A&E visits
22. Mr E attended A&E twice in November 2022. The first time he attended in pain and having difficulty breathing. The Trust gave him oral antibiotics and discharged him.
23. He returned a week later with worsening breathing problems. The radiology reports stated ‘unchanged appearance.’
24. When Mr E attended for a third time, in early December 2022, the Trust admitted him into hospital and gave antibiotics directly into his vein.
25. Mrs E says the unchanged appearance in the second report was an indication the antibiotics were not working. She says the Trust should have admitted to hospital and treated Mr E sooner.
26. The Trust say oral antibiotics were a reasonable course of action initially for Mr E’s chest infection.
27. The records show when Mr E attended A&E the first time in November 2022, he had a productive cough and increased shortness of breath. Blood tests showed he had inflammation in his body and a raised white blood cell count which are indications of an infection.
28. Clinical observations showed Mr E was receiving adequate oxygen and had no signs of respiratory distress. The Trust prescribed moxifloxacin which is a type of antibiotic to treat infection.
29. We are sorry to hear how the second time Mr E attended A&E in November 2022 he felt much more unwell. Blood tests showed the inflammation had improved. A chest X-ray showed stable appearances.
30. There is no formal guidance regarding when a patient should or should not be admitted to hospital as this will differ greatly dependent on individual circumstances.
31. Our adviser explained stable or improving test results would mean a hospital admission was not mandatory.
32. GMC guidance for good medical practice says clinicians must:
• adequately assess the patient’s conditions, taking account of their history (including the symptoms and psychological, spiritual, social and cultural factors), their views and values; where necessary, examine the patient
and
• promptly provide or arrange suitable advice, investigations or treatment where necessary.
33. We consider the Trust acted in line with this. It listened to Mr E’s symptoms and arranged appropriate tests such as the blood tests and X-ray. The Trust also safety netted by advising Mr E to return if things did not improve.
34. The records show Mr E agreed with the discharge plan which is also in line with GMC guidance for good medical practice. It says: ‘all patients have the right to be involved in decisions about their treatment and care and be supported to make informed decisions if they are able to.’
35. We are sorry to hear how Mr E suffered with his symptoms. From what we have seen, the Trust acted in line with GMC guidance, therefore we do not uphold this part of the complaint.
Abdominal drain
36. Mrs E says the Trust should have arranged an abdominal drain during his first admission. An abdominal drain is a medical procedure used to remove excess fluid. Mrs E says Mr E repeatedly mentioned how bloated he felt.
37. In its response the Trust say it was aware of small volume ascites that did not require draining. Ascites is a condition causing fluid to collect in the abdomen.
38. Mrs E says her husband lost 10lbs during this admission as the discomfort he suffered from abdominal swelling meant he could not eat. She says once he had the drain during his second admission his appetite much improved.
39. A CT scan (computer guided X-ray) showed ‘new small volume ascites’ (a small amount of fluid build-up).
40. The records show Mr E was able to mobilise and shower himself. There are frequent mentions of him eating and drinking well and independently in the nursing notes. It says ‘patient comfortable.’ The records describe Mr E’s abdomen as soft and non tender or mild tenderness.
41. Cancer research explains ascites can make your tummy feel tight and very uncomfortable. Other symptoms may include bloating, abdominal pain and difficulty sitting comfortably and moving around. It says it often develops over a few weeks.
42. There is no specific guidance for when to drain ascites as this will differ dependent on each person’s circumstances.
43. Our adviser explained to safely drain ascites there must be significant volume otherwise there is an increased risk of making a hole in the bowel.
44. When Mr E eventually had his ascites drained in January, the volume of the ascites had increased.
45. GMC guidance for good medical practice says clinician’s must adequately assess the patient’s conditions, taking account of their history (including the symptoms and psychological, spiritual, social and cultural factors), their views and values; where necessary, examine the patient.
46. From what we have seen, the Trust examined Mr E’s abdomen. The records indicate Mr E did not show signs of significant ascites during his December admission.
47. We acknowledge Mrs E account that Mr E was struggling to eat and losing weight and how distressing that must have been to see.
48. We consider the Trust acted in line with GMC guidance in assessing and examining Mr E’s abdomen.
49. We recognise this was an extremely difficult time for Mr and Mrs E. We have not seen indications the Trust should have arranged a drain when the ascites were small and did not appear to be causing Mr E significant symptoms. For this reason, we do not uphold this part of the complaint.
Palliative radiotherapy
50. Mrs E explained Mr E sadly suffered with extreme pain before he died. She says palliative radiotherapy had helped ease the pain considerably in the past.
51. Mrs E says they asked for the palliative radiotherapy throughout his second admission. She says the Trust did not inform her it had decided against it.
52. In its complaint response the Trust acknowledge it had agreed to discuss palliative radiotherapy with Mr E’s private oncologist but failed to do so and apologised for this. The Trust also acknowledged it could have discussed this with the radiotherapy team.
53. The notes from the Trust multidisciplinary meeting in February 2023 say, ‘contact his private oncologist in London to consider radiotherapy.’
54. GMC guidance for good medical practice says:
• share all relevant information with colleagues involved in your patients’ care within and outside the team
and
• you must work in partnership with patients, sharing with them the information they will need to make decisions about their care.
55. The Trust did not communicate its decision to Mr and Mrs E and did not do what it said about speaking to Mr E’s private oncologist. For these reasons, we consider the Trust did not act in line with GMC guidance and there is an indication of a failing.
