Monitoring
18. Before we decide if we should conduct a detailed investigation of 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 and have not found any indications that something has gone wrong.
19. Miss C is concerned the Trust did not spot the signs of her aunt having an ischaemic bowel (limited blood supply to the bowel because of hardening and narrowing of the arteries supplying it) at the earliest opportunity.
20. Mr C’s medical records show the Trust did monitor Mrs C’s condition regularly from the time of her admission to hospital, until 30 April 2024.
21. The medical records document the Trust triaged Mrs C in the emergency department. The Trust documented a comprehensive history of her fall, noted down her previous medical history and carried out a full physical examination. This doctor requested X-rays of Mrs C’s left hip and pelvis as she was complaining of left groin pain. The left hip X-ray showed a fracture of the hip.
22. Medical records document Mrs C had had surgery (left hip replacement) the day after admission. A day after the surgery, medical records detail a doctor reviewed Mrs C and it was noted on examination the wound from the hip operation was dry and Mrs C was comfortable and showing no complications following the surgery.
23. Medical records also document, a day after surgery, orthogeriatric team (these are doctors specialising in geriatric medicine who provide a perioperative service for older patients with fractures who have undergone surgery to ensure that any complications are picked up and attended to early) provided a full assessment.
24. Medical records document, from the 15 April 2024 onwards the clinical team reviewed Mrs C daily during ward rounds. Records document the medical team worked to optimise Mrs C’s care plan to facilitate discharge.
25. From 19 April 2024 Mrs C was deemed to be medically fit for discharge but continued to have daily reviews by doctors with the nursing staff doing daily observations and daily intentional checks. Her National Early Warning Score (NEWS) remained between 0 and 2 until midday 30 April 2024 when her NEWS score increased to 4.
26. NICE guidance explains NEWS (National Early Warning Score) is a tool which improves the detection and response to clinical deterioration in adult patients and is a key element of patient safety and improving patient outcomes. NEWS scores the physiological measurements that are routinely recorded at the patient's bedside. Its purpose is to identify acutely ill patients, including those with sepsis, in hospitals in England. The NEWS scoring system measures six physiological parameters: respiration rate, oxygen saturation, systolic blood pressure, pulse rate, level of consciousness or new-onset confusion and temperature. The NEWS scoring system provides scores for a patient from 0 (no signs of deterioration) to 20 (indicating severe deterioration).
27. Medical records document, in addition to being reviewed by clinical team during her admission, Mrs C also received input from the pain team, who reviewed her drug chart and ensured that she was prescribed morphine as required every four hourly. She received regular physiotherapy input and was assessed by the occupational therapy team. During her admission Mrs C also received input from the speech and language therapy team.
28. Medical records document, from the time admission, clinical team examined Mrs C’s abdomen during the daily examinations. It is recorded her abdomen was always found to be soft and non-tender with normal bowel sounds. It is also recorded, when Mrs C deteriorated after 27 April 2024, the doctors who examined her found her abdomen was generally tender.
29. Records document, from 27 April 2024, Mrs C’s symptoms were diarrhoea, worsening abdominal pain, bloating and general tenderness. Medical records show Mrs C did not have a temperature, she reported feeling some nausea but not vomiting and there was no blood in the stool.
30. Medical records, show clinicians considered colitis (inflammation of the colon) and/or infection as a working diagnosis at this stage. Doctors recommended a computed tomography (CT) of the abdomen and pelvis, full blood count and inter-abdominal pathology (collecting sample of stool and screening for viral or bacterial causes of diarrhoea).
31. On 28 April 2024, the stool microbiology report, of the sample collected a day before, detailed there was no evidence of C.diff (a type of bacteria that can cause diarrhoea) infection and recommended a repetition of the testing after 72 hours.
32. On 29 April 2024, the blood tests of the sample collected on the same day, showed high C-reactive protein (CRP) levels. On the same day, it is recorded Mrs C vomited blood.
33. High CRP levels indicate significant inflammation in the body, which may stem from various health conditions like infections, cardiovascular diseases, or autoimmune disorders. Measured through a CRP blood test, these levels reflect inflammation's presence and extent but not its cause, so further investigation is necessary to identify the underlying issue.
34. On 30 April 2024, the CT scan (a computer guided X-ray) showed fluid in the stomach, bowel inflammation with enlarged small and large bowel with fluid in it, and a small amount of free fluid in the abdomen.
