14. Mrs D told us the Trust did not test her husband for flu when he was admitted to hospital. She said she thinks the Trust mixed up his tests with those of another patient. We looked at what happened to see if it was in line with guidance.
15. Mr D was already critically unwell when he was admitted. Prompt admission to intensive care for supportive treatment was essential, and this is what happened.
16. We can see from the records the Trust took a clear medical history, moved Mr D to ITU, maintained the intubation (tube in the airway to help with breathing) started by the air ambulance team, and gave intravenous (IV) fluids to manage blood pressure and immediate antibiotics for any infection.
17. Our adviser told us the doctors treating Mr D made a reasonable differential diagnosis (a clinical process of deciding the most likely diagnosis based on presentation and symptoms) that he had potential encephalitis (an inflammation of the brain, most often caused by infections). This initial treatment was in line with GMC Good Medical Practice. This says:
‘In providing clinical care you must: • adequately assess a patient’s condition(s), taking account of their history, including symptoms, […] • carry out a physical examination where necessary • promptly provide (or arrange) suitable advice, investigation or treatment where necessary • propose, provide or prescribe drugs or treatment (including repeat prescriptions) only when you have adequate knowledge of the patient’s health and are satisfied that the drugs or treatment will meet their needs • propose, provide or prescribe effective treatment based on the best available evidence […] • consult colleagues or seek advice from your supervising clinician, where appropriate • refer a patient to another suitably qualified practitioner when this serves their needs.’
18. The ‘Seasonal influenza, Guidance for adult critical care units’ says it is important to consider flu in the differential diagnosis of a patient presenting with compatible symptoms, such as pneumonia and encephalitis, both of which Mr D had. We can see the Trust considered flu as a possible cause of the symptoms.
19. The guidance also says appropriate diagnostic samples should be obtained as soon flu is suspected. There is no evidence to show that flu swabs were taken in line with this guidance.
20. It is not clear from the records when the flu swabs were taken. An entry in the medical records at 12.30am on 29 December reads ‘flu swab not done ?missed’. An entry on 29 December completed at 7.42am says ‘Respiratory screen sent including flu and covid swabs’. It is reasonable to conclude the flu swabs had been sent by 7.42am. This was not in line with the expectations of the guidance and so is a failing.
21. The ‘UKHSA Guidance on the use of antiviral agents for the treatment and prophylaxis of seasonal influenza’ says all patients admitted with suspected or confirmed flu should be treated with oseltamivir immediately. It is not clear from the records when oseltamivir was started. The medical records appear to show it was given at 5pm on 30 December.
22. This was not in line with the guidance and is also a failing.
23. We considered whether we could reach the conclusion Mrs D has. She told us that as a result of the failure to test for flu the Trust failed to diagnose ALHE, and this in turn led to a missed opportunity to give treatment and prolong Mr D’s life.
24. We found the Trust acted in line with guidance when initially treating Mr D and trying to establish the cause of his symptoms. We could not make a link between the failings and the Trust not diagnosing AHLE, which was diagnosed postmortem.
25. AHLE is described in the publication ‘Acute Haemorrhagic Leukoencephalitis (AHLE): A Comprehensive Review on Causes, Symptoms, Link with COVID-19, Diagnosis, and Treatment, 2022’. This explains it is a rare disorder that causes rapid neurologic deterioration and death. It is most commonly described as a postinfectious complication of an upper respiratory illness. It is usually diagnosed by MRI scanning and brain biopsy.
26. AHLE has an acute onset and rapid progression of inflammation. The overall mortality rate of AHLE is high, at an estimated 70%. Our adviser told us that given this high mortality rate, we must conclude that on the balance of probabilities Mr D would not have survived.
27. The publication ‘Oseltamivir: a review of its use in influenza, 2001’ outlines that oseltamivir can reduce the duration and severity of illness. At the stage Mr D was admitted he was already too poorly to be likely to benefit from the reduction in severity and duration of flu, even with earlier treatment. He was so unwell the main aim for the Trust was to try and prevent organ failure and death.
28. Our adviser said Mr D was very unwell and unstable during his stay in ITU. They said this was due to multiorgan failure and not AHLE. It is unlikely AHLE would have been identified and treated before Mr D sadly died of multiorgan failure.
29. The Trust gave Mr D maximal supportive therapy, which is the highest level of intervention available. Despite this his condition continued to deteriorate. Earlier testing for flu, and earlier prescription of oseltamivir would not have made a difference to the sad outcome as neither could have halted or slowed the deterioration.
30. It our adviser’s view that sadly Mr D’s condition was so severe he would not have survived, no matter what intervention the Trust gave.
31. We looked to see whether the actions the Trust has already taken are sufficient to provide a resolution for the failings we found. We did not think they were.
32. We can see the Trust has recognised there was some delay in diagnosing and initiating flu treatment. It has made sincere apologies and accepted it should have acted differently. We consider this the right action to take, in line with the Ombudsman’s Principles for Remedy. These say public bodies should promptly identify and acknowledge poor service, and apologise for it.
33. We also considered whether this action met the part of the Principles which says organisations should look what action it could take to prevent the same thing happening again. We do not feel reassured the Trust has taken sufficient action in line with this.
34. While we cannot say different actions would have led to a different outcome for Mr D, we can see Mrs D has been left with the injustice of not being assured this would not happen again to someone in the future.
35. We cannot see why there was a delay in carrying out the flu test and providing the medication. The Trust has put forward the suggestion this was due to the team’s attention being given to stabilising Mr D’s organs. Mrs D told us she thinks it was because the Trust mistakenly mixed up patient records and results.
36. There is nothing in the records to show the reasons for the delay. It would not be right for us to speculate.
37. We recognise the ITU will always be a busy unit, providing lifesaving treatment. Mr D was cared for in the ITU for four days. The time period he was there prior to testing leads us to conclude the reason given by the Trust is not reasonable. We need to be assured that there are systems in place to ensure essential tests and treatments happen when they need to.
38. We do not consider the Trust has taken sufficient action to look at what led to the failings, and make systemic, procedural changes or introduce training to prevent a recurrence. We have made a recommendation about this in paragraphs 40 and 41.