56. Mrs E says she and Mr E were asking every day about if he could have palliative radiotherapy. She says had the Trust made them aware of the decision not to carry out palliative radiotherapy sooner they would have arranged for this privately sooner.
57. We can also see Mrs E had contacted Mr E’s solicitor in February 2023 to enquire about private palliative radiotherapy using his compensation. They said Mr E’s private oncologist agreed palliative radiotherapy could be useful.
58. Mrs E did not contact Mr E’s private oncologist again until March 2023 when she found out the Trust were not making a referral. We are sorry to hear Mr E became too unwell to go through with the palliative radiotherapy.
59. Our NHS Complaint Standards say we would expect organisations to acknowledge mistakes and apologise for the impact these mistakes had. We would also expect organisations to take action to learn and improve from its mistakes.
60. The Trust has acknowledged its mistake and apologised it did not communicate about its decision. In its complaint response the Trust noted communication as an area for development.
61. The Trust set out an action plan to feedback at a clinical governance meeting about the importance of ensuring patient teams and relatives understand clinical plans and decisions.
62. We consider this indicates the Trust have taken the steps to put things right by apologising and issuing learning to its staff to prevent this reoccurring.
63. We appreciate it must have been highly frustrating for Mrs E continuously chasing for updates whilst tending to her husband in extreme pain. We do not underestimate how difficult that time was.
64. We think the Trust has done enough to put things right and we would not expect anything further from it. The Trust has already acted in line with NHS complaint standards. For this reason, we will not take further action on this part of the complaint.
Delayed stent
65. A CT scan in February 2023 showed indications Mr E had SVC compression. SVC compression is caused by an obstruction to a major vein in the body. A Trust doctor recommended an urgent stent which is a procedure to enable the vein to stay open.
66. Mr E did not have the procedure until over two weeks later. The Trust explained this was because it had numerous discussions with radiologists about whether the benefits of the stent outweighed the risk of complications. There was also a lack of available beds and working machine.
67. Mrs E said every day she and Mr E were asking when the procedure would be done. She said no one listened to her queries about having the procedure done privately. We are sorry to hear how she was left feeling dismissed.
68. The Trust explained it was confident it could perform the procedure in the NHS rather than having Mr E transferred to a private hospital.
69. The Trust did not have its own interventional radiology service. It was reliant on another service out of the area who were under increased demand from two other hospitals.
70. The Trust explained it was a changing situation where each day it was waiting for an available bed which could have come about at any time.
71. There are no guidelines that set out recommended timescales for SVC stents.
72. Our adviser said there is no doubt it would have been preferable for Mr E to have the procedure sooner. They explained there is a known lack of radiologists and facilities in this area of expertise.
73. In our adviser’s opinion, the Trust attempted to arrange the procedure in a timely fashion but fell short due to logistical difficulties.
74. GMC guidance for good medical practice says clinicians must make good use of the resources available.
75. We are sorry to hear how excruciating the wait was for Mr E. Mrs E explained every day Mr E thought it was his last and he just wanted to be at home with his family. We appreciate it was a highly distressing time.
76. From what we have seen, the Trust addressed the issue daily. We consider the Trust did what it could with the limited resource it had. For these reasons we do not uphold this part of the complaint.
Leg swelling
77. Mrs E says the Trust did not treat the swelling in Mr E’s legs throughout his hospital admission at the end of January which caused his mobility to deteriorate. Mrs E says community nurses were able to reduce the swelling in eight days after discharge using bandages.
78. In its complaint response the Trust said low albumin in Mr E’s blood caused the swelling. Albumin is a protein found in blood. The Trust said this was caused by disease such as cancer. It said the way to affect the swelling was by treating the underlying disease which it was doing.
79. Mr E suffered from an obstruction of his superior vena cava (SVCO). Our adviser explained the steroids administered for SVCO tend to worsen the swelling and oedema is difficult to control generally. Oedema is a clinical term for swelling caused by a build up of fluid in the body.
80. In our adviser’s extensive experience, bandaging is not an accepted treatment for limb oedema related to cancer except in chronic lymphoedema due to lymphatic obstruction which was not the cause for Mr E.
81. Lymphoedema is a long-term (chronic) condition that causes swelling in the body's tissues. NHS overview for lymphoedema explains it can affect any part of the body but usually develops in the arms or legs. The symptoms can be managed using compression bandages.
82. Mr E’s oedema (swelling) was a result of his cancer. We have not seen evidence to suggest bandages were recommended for Mr E’s condition.
83. The records show the Trust prescribed furosemide, a diuretic medication used to treat fluid retention and oedema.
84. From this we consider the Trust acted in line with GMC guidance previously referenced which says to promptly provide or arrange suitable advice, investigations or treatment where necessary.
85. We do not underestimate how difficult it was for Mr and Mrs E as his mobility became increasingly difficult. We are sorry to hear it eventually became too painful for Mr E to walk.
86. Unfortunately, lower limb swelling is common in terminally ill patients.
87. From what we have seen, the Trust were aware of Mr E’s leg swelling and prescribed appropriate medication to try and treat it. For this reason, we do not uphold this part of the complaint.
Closing remarks
88. It is clear to see from Mrs E and her sons that Mr E was very well loved and is greatly missed. He was a private family man and his death had a devastating impact on those close to him.
89. It is important to acknowledge that where we have not identified any indications that something went wrong, it does not detract from the family’s experience, nor the impact this has had on them.
90. We thank Mrs E for bringing the complaint and sharing such sad and sensitive information.
91. Our final decision is we do not uphold Mrs E’s complaint.