Leeds Teaching Hospitals NHS Trust
ICU admission and aftercare
20. Mrs K complains the Trust did not provide appropriate aftercare for Ms K following her admission to the ICU on 7 February 2023.
21. Ms K was diagnosed with persistent high blood pressure in 2020. She was prescribed ramipril and amlodipine, which are medications to help lower blood pressure and given a home blood pressure monitor.
22. Blood pressure is measured in millimetres of mercury (mmHg). Systolic blood pressure is the first (top) number and is the highest level a person’s blood pressure reaches when their heart beats. Diastolic blood pressure is the second (bottom) number and is the lowest level a person’s blood pressure reaches as their heart relaxes between beats. The Blood Pressure UK guidance says normal blood pressure for most adults is generally considered to be between 90/60 mmHg and 120/80 mmHg.
23. The NICE hypertension guidance says hypertension increases the risk of a number of conditions, including heart failure, coronary artery disease, stroke and chronic kidney disease. Hypertension is classified according to severity: • stage one: blood pressure ranging from 140/90 mmHg to 159/99 mmHg • stage two: blood pressure of 160/100 mmHg or higher but less than 180/120 mmHg • stage three or severe hypertension: systolic blood pressure of 180 mmHg or higher, or diastolic blood pressure of 120 mmHg or higher • malignant hypertension: a severe increase in blood pressure to 180/120 mmHg or higher.
Primary hypertension, which occurs in about 90% of people, has no identifiable cause. Secondary hypertension has a known underlying cause.
24. We can see from records made by a different trust in 2021, where Ms K was seen for medical issues not related to her blood pressure, and the Trust in 2022 that Ms K was known to show poor compliance with her blood pressure medication. Poor compliance means she was not taking her medication as advised.
25. On 6 February 2023 Ms K called an ambulance. She said she had a migraine, and her blood pressure, taken on her home blood pressure machine, was very high. She told the ambulance crew she had not taken her blood pressure medication for the last week.
26. Ms K was taken to the Trust’s ED. An initial reading said her blood pressure was 222/157 and a second said it was 226/159. She was diagnosed with malignant hypertension with an unknown cause.
27. The BMJ hypertensive emergencies guidance says in hypertensive emergencies, the patient’s blood pressure must be lowered over minutes to hours with parenteral medications in an intensive care setting. Parenteral medications are drugs usually given by injection or infusion.
28. Ms K was admitted to the ICU in the early hours of 7 February and treated with intravenous labetalol. This is used in hospital settings for the rapid treatment of severe hypertension and hypertensive emergencies. Ms K’s blood pressure stabilised and on 8 February it was recorded as 120/80. Her regular blood pressure medication was restarted.
29. Having discussed this with our emergency medicine adviser we can see Ms K’s initial treatment in the ICU was in line with the BMJ hypertensive emergencies guidance.
30. Ms K was diagnosed with an acute kidney injury (AKI) which resulted from the malignant hypertension. She was discharged from the ICU to a renal ward on 8 February for ongoing monitoring of her blood pressure and kidney function.
31. Section 1.4 of the NICE hypertension guidance says consideration should be given to seeking specialist evaluation of secondary causes of hypertension for adults aged under 40.
32. We can see from the Trust’s records that during this admission, it started investigations to see if there was a secondary cause for Ms K’s hypertension, in line with the above NICE guidance. These included blood tests, a kidney biopsy and immunology testing to look for autoimmune diseases which are associated with an increased risk for secondary hypertension.
33. Ms K was discharged home on 18 February. The discharge notice said her primary diagnosis was hypertensive crisis and AKI secondary to hypertension. Her secondary care follow up was for appointments at the renal intervention clinic (RIC), for general nephrology staff (who treat conditions of the kidneys) to review her kidney function, and a review of the outcomes of the biopsy and genetic testing to try and identify a reason for her hypertension.
34. The ESC/ESH guidelines say after a patient who has had malignant hypertension is discharged from hospital, frequent (at least monthly) visits in a specialised setting until the optimal target blood pressure is achieved are recommended.
35. Ms K attended a RIC appointment on 24 February. The doctor recorded the biopsy results were consistent with accelerated hypertension. This is another name for malignant hypertension. They told Ms K she needed to ‘have tighter control’ of her blood pressure, although they did not explain what they meant by that, and she should monitor it by using a home blood pressure monitor.
36. On 28 March the Trust recorded the results of genetic testing were received and no genetic component to Ms K’s hypertension was found.
37. We can see Ms K attended appointments at the RIC on 24 April, 1 May, 23 May, 25 July, and 4 August. Her blood pressure was monitored during these appointments. Records show she did not attend RIC appointments scheduled for 27 June and 7 November. Her GP records show she attended an appointment on 9 October for a blood pressure check which was requested by the RIC.
38. Having discussed this with our haematology adviser we think the Trust followed the guidance we have referred to following Ms K’s admission to the ICU. Specifically, we can see that: • Ms K’s malignant hypertension was treated in line with the BMJ hypertensive emergencies guidance • the Trust investigated possible secondary causes for Ms K’s hypertension which, is in line with the NICE guidelines, and we can see these tests did not find any secondary cause • after she was discharged, Ms K had regular appointments at the RIC and with her GP where her blood pressure was monitored, and this is in line with the ESC/ESH guidelines.
39. We acknowledge Mrs K’s concerns about the Trust’s follow up after Ms K was discharged on 18 February. We hope to reassure her that we have not identified any indications of mistakes in care, nor any errors by the Trust which contributed to Ms K’s death. For this reason, we will take no further action with this part of her complaint.
