efforts to find evidence to confirm a diagnosis were still ongoing.
56. After the biopsy results, this looked much less likely. It was not unreasonable to continue the line of inquiry into this with the MRI scan, but this would not have to be exhausted to consider other possibilities. The review in November represents a clear opportunity to consider other causes, including MI as a possible differential diagnosis.
57. Mrs E had many of the significant risk factors for MI, as outlined in the BMJ guidance a gastroenterologist would be aware of. The lack of consideration of this possibility by this point is less justifiable. There is no evidence to indicate MI had been considered by the consultant, or if it had, why it was not now included in investigations.
58. We should at this point address concerns about Mrs E’s repeated attendances to ED during this period and whether other opportunities to consider MI were missed. As explained earlier, our gastroenterology adviser said ED teams would not be expected to make a diagnosis of MI. It is a complex to diagnose condition, and they said we should not criticise ED doctors for not making such a diagnosis.
59. We have also established the two types of specialised scan needed to make such a diagnosis would not be available to the ED department. We therefore consider it would be right for the ED team to defer to any specialists working to establish a diagnosis, to focus its efforts on Mrs E’s immediate needs.
60. Mrs E was admitted to hospital on 19 November for two days on the advice of her consultant who felt she needed blood tests. She felt faint and weak, in severe pain, had altered bowel habit and had been unable to eat. Following blood tests and an abdominal Xray that did not reveal any clear acute cause, she was discharged home. On 9 December she was admitted to hospital via ambulance after fainting and again being in severe pain. She was discharged home after being rehydrated with IV fluids.
61. We asked the Trust if the ED had considered escalating Mrs E’s care at these times. It confirmed ED was aware of the ongoing investigations by gastroenterology, made the team aware of her admissions, and focused on addressing her immediate acute condition at those times. The ED team were aware of the current status of those investigations, which at the time were still treating IBD as a possibility (and to a lesser extent had still not ruled out IBS as a factor). ED was aware Mrs E was awaiting an MRI scan. This was an ongoing process, and this informed the ED team’s decision making in terms of the possible causes during these times when her symptoms were very intense.
62. We see the ED team did consider escalating matters and acted appropriately. The ED team ensured there was no urgent condition that needed its immediate intervention as arrangements were already in place for longer term investigations into an underlying cause.
63. Our current thinking is that the weight of clinical evidence was sufficient to reasonably expect suspicion of MI by November 2020. We recognise Mrs E had not had any more acute admissions since August at this point, but she was still strongly symptomatic and still losing weight. This does appear to be an individual failing, one of flawed clinical judgement, on the part of the consultant. As with the August admission, we do not consider the ED team would have a role to play intervening in that diagnostic process.
64. We think, in line with BMJ guidance, the consultant should have requested a doppler scan or angiography, at that point. Or if not, at least some documented clinical reasoning be provided to show Mrs E’s relevant history had been taken into account, and why her vascular disease was still not at that point considered as a contributory factor to her illness.
65. If not for this failing, investigations to confirm or rule out MI would have been arranged nearly two months earlier than they were. While the true missed opportunity is not as far back as Mrs O feared it was, it is still significant, and we agree the Trust has not fully recognised this in its investigations. We therefore see that Mrs O’s concerns were to an extent justified.
66. We therefore partly uphold this part of the complaint. We next go on to explore what the scanning imagery can tell us about the progress of Mrs E’s MI, whether the Trust should have conducted a Serious Incident review as asked, and the impact of any failings.
Consideration of the Serious Incident Framework and impact of failings 67. At this point is helpful to outline what our radiologist adviser was able to tell us about the scan’s Mrs E had over the course of the six months in question.
68. They explained the CT scan from August 2020 was not optimised for visualising mesenteric arteries. It does show a narrowed SMA at its origin but, on a wider scale, the CT scan also features showing extensive narrowing of arteries thought the body. However, the later CT scan from January 2021 shows Mrs E’s body had fed the bowel through alternative arteries, providing additional blood flow to bypass the narrowed section over time.
69. The report states ‘there is no definite evidence to suggest ischaemia on this study’. This means the narrowing present on the August scan is unlikely to have been the main reason for poor blood supply to the bowel. Therefore, the narrowing of the SMA visible on the earlier scan is unlikely to have been as significant as feared.
