Stent procedure
17. Mrs A complained that there was a delay in providing a stent for her mother. She believes this treatment should have been prioritised.
18. The Surgical Adviser told us there were no specific guidelines relating to when to insert a stent for patients who were in Mrs R’s position. They said there are several documents that explain how clinicians should investigate and manage gastric outlet obstructions. This is what doctors at the Hospital treated Mrs R for because pancreatic cancer was not confirmed.
19. The Surgical Adviser said the principles of treatment include providing intravenous fluids and placing a nasogastric tube (NG Tube) into the stomach to drain fluid. It also involves examining the stomach using a scope to try and establish the cause of the obstruction. Clinicians should provide appropriate nutrition support and intervene if necessary to address the obstruction. These all happened in Mrs R’s case.
20. Good Medical Practice says doctors must provide a good standard of care. This includes carrying out adequate assessments, taking account of the patient’s history and examining them if necessary. Doctors should also arrange timely treatment and appropriate investigations or referrals if needed. They must consult colleagues or request advice when appropriate.
21. The clinical records show doctors were aware when Mrs R arrived at the Hospital on 6 September 2023 that she was known to the team at the specialist hospital. They suspected she had pancreatic cancer, but this could not be confirmed. The records show she had a blockage in the duodenum which was obstructing her bile duct. Surgery was not possible because of narrowing in one of her arteries.
22. Mrs R had a CT scan on 11 September 2023. This showed the disease had progressed. The Surgical Adviser told us it was appropriate for the treating team to await a discussion with the team at the specialist hospital to guide their treatment. The initial plan, discussed on 13 September, was to improve Mrs R’s nutrition using total parenteral nutrition (TPN – artificial feeding into a vein) and then have a further discussion with the specialist hospital about the next appropriate step. For example, placing a duodenal stent or carrying out a surgical bypass.
23. The Surgical Adviser agreed there was a wait from Mrs R’s admission until the attempted placement of the stent. Their opinion is that it could not have been done sooner because the team was following guidance from the regional specialist team and was taking advice about treatment options. This guidance was that Mrs R’s health needed to built up with nutritional support to increase her weight. The records show she received nutritional support throughout this period.
24. On 27 September 2023 the specialist hospital recommended attempting to insert a stent. The procedure was booked the following day to take place on 29 September. Unfortunately, the surgeon could not insert the stent because of the obstruction in the bowel.
25. We find the treating team were right to wait before attempting to insert the stent for Mrs R. This was based on specialist advice that Mrs R’s weight needed to increase first. We have seen no evidence of any significant delays by the clinical team. We can see how the need to wait was distressing for Mrs R’s family. The evidence we have seen suggests doctors provided a good standard of care and consulted colleagues for advice. They followed Good Medical Practice.
Hydration and nutrition
26. Mrs A says nurses left her mother for long periods without food. She says they only gave her sips of water. She says the nutrition they provided was not working and clinicians failed to realise this. She believes her mother was starved and that she should have had intravenous fluids.
27. The Nutrition Guideline says clinicians should screen all patients for malnutrition or the risk of malnutrition on admission to hospital. It says nutrition support should be considered for people who have eaten little or nothing for more than five days and/or are likely to eat little or nothing for the next five days or longer.
28. The Nursing Standards say nurses must use evidence-based, best practice, approaches for meeting a person's nutrition and hydration needs. They should accurately assess the person's capacity for independence and self-care and initiate appropriate interventions. Nurses should assess and optimise nutrition and hydration status and use contemporary nutritional assessment tools. They should record fluid intake and output and identify, respond to, and manage dehydration or fluid retention.
29. The NMC Code says nurses should make a timely referral to another practitioner when any action, care or treatment is required. It says they should ask for help from a suitably qualified practitioner to carry out any procedures that are beyond the limits of their competence.
30. The clinical records show nurses assessed Mrs R’s risk of malnutrition using am appropriate nutritional assessment tool. They established she had a high risk of malnutrition. On admission Mrs R had been unable to keep any food down for around a week. She could not take oral food and drink because of her gastric outlet obstruction. This meant clinicians needed to use an alternative method to give her nutrients and fluids.
31. On 7 September 2023 clinicians tried to insert an NG tube, but the attempt failed. This meant that Mrs R’s stomach had to be bypassed with feeding into the bowel using a nasojejunal tube (NJ tube). This was inserted on 8 September.
