1. We have carefully considered the information provided by Mrs T, and we are extremely sorry to hear about Mr R and his families experience, and the continuous impact that this understandably has. We also offer our sincere condolences to Mrs T and her family.
2. We have also reviewed the medical records and complaint information provided by Gateshead Health NHS Foundation Trust (the Trust).
3. We have sought clinical advice from a Consultant Physician as well as considering the standards and guidance relevant to Mr R’s care and treatment.
4. We identified service failures in relation to the Trust not acknowledging Mr R’s rapid decline and failing to carry out observations when staff were alerted that Mr R felt like he was deteriorating.
5. Whilst we cannot say Mr R’s death could have been prevented, we consider there were missed opportunities to potentially change Mr R’s treatment plan or start an alternative treatment sooner. We recognise this has caused upset, distress, and uncertainty for Mrs T and her family. It is therefore likely we will partly uphold this aspect of the complaint.
6. We have not identified service failures by way of a delayed diagnosis or the treatment plan Mr R initially received.
7. We are recommending the Trust writes to Mrs T and provides an acknowledge of the impact that the complaint has had on her and her family, as well as providing a financial remedy which reflects the impact of the failings we have identified. We also recommend the Trust implements service improvements to prevent any similar incidents reoccurring in the future. We will explain this further, below.
8. We will explain the reasons for our final decision in this report. Complaints give us valuable insight into the organisations we investigate, so we would like to thank Mrs T for sharing her experience with us. It is important to acknowledge that where we have not found failings in care, this does not diminish Mr R or Mrs T’s experience, nor the impact this had on their family.
The complaint
9. Mrs T complains about aspects of the care and treatment that Gateshead Health NHS Foundation Trust (the Trust) provided to her husband, the late Mr R, between 9 June 2022 and 17 June 2022.
10. Mrs T specifically complains that:
• there was a delayed diagnosis of a pulmonary embolism (PE) as Mr R was discharged on both 9 and 10 June 2022 without the relevant tests being carried out to diagnose this • no treatment plan was put in place following Mr R’s PE diagnosis • Mr R and his family were ignored when they advised the staff that he felt himself rapidly declining, prior to his death. When this was raised, no observations were carried out.
11. Mrs T says Mr R died because of the claimed failings, and this was avoidable. She says these events have created a devastating amount of trauma for herself and her daughters.
12. As a result of her complaint, Mrs T would like an acknowledgement of the claimed failings and a financial remedy.
Background
13. On 8 June 2022, Mr R started to feel unwell. He experienced breathlessness and his speech started to slur.
14. On 9 June 2022, Mr R went to the Trust’s Accident and Emergency (A&E) Department due to his symptoms worsening. The Trust wanted to admit Mr R and said it was going to arrange an Magnetic Resonance Imaging (MRI) scan, but this would likely be as an outpatient. As an MRI scan was being arranged for 16 June 2022.
15. An MRI scan takes detailed pictures of the inside of the body. It is used to help diagnose conditions, plan treatment and check how well treatment is working.
16. The Trust wanted to admit Mr R. Whilst he was waiting to see a consultant, Mr R decided to leave the hospital. This is It was agreed that Mr R would go back the following morning.
17. On 10 June 2022, Mr R went back to A&E due to his continued deterioration. There were various tests carried out such as blood pressure checks and blood tests. Mr R was diabetic and so a diabetic nurse was called to A&E to examined him. Mr R was told his presenting symptoms could be due to his diabetes.
18. Following the tests that were carried out, it was explained to Mr R that he had probably had a small stroke and that his breathlessness was a byproduct of this. A stroke is when blood flow to the brain is interrupted or reduced. Mr R was told the MRI scan, booked for 16 June 2022, would confirm if he had had a mini stroke or not. This must have been very worrying news for Mr R and Mrs T.
19. On 14 June 2022, Mr R’s symptoms continued to worsen. Mrs T called NHS 111 (A 24 hour health advice line for urgent but not life-threatening medical problems). NHS111 advised Mrs T that an ambulance should be called for Mr R to take him to hospital. Sadly, Mr R refused this.
20. On 15 June 2022, Mrs T called their GP Practice due to being concerned about Mr R’s condition. The GP Practice sent an emergency team out to see Mr R and found that his blood oxygen levels were far too low. As a result, an emergency ambulance was called to take Mr R to hospital.
21. Mr R was admitted to a hospital at the Trust and numerous tests were carried out. He had a chest X-ray and a potential PE was considered. A pulmonary embolism (PE) is when a blood clot blocks a blood vessel in the lungs. It can be life-threatening if not treated quickly.
