Admission 29-30 October 2020
16. Mr X attended the Trust’s ED on 29 October, and an ED doctor assessed him. The relevant guidance that applies here is the GMC’s Good Medical Practice 2014 paragraph 15, which states that doctors 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 • refer a patient to another practitioner when this serves the patient’s needs.
17. The records available to us indicate the ED doctor assessed Mr X in line with the above GMC guidance. The doctor recorded a relevant history, examined Mr X and arranged for him to have a number of investigations. The working diagnosis was recorded as a lower respiratory tract infection (infection in the lung) and intravenous antibiotics were administered. Mr X was referred to the on-call medical team for further assessment. Our EM adviser said there was no indication that Mr X had sepsis during the course of his care under the ED team.
18. Mr X had a fever of up to 38.3 degrees and a tachycardia (fast heart rate) of 124 beats/min. His c-reactive protein (CRP) level was significantly elevated at 193 and his white cell count elevated at 16. CRP is a substance produced by the liver when there is inflammation in the body. All of these are features of possible infection.
19. Staff had documented Mr X had been coughing grey sputum and had been sweating. His chest X-ray was similar to previous imaging. The medical team treated him with a combination of two antibiotics (initially treating him intravenously with cefotaxime, and then with oral co-amoxiclav and clarithromycin) as he was improving. This is in line with NICE guidelines on pneumonia, where this combination of drugs is indicated for severe pneumonia. Our acute medicine adviser said treating Mr X for severe pneumonia was appropriate and in line with the same NICE guidelines, given his observations and history of immunosuppression.
20. The medical team discharged Mr X on 30 October. The NICE guidelines on pneumonia provide some guidance on when it is safe to discharge a patient with pneumonia. They state:
“Do not routinely discharge people with community-acquired pneumonia if in the past 24 hours they have had 2 or more of the following findings:
• temperature higher than 37.5°C • respiratory rate 24 breaths per minute or more • heart rate over 100 beats per minute • systolic blood pressure 90 mmHg or less • oxygen saturation under 90% on room air • abnormal mental status • inability to eat without assistance”
21. On the morning of discharge, Mr X had a heart rate of 115 beats/min and his blood pressure was also borderline (above 90 mmHg). Our acute medicine adviser said extra caution should have been applied, given his immunosuppressed state, as this would have been most in keeping with the NICE guidance on pneumonia mentioned above.
22. Our respiratory adviser notes this was Mr X’s second admission in October. At the time of this admission Mr X was recorded to have elevated temperature readings (within the last 24 hours of this second discharge) and had an elevated heart rate. Trust staff also noted that markers of infection/inflammation (Mr X’s white cell count and CRP levels) were high. Mr X had a history of using immunosuppressive medication. We understand from our respiratory adviser all this was pointing towards ongoing non-settling infection.
23. We understand that Mr X should have received intravenous broad-spectrum antibiotics as per NICE guidance to treat possible pneumonia and antibiotic-resistant bacteria, initially for at least 24 to 48 hours. The guidance also indicates the Trust should have obtained input from a microbiologist, testing for urinary bacteria, testing of pro-calcitonin levels (this is protein marker that can help indicate the presence and severity of bacterial infections), and cultures results for at least sputum and blood cultures. These were needed to make further changes in the treatment plan. In order to look for complications of pneumonia, the Trust should also have arranged for a CT thorax with contrast. A CT thorax scan with contrast is a type of computed tomography (CT) scan that focuses on the chest area. CT scans use X-rays to create cross-sectional images of the body.
24. Taking into account the above clinical advice and guidance, we can see indications that as Mr X had an ongoing infection which was not resolving he should not have been discharged on 30 October. Instead, he should have undergone further investigation to find the cause of his underlying infection. This did not happen and resulted in the Trust having to re-admit him on 1 November. We have found it was a failing to discharge him.
25. While we have found there was a failing on the part of the Trust regarding this discharge, we are unable to say that this had any impact on Mr X’s outcome as he was re-admitted within 48 hours, and so there was very little delay in him receiving the treatment he would have received if that discharge had not occurred. However, we can see his discharge while he was still unwell would have added to Mrs X’ worry and concern at that time. It will also be a source of upset to Mrs X that her husband’s care and treatment was not managed in line with guidance. This has not been recognised by the Trust and we have made recommendations below to address this.