32. The records show that clinicians explained to Mrs R that she could only have sips of water. This was because if she had swallowed water it would have been drained by the NG tube that was in place to remove fluids. Sips of water would have been offered to maintain her comfort. Mrs R had intravenous fluids throughout, and nurses kept records of her fluid balance.
33. On 14 September 2023 clinicians inserted a peripherally inserted central catheter (a PICC line) to deliver TPN. This bypasses the digestive system completely to deliver nutrition.
34. The clinical records clearly show nurses delivered food and fluids using the NJ tube or TPN following advice from the medical team. There were some episodes of vomiting which nurses reported to doctors. On 17 and 19 September 2023 there were occasions when Mrs R could not tolerate the feed. Nurses escalated this to dieticians and then adjusted her level of feed.
35. The Nursing Adviser told us nurses managed Mrs R’s nutrition and hydration in line with the relevant standards. We can also see that dieticians reviewed Mrs R three times during her admission
36. We find the nurses followed the Nutrition Guideline, the Nursing Standards and the NMC Code when providing hydration and nutrition for Mrs R. They screened her appropriately on arrival, recorded her fluid intake and escalated care to other colleagues when necessary. The evidence we have seen shows that nurses gave Mrs R the nutrition and fluid she needed.
Bile drainage
37. Mrs A complains that clinicians should have drained her mother’s stomach contents more frequently. She understood this should have been happening twice each day. She believes this could have led to the stent insertion being unsuccessful.
38. The Surgical Adviser told us, the standard management for draining stomach contents is to insert an NG tube with a bag attached. The tube should be kept open so that it drains freely and stomach contents should also be drained (aspirated) occasionally, and this commonly happens every four hours. There is no specific national standard about this. This is more commonly carried out by nurses who would have been expected to follow the Nursing Standards as detailed above.
39. The clinical records include nursing notes and fluid balance charts completed during Mrs R’s admission. These show the NG tube was always kept open and that stomach contents were also aspirated regularly. The records clearly show the amounts that were drained. The Surgical Adviser said the management of the NG tube was in keeping with commonly accepted practice. We can see that nurses followed the Nursing Standards as detailed above.
40. We find that clinicians followed the relevant standards in terms of regular draining of stomach contents.
Peritonitis
41. Mrs A complains there was evidence her mother had peritonitis on 29 September 2023 and staff at the Hospital failed to respond. She believes doctors should have intervened to remove the blockage in the bowel.
42. Doctors should have followed Good Medical Practice as detailed earlier in this report.
43. The Surgical Adviser told us the common signs of peritonitis include severe abdominal pain or discomfort, a firm or tense abdominal wall and some degree of concerning changes in the person’s observations (for example fast heart rate or low blood pressure).
44. The clinical records show that a doctor reviewed Mrs R on 29 September 2023. Her observations at that point were normal as were blood test results. Her heart rate was slightly raised but Mrs R said she felt well. On clinical examination Mrs R did not say she was in pain.
45. The Surgical Adviser said Mrs R’s observations were noted regularly throughout her admission to the Hospital. She had intermittent blood tests throughout her stay which showed no indication of peritonitis. Mrs R experienced episodes of abdominal pain during the admission, but there were no significant changes until the night of 3 October 2023.
46. On 3 October 2023 Mrs R described abdominal pain in the morning. However, later in the day she said this had improved and, by the afternoon, her observations were normal. Doctors planned to carry out further investigations later that evening. The first signs of a possible perforation were at 9.30pm. There is no evidence this development could have been anticipated by the team who were caring for Mrs R.
47. The Surgical Adviser said they had no concerns that Mrs R showed any signs of an impending perforation that were missed by clinicians from 29 September 2023 onwards. The Surgical Adviser said the treatment was in keeping with what would be expected on a surgical ward.
48. We find the doctors carried out appropriate assessments and examinations when they reviewed Mrs R during her admission to the Hospital. They arranged investigations and treatments that were needed. They followed Good Medical Practice.
Conclusion
49. We appreciate how distressing it must have been for Mrs R’s family when her health suddenly deteriorated on 3 October 2023. We have seen nothing to suggest that her declining health was due to any failings in care and treatment by the healthcare professionals who treated her at the Hospital. We hope Mrs A is reassured that we have seen no evidence of any failings relating to the issues we have investigated. We cannot say Mrs R’s death could have been avoided.
50. We do not uphold Mrs A’s complaint.