22. On 16 June 2022, Mr R had a neurological MRI scan, and a computer tomography angiogram pulmonary (CPAT) scan. A neurological MRI creates detailed images of the brain, spinal cord and surrounding structures. A CPAT is a scan that creates a detailed image of the pulmonary (breathing system) arteries. Arteries carry oxygenated blood around the body from the heart.
23. The Trust told Mr R it had found a massive PE (a medical term for a high-risk PE) that was covering his aorta (the main and largest artery in the human body). The Trust explained to Mr R this could be life threatening. Mr R was already on anticoagulant medication (blood thinning medication) that can be used when a PE is diagnosed, and Mr R was to continue on this medication as part of his treatment plan.
24. On 17 June 2022, Mr R began to feel extremely unwell and asked his wife to attend the Trust. Mr R went into cardiac arrest meaning his heart stopped beating. The PE blocked more of the artery, which obstructed the natural flow of blood through Mr R’s body. Mr R sadly died.
Evidence we are considering
25. We have used the following evidence whilst investigating Mrs T’s complaint:
• information provided by Mrs T, including her complaint form, and her account of the events that occurred • Mr R’s medical records • the Trust’s complaint file.
26. We have received clinical advice from a consultant physician (our adviser) practising in acute and geriatric medicine with for more than 18 years of experience. The advice has helped us to understand the clinical issues, and we have used it to help us to form our views on the issues raised.
27. We use relevant law, policy, guidance and standard to inform our thinking. This allows us to consider what should have happened. We have referred to the following standards:
• European Society of Cardiology Guidelines, Diagnosis and Management of Acute Pulmonary Embolism (ESC Guidelines), 2019 • Patient Guidelines, Pulmonary Embolism, (the Patient Guidelines), reviewed 2023. Whilst this guidance outdates the events, this was reviewed and not amended in 2023. As such, we feel the guidance is still relevant.
Findings
Delayed diagnosis
28. Mrs T complains Mr R was discharged from hospital on both 9 and 10 June 2022 without the relevant tests being carried out and a proper diagnosis of PE. Mrs T says that due to investigatory tests not being carried out sooner, this led to delayed treatment and contributed to causing the death of Mr R.
29. Within its complaint response letter dated 29 December 2023, the Trust said Mrs T had asked its medical examiner if Mr R’s PE could have been picked up when he first presented at A&E on 9 June 2022. The medical examiner advised Mr T that they did not think the PE could have been picked up earlier as Mr R’s vital signs (blood pressure and pulse) were normal on 9 and 10 June 2022.
30. The Trust says that on Mr R’s first presentation to the Trust with shortness of breath and slurred speech, it was felt that Mr R may have had a small stroke. Mr R did not wish to wait for a bed and therefore the plan was for him to return the next day for review at the Same Day Emergency Care Department. Here, Mr R was seen and his case was discussed with one of the Trust’s stroke consultants.
31. A plan was then made for Mr R to have an outpatient MRI within the week and he was prescribed aspirin. Aspirin is a drug that is often used to prevent heart attacks and strokes. The Trust say that this was a correct pathway for the working diagnosis at that time.
32. We refer to the Patient Guidelines on pulmonary embolism, which explains the symptoms of a PE as:
‘A small PE may cause: • no symptoms at all (common) • breathlessness - this can vary in degree from very mild to obvious shortness of breath • chest pain which is pleuritic, meaning sharp pain felt when breathing in. Often you feel like you cannot breathe deeply, as this causes you to catch your breath. This happens because the blood clot may irritate the lining layer (pleura) around the lung. Shallow breathing is more comfortable • coughing up blood (haemoptysis) • a mildly raised temperature (fever) • a fast heart rate (tachycardia).
A massive PE or lots of clots (multiple emboli) may cause: • severe breathlessness • chest pain - with a large PE the pain may be felt in the centre of the chest behind the breastbone • feeling faint, feeling unwell, or a collapse. This is because a large blood clot interferes with the heart and blood circulation, causing the blood pressure to drop dramatically • rarely, in extreme cases, a massive PE can cause cardiac arrest, where the heart stops pumping due to the clot. This can result in death, even if resuscitation is attempted.’
33. The clinical features of a PE are therefore very variable and may be without any symptoms or signs.
34. We have analysed Mr R’s medical records from 9 June 2022 when he was first seen by the Trust. We asked our adviser if on this date Mr R’s clinical observations were normal.
