12. When we consider whether there is an indication of a failing in the care and treatment complained about, we first determine what should have happened in line with relevant policies, guidelines, standards and good clinical practice. We then use all available evidence to determine if we can say what should have happened, did happen. If it did not, we then consider if what did happen fell so far short of what should have happened that it amounts to an indication of a failing.
13. Only if we identify an indication of a failing in the care and treatment provided, do we then consider the impact of this failing.
Scan
14. Mr E complains the Trust would not scan his appendix, and instead only performed blood tests.
15. The Trust said it had planned to scan Mr E, but it was waiting for the results of all his blood tests, as these would have helped determine what type of scan was most appropriate. This is because an ultrasound is preferred for suspected gallbladder issues, but a CT (computed tomography) scan is preferred for suspected appendicitis.
16. The doctor wrote their notes in the Trust records retrospectively, after Mr E raised his complaint. The Trust told us the doctor did not do this on the day as they should have due to human error.
17. The notes say Mr E attended with a friend (who is in fact his cousin) complaining of right sided abdominal pain for one day. On examination, the doctor observed Mr E having tenderness in both the upper and lower quadrants of his right sided abdomen. The plan was to try and find the exact point of Mr E’s tenderness after giving him pain relief, as upper right pain would suggest an ultrasound for potential gallbladder issues and lower right pain would suggest a CT scan and discussion with surgeons. As Mr E declined any pain relief due to his medical history, the plan was then to wait for the results of his blood tests instead. Mr E then self-discharged before all the results from his blood tests had come back.
18. NICE CKS guidance says, ‘Suspect a diagnosis of acute appendicitis if there are suggestive clinical features on history and examination. Establishing a diagnosis may be challenging, as it may present atypically and vary in severity.’ It says clinicians should, ‘Take a full history, including current medication use.’, ‘Ask about typical symptoms’, ‘Examine the person’, and ‘Consider the need for additional investigations to exclude an alternative cause, depending on clinical judgement.’
19. NICE CKS guidance lists various symptoms for clinicians to consider when assessing for suspected appendicitis but does not give any definitive combination of symptoms that confirm a diagnosis. Our adviser told us blood tests will often contribute to a management plan, alongside a clinician’s consideration of symptoms. A clinician can also use blood tests to ascertain any potential non-surgical causes of abdominal pain.
20. With regards to imaging, NICE CKS guidance says, ‘Specialist management of suspected acute appendicitis may include: • Imaging investigations • Imaging studies in people with a clinical suspicion of acute appendicitis can reduce the negative appendectomy rate, which has been reported to be as high as 30%. Ultrasonography, abdominal computed tomography (CT) and magnetic resonance imaging (MRI) are most commonly used.
• Selective imaging [choosing the right type of scan] may be used when the diagnosis is uncertain given the risks, benefits, costs, and time delay to surgery associated with imaging.’
21. Again, NICE CKS guidance provides options for clinicians to consider when it comes to imaging but does not dictate a particular imaging modality. Our adviser told us in their experience an ultrasound is the preferred imaging modality to identify possible gall bladder issues, and a CT scan is preferred for suspected appendicitis.
22. Our adviser told us the Trust’s management of Mr E was appropriate, based on the retrospective notes. We recognise Mr E’s recollection of that day is different in some areas. We therefore need to carefully consider what both parties have told us.
23. The notes are based on the doctor’s recollection, 26 days after the events, during which time they would have seen many more patients. We note what the doctor has said regarding remembering the case well due to Mr E’s past medical history. We need to balance this with the fact that Mr E’s cousin has substantiated his version of events, while also noting we cannot consider them an independent third party.
24. Mr E says his vitals were not normal as the Trust claim, as his blood pressure and temperature were raised, and he was very clammy and in considerable pain. Mr E says he made staff aware the pain was in the appendix area, rather than just being across the whole right side. Mr E also says he stressed he believed it was appendicitis due to the pain, lack of appetite, and his history of parasites, and directly asked staff to perform a scan.
25. The Trust records contain Mr E’s observations, and it recorded these contemporaneously. These give Mr E’s temperature as approximately 36.5, his blood pressure as approximately 155/100 and 150/105, and his pain score as a six. We have no reason to believe these may be not accurate recordings.
26. A temperature of 36.5 degrees is normal. 155/100 and 150/105 are both high blood pressure readings. Our adviser told us a rise in blood pressure is a physiological response to pain, not a sign independently associated with appendicitis. A pain score of six is considered moderate pain on the zero to ten scale.
27. We recognise Mr E says he made staff aware the pain was coming from his appendix. Our adviser told us it can be more difficult than a person may realise to localise pain within themselves. This means it still would have been appropriate for the Trust to wait for the results of the blood tests before ordering a scan. We also would not expect the Trust to scan Mr E just because he asked for one.
28. We recognise how distressing it can be not to receive the investigations you believe you need. We have seen it was appropriate for the Trust to order blood tests, and wait for the results of these, before arranging a scan for Mr E. This is regardless of whether we take the Trust’s or Mr E’s version of events as accurate. We therefore will not consider this aspect of the complaint any further.
Further management
29. Mr E complains the Trust told him all it could do was give him antibiotics, regardless of the outcome of the blood tests. Mr E says as he could not take antibiotics, he chose to self-discharge.
30. The Trust said the doctor is certain they did not tell Mr E the results of the blood tests would not alter their plan of care. The doctor also does not recall offering Mr E antibiotics.
31. The retrospective notes say the Trust told Mr E it would make further clinical management decisions based on the results of the blood tests. There is no record of the Trust offering Mr E antibiotics.
32. There is a clear discrepancy in recollections about whether or not the Trust offered Mr E antibiotics. We do not need to consider whether antibiotics would have been appropriate for Mr E’s presentation, as he did not take them. What is important to consider is whether the Trust told Mr E that the results of the blood tests would not have changed their management of him going forward.
33. As before, we need to take into consideration that the Trust notes are based on the doctor’s recollection after the fact, and that Mr E’s cousin supports his recollection. We do not dispute any party’s recollection of events. As we were not there, we cannot say for certain what happened that day.
34. We know how frustrating it is to be in a ‘he said, she said’ type situation. We consider we do not have enough corroborating evidence to form a view on whether the Trust told Mr E that the results of the blood tests would not have changed their management of him going forward. While this means we cannot say for sure that the Trust did give Mr E the correct information, it also means we cannot say for sure that they did not. As a result, we cannot say there is a potential failing in the Trust’s actions here. We will therefore not consider this aspect of the complaint any further.
35. This concludes our consideration of Mr E’s complaint. We thank Mr E for bringing his complaint to our attention and wish him all the best for the future.