Admission 1-9 November 2020
26. Mr X attended the ED on 1 November as he continued to be unwell. An ED doctor assessed Mr X and they suspected sepsis from a lower respiratory tract infection. The records indicate that the doctor followed a sepsis protocol and treated Mr X with intravenous antibiotics within one hour of sepsis being suspected, and oxygen and intravenous fluids were given. This was in line with NICE NG51 guidance where sepsis is suspected
27. Mr X was noted to have a cough with yellow sputum, which is a sign of a chest infection/or pneumonia. The medical team had treated him with antibiotics co-amoxiclav and clarithromycin on both of his previous admissions. The records show the medical team had a discussion with the microbiology team, who raised the possibility of Pneumocystis (PCP) pneumonia. PCP pneumonia is a rare, serious lung infection caused by a fungus. Our acute medicine adviser said this is an unusual cause of pneumonia that can occur in immunosuppressed patients, and the Trust should have considered this here, given the worsening of the infection despite two courses of appropriate antibiotics. The medical team started Mr X on Tazocin (an intravenous antibiotic) and clarithromycin, which we understand from our adviser was appropriate and in line with the above NICE guidance.
28. A CT scan showed infection in the middle zone of the left lung. A plan for sputum cultures was made, which our acute medicine adviser said showed normal bacteria you would expect (as opposed to anything that would cause infection). A urine legionella test for legionnaire’s disease was negative, as were blood cultures and COVID tests. An ultrasound scan was performed and showed a small pleural effusion (fluid in the chest between the lining of the chest and the lung) on the left, but not enough for the Trust to be able to take a sample of this safely.
29. On 8 and 9 November 2020, Mr X’s pulse rate was greater than 100 beats/min (known as tachycardia). Our acute medicine adviser said it would have been appropriate to have sought input from a respiratory physician in view of Mr X’s multiple episodes of infection in short succession. This would have been in line with the British Thoracic Society guidance for the management of community acquired pneumonia in adults. However, on 9 November it was documented Mr X felt well enough to go home and that he had said it was the 'best I've felt in weeks'. The Trust discharged Mr X home.
30. We note that the records say Mr X was feeling better. However, our respiratory physician adviser noted this was the third admission with the same presentation and worsening X-ray changes. Mr X’s symptoms and blood tests were not showing any improvement in the respiratory tract infection. We understand this should have prompted a specialist respiratory opinion, in line with BTS guidance. This did not happen.
31. The Trust has told us that it is important to note that the BTS guidelines are designed for use within a normally functioning healthcare system. However, it said in the case of Mr X, the extraordinary circumstances of the COVID-19 pandemic significantly impacted the applicability of such guidelines. The Trust said the acute hospital environment was operating under unprecedented pressures, and clinical teams were required to make decisions within rapidly evolving constraints. It said these guidelines, while valuable, could not always be applied in their entirety under such conditions. The Trust has provided information to support its view that these were extraordinary times and the pressures it faced.
32. We recognise the Trust was under pressure but we do not consider this meant that Mr X should not have received appropriate care and treatment. To provide him with the care that was clinically indicated would not only be in line with BTS guidance but the above GMC guidance too. This view is supported by the advice from our respiratory physician adviser.
33. Furthermore, NHS England wrote to the chief executives of all NHS Trusts on 31 July 2020 regarding the third phase of the NHS response to Covid-19. The letter set out the priorities from August 2020 stating, ‘Having pulled out all the stops to treat Covid patients over the last few months, our health services now need to redouble their focus on the needs of all other patients too, while recognising the new challenges of overcoming our current Covid-related capacity constraints’. Whilst recognising that this was an extremely difficult time for NHS services, and those undertaking to provide those services, we have not seen anything in the guidance available to us that omitting the steps identified above was an appropriate option, even in such challenging circumstances.
34. Our respiratory physician adviser said that referral to the respiratory team would have meant that the Trust could have considered several further investigations, in line with the BTS guidance, including a bronchoscopy. This is a medical procedure where a thin, flexible tube (bronchoscope) with a light and camera is inserted into the airways to examine them and potentially collect tissue samples or perform other treatments. It helps with diagnosis of lung problems.
35. Our respiratory physician adviser said that indications that Mr X felt better suggest he was able to undergo a bronchoscopy. This was a missed opportunity and we find this was a failing on the part of the Trust.
36. We have considered the impact of the potential failings in care on Mr X. The BTS guidelines refer to a study showing that when patients were discharged with one or more unstable factors (temperature >37.8 C, heart rate >100/min, respiratory rate >24/min, systolic blood pressure <90 mm Hg, oxygen saturation <90%, inability to take oral medication or abnormal mental status) mortality increased from 2.1% to 14.6% and the rate of readmission increased within 60 days. Mr X was discharged while his record showed he was tachycardic on 8 and 9 November 2020, as his heart rate was greater than 100 beats/minute.
37. The post-mortem indicates Mr X died of sepsis and suffered from DIC. Our respiratory physician adviser said it is likely that in this case life-threatening sepsis and DIC were a result of this non-settling chest infection.
38. The clinical records indicate that at the time of each re-admission Mr X’s main symptoms were suggestive of ongoing chest infection. We understand from our respiratory physician that non-settling infection was playing a major role in Mr X’s deteriorating condition. The above mentioned investigations could have helped in identifying the underlying responsible organism earlier in the course of illness and might have resulted in a different outcome with the help of targeted treatment. However, our respiratory physician adviser said that in some cases, despite best efforts, it is not possible to find out the responsible organism in cases of pneumonia. The BTS guidance also states that usually a microbiological cause is not found in 25% to 60% cases.