35. On 30 April 2024, medical records document, Mrs C’s condition worsen further and she was vomiting blood regularly.
36. The medical records show, the evening of the 30 April 2024 after a clinical review, the Trust concluded Mrs C most likely had an ischaemic bowel.
37. NICE’s ‘Ulcerative colitis’ explains the symptoms of colitis are abdominal pain, persisting bloody diarrhoea. It recommends clinicians consider the following investigations if they suspect colitis: full blood count, stool microscopy and culture, serum urea and electrolytes and a CT scan.
38. NHS ‘Clostridioides difficile (C. diff) infection’ is relevant to this complaint as the trust suspected Mrs C had a bacterial infection. NHS details the common symptoms of a C. diff infection include diarrhoea, feeling sick and a stomach ache.
39. Bowel Research UK explains bowel ischaemia by its very nature can occur suddenly in an apparently stable patient, because it is caused by the sudden blockage of a blood vessel supplying the bowel. This is rather like a heart attack is caused by the sudden blockage of a blood vessel to the heart and a stroke is caused by the sudden blockage of a blood vessel to the brain. It also explains diagnosis is also difficult, as no simple bedside test for bowel ischaemia currently exists.
40. BMJ research ‘Best Practice- Ischemic bowel disease’, details the symptoms of ischemic bowel disease can be abdominal pain, abdominal tenderness, the presence of risk factors, diarrhoea, nausea, weight loss and bloody stool. It also details some patients are at higher risk of developing bowel ischemia. The risk factors are old age, history of smoking and arterial fibrillation (irregular heart rate). The guidance also recommends clinicals suspecting ischemic bowel disease consider the fallowing investigations: CT scan and blood tests for full blood count and urea and electrolytes.
41. Our adviser reviewed the medical records and confirmed the Trust monitored Mrs C in line with established clinical practice. Our adviser also confirmed the Trust undertook investigations once Mrs C deteriorated, These were in line with established GMC medical practice.
42. Based on medical records, NICE guidance on early warning system and independent clinical advice, we are of the view for most of the admission, until 27 April 2024, Mrs C’s condition was stable and she was at low clinical risk.
43. Based on evidence we have seen so far in the medical records we can see from 27 April 2024, Mrs C’s had new symptoms. We note Mrs C had symptoms that were common to a variety of conditions. We are pleased to see the Trust recommended investigations in line with, British Medical Journal, NHS and NICE guidelines (as discussed) to enable it to confirm a diagnosis.
44. We recognise Miss C was very close to her aunt and she is still very upset about her death. We acknowledge she is wondering if more could have been done on 27 April 2024 when the symptoms first appeared.
45. Sadly, we have seen with increasing age and in those patients who have risk factors like Mrs C had such as known coronary artery disease (she had a cardiac stent previously which means that she had hardening of the arteries supplying her heart) and atrial fibrillation (an abnormal heart rhythm which puts patients at increased risk of having blood clots such as a blood clot obstructing blood flow to the bowel).
46. In summary, based on clinical records, we are of the view the Trust took prompt action to investigate the source of the symptoms. We found the Trust carried out investigations in line with clinical guidance on suspected colitis, infection and ischemic bowel disease. As such, we have found no indications of service failure.
Palliative care
47. Before we decide if we should conduct a detailed investigation of 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 and have not found any indications that something has gone wrong.
48. Miss C complains the Trust did not consider palliative care as soon as possible. Miss C is concerned the Trust did not identify bowel ischemia as soon as possible and as such did not provide palliative care as soon as possible.
49. Medical records document, once the Trust concluded Mrs C’s abdominal pain and worsening condition was most likely to be the result of bowel ischaemia, it explained to her niece the treatment would mean a major abdominal operation called a laparotomy for which the risk would outweigh the chances of survival. The Trust also explained to Miss C there was no single test or scan to diagnose bowel ischaemia, however it felt this was most likely the correct diagnosis. It was after this review and discussion that the decision was made to start palliative care.
50. NHS ‘What end of life care involves’ explains palliative care is available as soon it is identified that a patient has a life-limiting (terminal) illness.
51. GMC’s ‘Treatment and care towards the end of life: good practice in decision making’ provides you with a framework to support you in meeting the needs of your patient as they come towards the end of their life. It explains the starting point for reaching good decisions is careful consideration of the patient’s clinical situation and carrying out a thorough assessment of the patient’s condition.