35. Our adviser has said Mr R’s observations were entirely normal, particularly his respiratory rate (breathing rate) which was very comfortable. His oxygen levels were good, and Mr R did not need supplemental oxygen. Mr R’s clinical features were of slight shortness of breath, slurred speech, lethargy (tiredness) and dizziness and unsteadiness.
36. Within the medical notes, The Trust have recorded ‘Denies any CP (chest pains), cough, haemoptysis’. By inquiring about these symptoms, it is suggestive that the Trust may have been considering a diagnosis of PE.
37. The Trust carried out an electrocardiogram scan (ECG) that records the electrical activity of the heart. The ECG showed no features that were suggestive of a PE. Mr R also had a normal heart rate. Our adviser says that if there was to be an ECG indicative of a small PE, it would usually show as a fast heart rate, though often the ECG is normal. Also, that mild shortness of breath can also be a feature of stress or anxiety, which would not be surprising for someone presenting with worrying neurological symptoms.
38. We can see that the Trust’s assessment was focussed on Mr R’s symptoms that suggested a stroke. The symptoms that could be suggestive of a PE (in Mr R’s case, at this point, just shortness of breath) were not accompanied by observation findings, examinations, or ECG results suggestive of a PE. As such, there was limited evidence for a PE.
39. Whilst Mr R did develop a PE, the timing of its onset remains unclear and cannot be specifically identified. The PE may have occurred in the days following rather than prior to Mr R’s first A&E visit.
40. Overall, we consider that it was reasonable for the Trust not to carry out investigations on Mr R to diagnose a PE on his visits to A&E. Mr R was not presenting with most of the symptoms for a PE, and at this time, Mr R’s symptoms were more in line with a small stroke. We also cannot say that Mr R had developed the PE yet, as this could have developed later.
41. For these reasons, our decision is not to uphold this part of the complaint.
No treatment plan was put in place following Mr R’s PE diagnosis
42. Mrs T has relayed the conversation that took place when Mr R was told that the Trust had found a PE. They were told that it is life threatening and it was covering Mr R’s aorta.
43. Mrs T has said that the members of staff did not know what the treatment plan would be, or what interventions would be carried out. Mrs T was advised that Mr R was already on blood thinners.
44. Within its complaint response, the Trust says that when Mr R was informed of the scan results, the Trust ensured he was clinically stable and that he had received the correct treatment.
45. It says that Mr R was clinically stable with a blood pressure of 110/71mmHg and a heart rate of 88. An average blood pressure reading for adults is 120/80mmHg and a standard heart rate is between 60 and 100 beats per minute.
46. Blood pressure is measured in millimetres of mercury (mmHg) and is given as two numbers. Systolic pressure is the pressure when the heart pushes blood out around the body. Diastolic pressure is the pressure when the heart rests between beats and blood is pushed around your heart. The highest number is always the systolic pressure and it is always given first.
47. The Trust said Mr R had already been prescribed Heparin (a blood thinning medication) which is the standard treatment for stable PE patients.
48. The Trust says that stable patients with a blood pressure of above 90 systolic would not routinely been considered for thrombolysis (a procedure to break up the blood clot using medication), as the risk of bleeding complications outweighs the potential benefits.
49. A member of staff discussed Mr R’s results and treatment with a resident doctor who agreed with the treatment plan. The plan was for Mr R to have his vital signs recorded four hourly overnight and be seen by the ward consultant the next day.
50. The Trust explained that sometimes it is unclear what the exact course of treatment would be going forward, as it is dependent on how a patient responds. It said the Trust discussed that if Mr R became more unwell, it would need to explore other treatments.
51. Within its final complaint response dated 29 December 2023, the Trust say that in most patients’ blood thinners would prevent further blood clots from occurring and give the body time to break the clot up. It said that the plan if Mr R deteriorated significantly would have been to start thrombolysis treatment, but as discussed, there was a possibility that Mr R could deteriorate so quickly that this treatment may not have time to work once started.
52. From viewing the available evidence, we can see that main treatments that were given to Mr R were in line with the ESC Guidelines, Section 6.6:
• Oxygen. This was delivered, and Mr R’s oxygen saturations were normal. Given the normal oxygen level on supplementary oxygen, he did not require any further assistance with breathing.
• Anticoagulation. Mr R was commenced on anticoagulation (‘blood thinning’ medication). There are a variety of anticoagulation agents, for Mr R, this was heparin. This is standard treatment for a PE.
53. As shown in the ESC Guidelines, there are other PE treatments that are sometimes given after a cardiac arrest or when the blood pressure is very low, (less than 90mmHg), such as:
• Thrombolysis (injecting thrombolytic clot-busting agent). Our adviser says that this is usually the first recommended treatment for high-risk PE. As Mr R was suspected as having a recent stroke, this treatment is a contraindication for thrombolysis • Surgical pulmonary embolectomy (opening the chest and removing the clot). This is an option for when thrombolysis is contraindicated or has failed.