39. We have found failings in care relating to the involvement of a respiratory physician and investigations which may have improved Mr X’s outcome, but having considered everything available to us we cannot say that on the balance of probabilities his death could have been avoided. Rather, we consider there was a missed opportunity to improve his chances of a better outcome and Mrs X has been left with uncertainty about whether her husband’s death at that time might have been avoided. This will be a source of significant distress for her, and we do not underestimate that. Mrs X says she and her family are devastated by the loss of Mr X. It will also be a further source of upset that his treatment was not managed in line with guidance.
40. The Trust has not fully acknowledged the failings in care provided to Mr X or the significant impact this has had on Mrs X. We have therefore made recommendations below to below to address this.
Failure to provide information on sepsis
41. Mrs X complains that the Trust did not give her husband any advice or information about sepsis when he was discharged on 30 October and 9 November 2022. The Trust said that the doctors felt they had provided adequate information to Mr X by advising him to return if his condition became worse.
42. Our acute medicine adviser explained the NICE guidelines on sepsis indicate that patients with suspected sepsis (even if not diagnosed as sepsis) should be given,
• verbal and written information about what sepsis is • why it was suspected • what tests have been done • instructions on what symptoms to monitor • when to get medical attention if their illness continues • and how to get medical attention if they need to seek help urgently.
43. The Trust has provided us with a copy of its leaflet ‘Sepsis – Information for patients relatives and carers’ which was in use in 2020. This includes information on sepsis symptoms and what to do if the patient becomes unwell again. However, it has told us that this leaflet was not given out to patients due to the risk of the transmission of Covid-19.
44. However, we cannot find any documentation in the notes to indicate that this information was given orally on the 30 October or 9 November when the Trust discharged Mr X. Mrs X said no information was provided to her husband. The Trust has also confirmed there is no record in the notes of safety advice being provided. We consider it likely that if the Trust had provided the information, Mr and Mrs X would have acted on it. We find that on the balance of probabilities this information was not provided and this was a failing.
45. Mrs X says this lack of information affected the way they sought medical help, which impacted her husband’s outcome.
46. We consider it is unlikely the failure by the Trust to provide information on 30 October had any significant clinical impact as Mr X was readmitted to hospital two days later, as explained previously.
47. However, following his discharge on 9 November Mr X remained unwell and he was re-admitted on 18 November. During this period Mrs X said on 14 November her husband was exhausted and was either sweating excessively or feeling cold and shivering. The first symptoms listed on the Trust’s leaflet under ‘Sepsis Symptoms’ are ‘Shivering, fever or very cold’.
48. The information leaflet advises a patient,
• You should see your GP if you feel you do not improve once discharged, or begin to feel unwell again • If you cannot wait for a GP appointment you should call 111 for advice • If you are too unwell for the above you should go direct to the ED.
49. Whilst we accept the Trust’s explanation as to why an information leaflet was not provided we would expect the verbal advice given to have been in line with the above NICE guidance and leaflet. We have found this did not happen.
50. Mr X said her husband was so exhausted that he went to bed on 14 November. She did contact Mr X’s GP practice on Monday 16 November as she had concerns about his medication and his ongoing symptoms. Mr X also had contact with the practice on the following day. He attended the practice again on 18 November and a GP called 999 for an ambulance to take him to hospital, where he sadly passed away on 21 November.
51. Mr X was showing symptoms listed in the leaflet on 14 November. We consider that this lack of information may have affected the decisions he and his wife made at that time. It is possible Mr X may have returned to the hospital sooner, rather than wait until the Monday 16 November to contact the GP. This may have resulted in him receiving further investigation and treatment. The failure to provide this information meant he was not given everything he needed in order to make an informed decision about what he wanted to do at that time. However, we are unable to say that, even if he had been admitted to hospital sooner, it would have made any difference to his outcome. That said, Mrs X has again been left with uncertainty about what might have been different regarding her husband’s outcome. This will be a source of significant distress for her. It will also be a further source of upset that he did not receive information in line with guidance.
52. The Trust has not fully acknowledged the failings in care provided to Mr X or the significant impact this has had on Mrs X. We have therefore made recommendations below to address this.
Conclusion
53. We have found failings in the Trust’s management of Mr X’s care. We are unable to say that but for these failings Mr X’s sad outcome would have been any different. However, the failings in care identified will mean Mrs X is left in a position of uncertainty as to whether the outcome for her husband could have been different. The Trust has not fully recognised the potential failings in the care provided to Mr X, nor the impact this has had on Mrs X. Therefore, we partly uphold the complaint.