52. Our adviser reviewed the medical records and confirmed it was not possible for the medical team to tell earlier in the admission that Mrs C would be for palliative care. This is because bowel ischaemia by its very nature can occur suddenly in an apparently stable patient .
53. We are sorry to hear Mrs C deteriorated rapidly. We can see, from medical records and Miss C’s account, Mrs C was very distressed and her condition and symptoms worsen in the last three day of admission. We recognise this must have been a very distressing time for Miss C.
54. Based on medical records, we are of the view the Trust considered palliative care as soon as it became apparent Mrs C did not have a treatable and reversible condition. We found the Trust considered Mrs Cs presenting symptoms and undertook further investigations enabling clinicians to reach a clinical decision based on the full clinical picture. This was done as early as possible, we find this is in line with GMC’s medical practice guidelines.
55. As such, we have not found any indications of service failure.
Pain relief on 30 April 2024
56. To decide if we should conduct a detailed investigation into a complaint, we first consider whether there are any indications something went wrong with the service provided by the organisation. If so, we then explore if the organisation would be willing to take further steps to put this right and resolve the complaint.
57. Miss C says her aunt’s pain was not managed appropriately as she remembers her aunt screaming in agony. This must have been very distressing for Miss C to witness.
58. Mrs C’s prescription chart document clinicians prescribed Mrs C pain medication to address any pain she had from the surgery. It is documented clinicians prescribed Mrs C codeine phosphate every four hours and the morphine sulphate (pain medication to treat severe pain) which was prescribed on the “as required”.
59. Medical records document on 30 April 2024, Mrs C was vomiting regularly. Records also document she received one gram of paracetamol, intravenous infusions (via a needle in a vein), at 8am, 12pm and 6pm. She was administered the first dose of morphine subcutaneously (via injection, just under the skin) at 7pm and then another dose at 10.40pm. Mrs C received a final dose at 12.05am on 1 May 2024.
60. Our adviser informed us as Mrs C had been vomiting she could not take the pain medication orally and derive any benefit from it (even if she was able to swallow it there was a chance she would vomit it back up again).
61. Based on medical records and independent clinical advice, we are of the view it is more likely than not that Mrs C would not have been able to take the codeine phosphate prescribed on the regular side of the drug chart or the morphine sulphate which was prescribed on the “as required” side of her drug chart. All she was getting was the regular paracetamol 1 gram intravenous infusions.
62. Based on the pain score reported by Mrs C in the medical records and her prescription chart, we are of the view paracetamol was not as strong a pain medication as either morphine sulphate or codeine. Therefore this may not have been enough to control her pain and keep her comfortable.
63. We are sorry to hear Mrs C was in pain on 30 April 2024. We recognise this must have been distressful for both Mrs C and Miss C.
64. We have indications the Trust did not manage Mrs C’s pain on 30 April 2024 in line with Mrs C’s prescription chart and GMC’smedical practice.
Communication
65. Miss C says the Trust informed her of her aunt’s poor prognosis in a public space and she says the process felt ‘cold and clinical’.
66. The Trust has already apologised to Miss C in respect to this part of the complaint. The Trust has accepted it has not delivered the distressing news in an appropriate setting.
67. The GMC’smedical practice guidance stresses doctors must respect every patient’s dignity and right to privacy. This means that any important and confidential information should have been shared out of the potential earshot of others preferably in a private room. The guidance also states that doctors should be considerate and compassionate to those close to a patient and sensitive and responsive in giving them support and information (point 37).
68. As the Trust has not communicated confidentially Mrs C’s prognosis and Miss C felt the whole process was “cold and clinical” the manner in which the distressing news was given to her has fallen short of the expected standard however unintentionally even though it was given honestly.
69. We are pleased to see the Trust has already taken action in respect to this part of the complaint.
70. During this process, we approached the Trust and asked if it would be willing to consider a financial remedy to put right the last two parts of the complaint, pain management and communication. The Trust agreed to this.
71. Our NHS Complaints Standards (2023) say organisations should find ‘suitable and appropriate ways to put things right for people who raise a complaint’.
72. In this case, we are satisfied the Trust has acknowledged it can provide Miss C with a financial remedy of £2,000 to address the last to points of the complaint, pain management and communication. As this is the outcome Miss H is seeking, we consider this will resolve her complaint. Therefore, we have decided not to take any further action
73. Complaints give us valuable insight into the organisations we investigate, and we recognise this has been an emotionally challenging process for Miss C. We would like to thank Miss C for sharing her experience with us.