• Percutaneous catheter-directed treatment (putting a tube through an artery in the groin and injecting thrombolytic agent close to the clot). This is an option for when thrombolysis is contraindicated or has failed.
54. Our adviser says that these other treatments were not indicated for Mr R when he initially presented because his blood pressure was acceptable, including up until the morning that he had the cardiac arrest.
55. Mr R’s observations at 5.03am on 17 June 2022, the last set of observations before he sustained a cardiac arrest, were very acceptable. Our adviser says that in fact the only abnormal observation is that Mr R was on an oxygen device at a low level of 28%.
56. Overall, we consider that there are no failings regarding Mr R not being started on an alternative treatment sooner. Mr R’s observations were stable, and as such, it was not indicated that any alternative treatment was needed at that time other than the medication he was already on.
57. For these reasons, our decision is not to uphold this part of the complaint.
Mr R and his family were ignored when they advised the staff that he felt himself rapidly declining, prior to his death. When this was raised, no observations were carried out.
58. On 17 June 2022, Mrs T received a telephone call from Mr R at the Trust. Mrs T states Mr R told her he felt unwell and strange. Mrs T immediately rang the ward at the Trust and explained to the ward staff Mr R felt very unwell. Mrs T was told by the wards staff that Mr R was fine, and he was just panicking. The Trust’s ward staff agreed to go and check on Mr R.
59. After checking on Mr R, the Trust contacted Mrs T and told her Mr R was fine, and that his observations were fine. Mr R called Mrs T twice more asking where his family were. Mrs T told the Trust that she was coming to the hospital to see Mr R.
60. Initially, Mrs T was refused when she tried to enter the ward as the message had not been relayed throughout the ward team that she would be coming to the hospital. Mrs T was told that she would only be allowed to stay for ten minutes.
61. When Mrs T got to Mr R, she says that due to his presentation, she knew he was dying. Mr R’s eyes then rolled back, became fixated, and his left eye drooped. Mrs T says that she told the staff that there was something wrong. Mrs T was then escorted to the day room and Mr R sadly died.
62. Within its response letter dated 20 March 2023, the Trust said the staff were reassured by Mr R’s observations being stable when they were carried out and that he had no issues with his oxygen requirements.
63. The Trust says that it has asked the staff to reflect on their practise with regards to addressing patient and relative’s concerns. It said despite how busy staff may be, if a family is concerned, they should do all they can to address the concerns.
64. The Trust says staff have apologised for refusing to let Mrs T on the ward initially. It said visitors to the ward are restricted for the safety and comfort of all patients on the ward. The Trust said the staff nurse apologises that they may not have relayed the information to the other staff on the ward. The staff nurse explained they were unaware Mrs T was attending the ward because of her concerns.
65. Within its complaint response dated 29 December 2023, the Trust acknowledges the lack of communication between the ward staff fell below the standard it expected. The Trust apologised for the distress this caused. It said these concerns had been fed back to the ward staff, and they have reflected on this.
66. In relation to the observations, the Trust apologised Mr R’s vital signs were not rechecked when he said that he felt more unwell. The Trust said it was unable to say why they were not check but that this should not have happened. It said this has been highlighted to ward staff and has been shared throughout the Trust as a significant learning for all departments.
67. We asked our adviser if further observations should have been carried out. They say it would have been appropriate to repeat Mr R’s set of observations, given Mr R’s concerns and presentation. We have found a failing by way of the Trust not doing so.
Impact
68. We can see Mrs T asked the Trust that if treatment had administered and Mr R’s concerns taken seriously would Mr R still be alive.
69. The Trust says it was difficult to comment on this as Mr R did receive thrombolysis following his collapse and subsequent cardiac arrest. CPR (check compressions) continued to allow treatment to take effect.
70. The Trust said it is possible that, had a doctor reviewed Mr R when he felt more unwell at 6am, this would have led to thrombolysis being started sooner. The Trust said it was unable to say whether the sad outcome would have been different.
71. The Trust recognised that Mr R deteriorated very quickly and suffered a cardiac arrest at approximately 7.15am. It says that it was possible the thrombolysis treatment would not have had time to take effect even if it had been started at or shortly after 6am.
72. Mr R did receive high dose thrombolysis during the cardiac arrest at approximately 7.30am. Sadly it was ineffective. The Trust apologised that Mr R’s deterioration was not recognised and responded to sooner. Although it is difficult to say whether this would have changed the outcome, it would have been reassuring.
