22. 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 also consider whether it looks like the mistake caused suffering, or affected someone in another way, and whether more needs to be done to address this.
Discharge 8 March 2024
23. Mrs E has raised concerns about the Trust’s discharge of her sister on 8 March 2024.
24. It is recorded in Miss A’s discharge summary that the Trust made a request for Miss A’s General practitioner (GP) to carry out repeat blood tests in two weeks’ time and then to reassess. The Trust also prescribed a seven-day course of antibiotics (co-amoxiclav).
25. Our Surgeon explained the Trust carried out a social assessment and clearly outlined its discharge planning. Our Surgeon explained Miss A’s blood sugar levels were within the normal range and there was nothing to indicate any concerns at the time of Miss A’s discharge.
26. It is also noted in Miss A’s clinical records she slept well the night before her discharge and there were no concerns documented in the clinical records.
27. Our Surgeon explained that Miss A’s CT scan appeared to have been unchanged from the previous year. As such, they explained with this, the safety netting advice and given there were no ongoing concerns, discharge was appropriate and in line with DoHSC guidance on discharge, where it states, ‘patients should be discharged to the best place for them to continue recovery (if needed) in a safe, appropriate and timely way’.
28. Based on the evidence available, the advice, and the guidelines, we are satisfied that the discharge on 8 March 2024 appeared to be appropriate.
Discharge 13 March 2024
29. We then looked at whether the discharge of Miss A was appropriate following her admission to hospital on 10 March 2024.
30. The clinical records show Miss A was admitted to hospital due to vomiting but during her admission there was no evidence of any further vomiting. Documentation suggests the surgical team reviewed Miss A and her clinical file and decided a further CT scan was not necessary given her blood results were within the normal range.
31. Our Surgeon explained Miss A was self-caring throughout her admission and there was no evidence of the Trust having any ongoing concerns.
32. Our Surgeon went on to say Miss A was hypoglycaemic (low blood sugars) on her admission but during her time in hospital was eating and drinking normally. They explained from the evidence available it does appear once the Trust adjusted Miss A’s medication, her blood sugars stabilised and she was fit enough to go home, as again, the Trust had no further concerns.
33. Furthermore, the Trust advised Miss A to return to ED if she had any further problems. Miss A’s GP were also still scheduled to carry out further blood tests, as previously outlined. Based on the evidence we have seen and the advice we have been given, it appears the discharge was again in line with DoHSC guidance.
Discharge 4 April 2024
34. We then looked at Miss A’s final discharge from hospital on 4 April 2024, following a two-week admission to hospital.
35. From the documentation Miss A was admitted again due to illnesses relating to low blood sugar levels and throughout her admission she was reviewed by the diabetic nurse specialist.
36. Our Surgeon explained that Miss A was suffering consistently with low blood sugar levels and given this was the third admission in a short amount of time, the Trust made the decision to keep her in hospital for a longer period. This allowed the Trust to stabilise Miss A’s blood sugar levels. Our Surgeon also explained there were no signs of sepsis as Miss A’s blood results were considered normal.
37. It appears Miss A was feeling ‘a lot better’ in the days leading up to her discharge and the Trust had arranged for follow up to monitor her blood sugars.
38. Our Surgeon explained on the day the Trust discharged Miss A’s The National Early Warning Score (NEWS) was zero. This is a national tool, used to assign numbers to physiological parameters to determine the appropriate clinical response to their clinical status and the frequency of future observations. A score of zero would suggest Miss A was not unwell and was fit for discharge.
39. Given the Trust had arranged follow up appointments and the evidence does not suggest Miss A was unwell, we are satisfied the Trust’s discharge of Miss A was appropriate and in line with DoHSC guidance.
Issues surrounding the abscess, inflammation and potential surgery
40. The terms, ‘inflammation, collection(s) and abscess’ in this case all relate to the same area in the abdomen close to liver. For context our Surgeon said Miss A’s ‘collections appeared to be ‘chronic’ but there is no evidence to suggest they had increased in size since the previous CT scan the year before.
41. Our Surgeon went told us that with complicated gallbladder surgery, there is a possibility that some gallstones can escape from the gallbladder and lie in the area near the liver and result in a collection.
42. The evidence suggests Miss A had a liver laceration at the time of one of her operations. A liver laceration can cause a collection of blood or bile to form in the local area around the liver.
43. Our Surgeon explained there is no indication the collections were causing any symptoms or signs of infection. They explained if the collections were causing an infection, there would have been signs of high temperature, persistent elevated white blood cell count and C-reactive protein (CRP) (inflammatory markers), which Miss A’s blood tests did not indicate.
44. Our Surgeon explained the evidence suggests Miss A’s collections were sterile and not the cause of her admissions to hospital between March and April 2024. The Trust initially considered surgery to drain the collection(s), but it deemed there was high risk of damaging the surrounding tissue (i.e. stomach, bowel and blood vessels)
45. Our Surgeon explained it does not appear surgery would have been appropriate given Miss A’s hospital admissions were not related to the collections and there was no indication of deterioration, linked to them. This is in line with GMC GMP guidance says clinicians must provide a good standard of practice and care, and if they assess diagnose or treat patients, they must: • adequately assess the patient’s conditions, taking account of their history (including the symptoms and psychological, spiritual, social and cultural factors), their views and values; where necessary, examine the patient.
• Promptly provide or arrange suitable advice, investigations or treatment where necessary.
46. We are satisfied the Trust acted appropriately when treating Miss A’s collection. There is no indication to suggest her symptoms had worsened over the previous year and nothing to suggest her hospital admissions were caused by her developing an infection.
Communication regarding diagnosis of abscess (collection)
47. Mrs E has told us the Trust did not communicate with her sister or the family about her abscess. Although, it is important to note there is evidence Miss A had collections the year prior to her hospital admission, we are only looking at the period between March and April 2024.
48. Mrs E has said neither she nor her sister were aware of the abscess, as this was not communicated by the Trust.
49. From the documented evidence, we cannot see any indication the Trust had any conversations with Miss A or her family concerning the management of the collections. Therefore, we are unable to say if there was any communication regarding the collection during this time.
50. GMC, decision making and consent guidance states:
‘All patients have the right to be involved in decisions about their treatment and care and be supported to make informed decisions if they are able to. You must start from the presumption that all adult patients have capacity to make decisions about their treatment and care.’
51. It also states:
‘The exchange of information between medical professionals and patients is central to good decision making. You must give patients the information they want or need in a way they can understand. This includes information about: • their condition(s), likely progression, and any uncertainties about diagnosis and prognosis • the options for treating or managing the condition(s), including the option to take no action • the potential benefits, risks of harm, uncertainties about, and likelihood of success for each option.’
52. As such, given we have seen no evidence to suggest the Trust adequately communicated with Miss A or her family regarding the collections, it does not appear it acted in line with GMC guidance.
53. However, we are satisfied there has been no lasting impact from any issues with communication. This is because, as we have already outlined in our report, there is no indication the collection was causing Miss A’s symptoms or causing her any ill health.
54. The Trust has also apologised for Mrs E’s experience and has assured her lessons have been learnt from the issues raised.
55. We are satisfied the Trust has acted in line NHS complaint standards, which state: ‘Organisations support and encourage staff to be open and honest when things have gone wrong or where improvements can be made. Staff recognise the need to be accountable for their actions and to identify what learning can be taken from a complaint. They are clear about how the learning will be used to improve services and support staff’.
56. We would like to thank Mrs E for bringing the matter to our attention. We appreciate the issues raised have been deeply upsetting for all involved. We hope our report clearly outlines the reasons to why we reached our decision.