16. When we consider a complaint, we look at whether there are signs the organisation has got something wrong. We do this by comparing what should have happened with what did happen. We have done this for each aspect of Mrs P’s complaint.
Discharge on 8 October
17. Mrs P complains the Trust discharged Mr O on 8 October when he was not medically fit. Specifically, she says he had low kidney function that should have been treated with dialysis, and a TWOC was not completed which would have shown Mr O was not passing urine.
18. RCP guidelines say all patients should receive a determination of their clinical criteria for discharge (CCD). NHS England guidelines explain the CCD is the minimum physiological, therapeutic and functional status the patient needs to achieve before discharge. CCD should not be described as ‘back to baseline’, i.e. the patient’s status before the condition that brought them into hospital.
19. Mr O was admitted to the Trust on 20 September with stage 3 AKI, which is a severe stage of kidney damage characterised by a significant drop in kidney function, and an estimated glomerular filtration rate (eGFR) of 6. An eGFR is a measure of how well a person’s kidneys are working and is an estimated number based on a blood test and age, sex, and body type. A healthy kidney function eGFR is generally considered to be 90 or higher. The ED admission notes say Mr O’s baseline eGFR was 23, likely due to his chronic kidney disease.
20. Mr O was placed under the care of the urology team (which focuses on surgical and medical diseases of the urinary system) and diagnosed with hydronephrosis. This is where one or both kidneys swell due to a buildup of urine, which happens when urine cannot drain properly, often due to a blockage. A catheter (a flexible tube used to drain urine from the bladder when a person cannot urinate normally) was inserted the same day. A catheter remained in place until Mr O was discharged on 8 October.
21. We can see from records that Mr O’s eGFR started increasing shortly after admission and by 26 September was 10.
22. On 2 October a urology consultant recorded Mr O’s hydronephrosis was improving. On 5 October the consultant noted they had made a referral to the renal (kidney) team to review Mr O’s kidney function, given his ‘persistently low eGFR’. They said he could go home after this review if it raised no concerns.
23. A renal consultant reviewed Mr O’s case on 6 October and said his current level of function (still 10) should be treated as his new baseline, although there might be some improvement in time. They said Mr O’s kidney function should continue to be monitored.
24. NICE renal guidance section 1.1.2 says dialysis should be considered if a patient has an eGFR between 5 and 7. We understand from our urologist adviser that the Trust followed this guidance when deciding it should not consider dialysis for Mr O. This is because his eGFR started improving shortly after his admission and by 6 October was 10. They explain although his kidney function was low, it did not meet the criteria for dialysis treatment. They explain Mr O already had low kidney function prior to his admission and a level of 10 was not a reason to stop him from being discharged.
25. On 8 October the urology consultant saw Mr O. They recorded Mr O felt well and there were no new concerns. The plan was to complete a TWOC and Mr O could go home with outpatient follow-up in six weeks.
26. Records show Mr O was reviewed by physical and occupational therapists in the morning of 8 October. They recorded he was keen to go home and was safe to do so.
27. A TWOC is the removal of a urinary catheter to see if the patient can pass urine and empty their bladder without it. A TWOC is usually completed by a trained healthcare professional, such as a urology nurse. BAUS guidance says after a catheter is removed, staff will: • examine the patient regularly • measure any urine they pass • see how much urine is left behind.
It says the patient will normally need to remain in hospital at least until they have passed urine satisfactorily.
28. Nursing records show the TWOC procedure started at 9.55am on 8 October when the catheter was removed. We can see no more records relating to the TWOC or Mr O’s urine output before he went home later that day. However, a falls risk monitoring checklist which was completed at 1.10pm asked ‘if catheter in situ, is it still required?’ and the person who completed the checklist ticked ‘yes’.
29. Having discussed this with our urologist adviser, we think it is likely the member of staff who completed the risk assessment recorded this in error. This is because earlier records say the catheter was removed in the morning and Mrs P also told us Mr O did not have a catheter when he returned home later that day.
30. We understand from our urologist adviser that when Mr O was admitted to the ED just over a week later, on 16 October, a catheter drained 150ml of urine. Our adviser says this indicates the TWOC was likely to have been successful. This is because, if Mr O had not been able to pass urine after the catheter was removed, they would expect a much larger volume of urine to build up in the intervening eight days. Therefore, although the TWOC outcome was not recorded, it is likely Mr O successfully passed urine after the catheter was removed and so the Trust acted in line with the BAUS guidance.