73. Understandably, Mr R’s death has had a considerable impact on Mrs T and her family and continues to do so. They have been left with unresolved doubts about whether Mr R’s death was related to the lack of observations and whether Mr R could have been saved if these had been carried out.
74. As we have identified failures in aspects of Mr R’s care. We have considered what would have happened if Mr T had been monitored when he started to deteriorate and potentially given medication sooner.
75. With our adviser we explored the impact of the potential delay in taking observations and starting alternative treatment. Mr R’s last set of observations on the day he died were carried out at 5.34am. Mr R voiced that he was beginning to severely deteriorate after this time at 6am. As such, it would have been appropriate to repeat his set of observations.
76. We understand it may be unlikely that taking Mr R’s observations at this time might have made a significant difference to Mr R’s outcome. Despite this, the staff were advised by both Mr R and Mrs T that Mr R felt like he was severely deteriorating. As such, his observations may have been different to what they had been previously, had they been taken at 6am.
77. We consider there was a missed opportunity to potentially treat Mr R with an alternative treatment for his PE sooner. There is a possibility the thrombolysis treatment he received at 7.30am would have had longer to take effect had it been given at 6am.
78. Whilst we cannot say for definite Mr R would have survived if he had been given this sooner, this will remain an unknown for Mrs T. This is an everlasting injustice to her and her family, which should not be underestimated.
79. We cannot say that had Mr R’s observations been checked earlier he would have survived, and this means we are unable to offer any reassurance about Mr R’s condition. We can say that Mr R’s observations should have been checked at 6am, as acknowledged by the Trust. Overall, there is a small possibility that had this been carried out, the Trust would have acted sooner, prior to Mr R having a cardiac arrest.
80. We consider this is likely to have a lasting impact on Mrs T as she comes to terms with the death of her husband Mr R, and the missed opportunity that we have identified in this report. We understand that from talking to Mrs T, Mr R’s death continues to seriously effect Mrs T and her family.
81. For these reasons, we are making recommendations to the Trust to put things right and to address the failing in service we have identified. We hope these recommendations reassure Mrs T that her concerns have been taken seriously.
Our current thinking on recommendations
82. In considering our recommendations, we have referred to the ‘NHS complaint standards’. These state that where poor service or maladministration has led to injustice or hardship, the organisation responsible should take steps to put things right. If possibly they should return the person affected to the position they would have been in if the poor service had not happened. If this is not possible, they should compensate them appropriately.
83. In line with this, we recommend the Trust writes to Mrs T to acknowledge and apologise for the lasting uncertainty and distress its failure to adequately monitor Mr R has caused, as well as the Trust not being reactive to hers and Mr R’s concerns. This means accepting responsibility and expressing sincere regret for the resulting injustice. The Trust should do so within one month of this report.
84. To decide on a level of financial remedy, we review similar cases where the person has experienced similar injustice, along with our severity of injustice scale (our scale). Our scale allows us to ensure the recommendations we make are consistent and transparent for everyone who uses our service. The figures included in the scale represent the Ombudsman’s judgement about the sort of sums that are both appropriate and proportionate for us to recommend.
85. Following this review, the Trust should pay Mrs T £1,200 in recognition of the distress and uncertainty which was caused by the Trust’s failure to monitor Mr R’s vital signs after at the point of his deterioration. Also, how this has exacerbated Mrs T and her family’s bereavement. It should make this payment within one of month of this report.
86. We want to be clear that the amount we have recommended is not intended to directly reflect the loss of Mr R. It is in recognition of the magnitude of the missed opportunity in this case, and the significant and long-lasting impact that this has had and continues to have on Mrs T and her family.
87. Our complaint standards say public organisations should look for continuous improvement and should use the lessons learnt from complaints to make sure they do not repeat maladministration or poor service.
88. In line with this, we recommend the Trust produces an action plan setting out the actions it has taken or will take to prevent a repeat of these events. This should include details of the reason for the failure, the improvements to be made, the timeframe for doing so, and the person responsible. The Trust should send this to action plan to Mrs T and us within three months of our final report.
89. To summarise, we cannot know whether Mr R would have been a suitable for any other treatments if his concerns were taken seriously and observations carried out. Even on the balance of probabilities, we cannot determine that this was avoidable death. We think it reasonable to conclude this was a missed opportunity to consider alternative clinical treatment sooner that may have given Mr R the best opportunity of survival.
90. 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.
91. We once again offer our sincere condolences to Mrs T and her family.