70. Also, the later CT scan established the bowel blockage Mrs E suffered in early 2021 was in the descending colon, which is supplied by a different artery, the inferior mesenteric artery (IMA). The biopsies taken from the colon in September 2020 did not show any signs of ischaemia to further increase suspicion of disease in this part of the bowel.
71. The MRI scan done in December 2020 showed a normal bowel appearance. Our radiologist adviser explained that, in the event the narrowed SMA had been noted in August, the MRI results would have not indicated this was affecting the bowel’s functioning. This further reduce the significance of the narrowing visible on the August scan. While we can understand why Mrs E’s surgeon told Mrs O that ischaemia was evident on the MRI scan, we recognise ischaemia was evidenced throughout her body due to her advanced vascular disease.
72. Our radiologist adviser concluded the cause of Mrs E’s impaired blood supply to the bowel was due to occlusion (‘furring up’ or narrowing) over time of the small-end and capillary blood vessels feeding the bowel from the larger SMA and LMA vessels. These features would be too fine to detect on the scans performed. Mrs E’s clinical history would point to this being likely, as her vascular disease was body-wide, but there was nothing missed on the imagery. They said, even if diagnosed earlier, there would be no treatment that could resolve this problem with the blood supply.
73. We hope this reassures Mrs O on her concerns about why the scans performed were not material in making a diagnosis for her mother. Her clinical history and risk factors were much more relevant. In short, as the Trust said, there would need to be a suspicion of MI to prompt specific scans to look for it, rather than scan results prompting that suspicion.
74. Our gastroenterologist adviser said that, while MI should have been diagnosed sooner, from their experience of dealing with patients with a similar history and presentation, it would be unlikely that she would be a candidate for active treatment such as vascular reconstruction or stenting. They said, it would have allowed an opportunity to discuss Mrs E with the vascular surgeons, but she would most likely have only been offered supportive care. We see this is consistent with our radiologist adviser's observations on lack of options to address the small blood vessel disease progress.
75. In their view this was not an avoidable death. And, sadly, the outcome would have been the same with an earlier diagnosis. They explained had Mrs E received the supportive care, there would have been a care plan in place, including dietician input to provide advice. This would have potentially avoided the repeated ED attendances and the uncertainty of not knowing the reason for her periodically extremely painful and distressing symptoms.
76. We concluded the impact of failing to consider an MI diagnosis earlier is not as severe as feared. There does not appear to have been any way to have increased her chances of living longer, or to have predicted what happened in earlier 2021. It would still have resulted in missed opportunities to support Mrs E better so her distress and suffering could have been managed better for her remaining time. The Trust has not recognised this impact fully yet.
77. In relation to Mrs O’s request for a serious incident investigation, we considered carefully the function of this process and the guidance around such reviews. The Serious Incident Framework Part One: Definitions and Thresholds 1. What is a Serious Incident? Sets out the parameters of that should be considered a serious incident.
78. The Serious Incident process was developed to identify and take learning from systemic failings. The definition is left deliberately non-prescriptive in what constitutes a serious incident to not limit the scope. However, it should be an event which highlights a ‘systemic weakness’ in a system or process leading to ‘serious harm’. Thes events should be ones where the potential for learning is so great it would justify additional resources to mount a comprehensive response.
79. Systemic failings include events signalling systemic failures within a commissioning or health system. Examples of serious harm defined in the framework include, permanent severe harm, continuous pain of over 12 weeks, continuous non temporary impairment of sensory motor or intellectual function of over 28 days.
80. In response to Mrs O’s request for a serious incident investigation, the Trust did reassure her that while one had not taken place, her concerns had been taken seriously and investigated under the complaints process. While the Trust could have clarified why the Serious Incident Framework was not a suitable process to consider Mrs O’s concerns under, we do agree this was the right decision and the Trust acted in line with the framework.
81. We do not think this was a systemic issue, but rather it was an individual failing in the diagnostic thinking of a clinician. Also, the impact of this failing was not as severe as feared or as defined as ‘serious harm’ the Framework. We do not doubt Mrs E suffered significantly in the time following the missed opportunity to diagnose her earlier, but much of this was not rooted in that failing, and unavoidable with earlier diagnosis.
82. We make recommendations to address that impact, but do not uphold the concern about the Trust’s decision to not proceed to a serious incident investigation. While there may be lessons that can be taken from what happened, we are not seeing a need for, or scope, widespread organisational learning this process was intended for.