31. We have seen no evidence to suggest Mr O did not meet the CCD in his case, and so we have not seen anything to indicate it did not act in line with the RCP guidelines. The condition he was diagnosed with after admission (hydronephrosis) had resolved by the date he was discharged, and his eGFR level meant he did not meet the criteria for dialysis treatment. Although his kidney function was low, it had improved since his admission, and the renal consultant considered it to be his new baseline. Whilst the TWOC procedure was not recorded in full, we think the evidence available to us shows it was properly completed.
32. We acknowledge Mrs P’s concerns about her father’s discharge and why she might think his death could have been avoided if he remained in hospital with different treatment. We hope to reassure Mrs P that, in our independent view, we have not identified any indications of mistakes in care, nor any errors which contributed to his death. For this reason, we will take no further action.
Infection
33. Mrs P complains the Trust delayed treating Mr O’s infection when he taken to the ED on 16 October.
34. GMP Domain 1, section 7, says doctors must provide a good standard of practice and care. They must: • adequately assess a patient’s condition(s), taking account of their history, including symptoms • promptly provide (or arrange) suitable advice, investigation or treatment where necessary • propose, provide or prescribe effective treatment based on the best available evidence.
35. Mr O was taken to the ED by ambulance at around 12.40pm on 16 October with symptoms of dysuria (pain or discomfort when passing urine) and lethargy (lacking energy). He was assessed just after 1.00pm, it was recorded he had possible sepsis and the ‘sepsis bundle’ was started.
36. The Sepsis Trust explains the sepsis bundle is a set of six actions which should be completed when sepsis is suspected. These include administering intravenous antibiotics and fluids.
37. Mr O was examined by an advanced clinical practitioner (ACP) at 2.05pm. An ACP is a registered healthcare professional who has completed additional training to gain advanced skills and can diagnose, treat, and prescribe. Their impression was Mr O had an obstruction in his urethra, urosepsis (sepsis caused by a urinary tract infection that has spread to the bloodstream and other parts of the body), and AKI deterioration. The plan included treating him with intravenous fluids and antibiotics.
38. NICE sepsis guidance says a patient with a National Early Warning Score (NEWS2, a standardised system used to assess the severity of illness in acutely ill patients) score of five or six has a moderate risk of severe illness or death from sepsis. In these cases, consideration should be given to deferring administration of a broad spectrum antibiotic treatment for up to three hours after calculating the NEWS2 score, and clinicians should gather information for a more specific diagnosis.
39. The first record we can see of Mr O’s NEWS2 score is at 4.00pm. His NEWS2 score was five, which means he was at moderate risk of severe illness or death from sepsis.
40. At about 5.00pm the ACP noted they discussed Mr O’s case with the urology team. This is in line with NICE guidance to consider a more specific diagnosis for people at moderate risk of death, and in line with the GMP guidance referenced in paragraph 35. They decided that Mr O was not fit for intervention and would be referred to the medical team.
41. We cannot see from records the exact time Mr O was first given fluids and antibiotics. A note written at 5.30pm says the sepsis bundle had been completed, which indicates he had received the appropriate treatment. A doctor also recorded at 11.22pm that Mr O had received intravenous fluids and antibiotics.
42. Records show Mr O continued to be monitored each hour. This is in line with NICE sepsis guidance for people with a NEWS2 score of five. His condition deteriorated significantly at around 3.45am and he was moved to resuscitation. A doctor noted that in view of Mr O’s sepsis, multi-organ failure and frailty with a background history of multiple comorbidities he would not be admitted to the Intensive Care Unit (ICU). Despite treatment Mr O continued to deteriorate, and he died at approximately 12.30pm.
43. We considered Mr O’s treatment with the help of our emergency medicine adviser. We can see from this that Mr O was managed in line with NICE sepsis and GMP guidelines from the time he arrived at the ED. This is because the sepsis bundle was initiated at assessment stage in line with NICE guidance, investigations were made to identify a more specific diagnosis, and he was treated with antibiotics and fluids. Our adviser explained that given Mr O’s frailty and existing health conditions, even if he was treated with fluids and antibiotics earlier, it is likely the sad outcome would not have been different.
44. With the above in mind, from the evidence we looked at, Mr O’s symptoms were investigated and treated in line with appropriate guidance. Sadly, he did not respond to treatment. We have seen no indication this was due to any failures or omissions by the Trust. As such, we will take no further action. We know this complaint is very important to Mrs P and these events were very distressing to her, and so we hope we have clearly set out how we thought about the concerns she raised and how we reached our decision in this case.