Hospital attendance on 16 September, 14 and 15 December
40. Mrs K complains the Trust did not investigate Ms K’s symptoms properly when she was seen on 16 September, 14 and 15 December.
41. Section 7 of GMP guidance says in providing clinical care doctors must: • adequately assess a patient’s condition(s), taking account of their history, including symptoms • carry out a physical examination where necessary • promptly provide (or arrange) suitable advice, investigation or treatment where necessary • propose, provide or prescribe effective treatment based on the best available evidence.
42. Ms K went to the ED on 16 September. She said she had had a headache for two weeks which was getting worse, had vomited and had woken that morning with blurred vision although it was not blurred currently.
43. A doctor examined Ms K. They recorded her blood pressure was 200/130 on admission and Ms K was having a hypertensive crisis. Staff took a sample of Ms K’s blood and urine, arranged a brain scan and conducted an electrocardiogram, which records the heart’s rhythm. This showed no irregularities. Ms K told the doctor she had taken her blood pressure medication that morning but sometimes forgot. The doctor noted they stressed the importance of medication compliance to Ms K.
44. The doctor prescribed intravenous labetalol which resolved Ms K’s high blood pressure. She was admitted to a ward and discharged on 18 September. The discharge summary sent to her GP said: • Ms K was medically fit for discharge • her blood pressure had returned to normal levels • she was reinstated onto her usual regime, which means she given her normal blood pressure medication • renal follow up was already in place, which refers to her ongoing appointments with the RIC • Ms K was inconsistent with concordance, which means she did not always follow her medication plan, and understood the risks of poor compliance.
45. We can see from the Trust’s records that Ms K went to the RIC on 27 September to ask for a prescription for blood pressure medication. It was noted she had not collected her medication following her discharge on 18 September and had not been taking her medication or using her home blood pressure machine. She was given ‘safety netting’ information, which is where patients are given instructions on what to do if their health symptoms do not improve, if they change, or if the patient develop new concerns, and told she should go to the ED immediately if she had a severe headache that was different from her usual migraines.
46. Ms K went to the ED on 13 December complaining she had had a headache for the past few days and was feeling dizzy. A doctor examined her and noted she had a history of hypertension. Her blood pressure was recorded as 173/120, which means it was stage two hypertension. We can see from records a doctor completed a full examination, including taking blood and urine samples and doing an ECG.
47. The doctor recorded their impression was Ms K had a migraine which was possibly related to hypertension, and they requested a computerised tomography (CT) scan of her head. This is a scan that takes detailed pictures of the inside of the body. They said if no abnormality was detected Ms K could go home. The CT report said there were no acute intracranial findings, meaning no issues were detected. Records show Ms K was prescribed painkillers and she was given safety netting and red flag advice. This means she was given information about urgent warning signs indicating potentially serious conditions, and what she should do in those circumstances. Ms K was discharged home in the early hours of 14 December.
48. Ms K went to her GP on 15 December and said she had a headache with nausea and vomiting. The GP recorded Mrs K’s blood pressure was slightly raised and advised her to go to the ED. Ms K went to the ED and her blood pressure was recorded as 148/87. This is stage one hypertension, and we can see it was lower than when she went to the ED on 13 December. Ms K told the doctor she thought she was having a migraine, and her symptoms were no worse than they had been on 13 December. She also said she was taking aspirin for pain relief, and her blood pressure was good, for her.
49. The doctor recorded Ms K had had a CT scan and blood samples taken when she was in the ED two days earlier. They said their impression was she had a migraine and prescribed migraine medication. They told Ms K to follow up with her GP if her symptoms did not settle.
50. We thought about whether the Trust followed the correct guidance on each occasion with the help of our emergency medicine adviser. We explained earlier that we can see the Trust had already put in place appropriate follow up after Ms K’s admission to the ICU in February. On the occasions she went to the ED in September and December, she was still regularly being seen at the RIC, and investigations into any secondary cause for her hypertension had been completed.
51. In our view, Ms K was treated in line with guidance when she went to the ED on all three occasions. Specifically, on each occasion the health complaints she went to the ED with were investigated and treated in line with the GMP guidance for clinical care. We do not think the Trust missed any opportunity to take action that might have prevented Ms K from suffering malignant hypertension. For this reason, we will not be looking at this matter further.
52. We understand that Mrs K is very worried that the Trust could have either treated or investigated Ms K’s symptoms more thoroughly when she went to the ED on three occasions between September and December 2024. We know she is concerned that if it had, Ms K would not have died of a brain haemorrhage caused by malignant hypertension. We hope we have been able to explain to her we have not seen anything to suggest this is the case. In our independent view, the Trust followed the appropriate guidance and did not miss an opportunity to prevent Ms K’s sad death.
The Practice
Appointment on 7 December
53. Mrs K complains the Practice did not make an appointment for Ms K on 7 December.
54. The NHS England GP guidance says patients should be offered an assessment of need, or signposted to an appropriate service, at first contact with the practice.
55. Ms K attended a scheduled appointment with a GP on 5 December. She said she had had a colposcopy, which is a medical examination of the cervix, and biopsy on 27 November following which she had heavier than normal bleeding for a couple of days. The bleeding then stopped but had started again that day. Ms K said the bleeding was very heavy and she was passing large clots.
56. The GP recorded they prescribed norethisterone and told Ms K to book an appointment for an internal examination and review once the bleeding stopped.
57. Ms K went to the Practice on Thursday 7 December and asked a receptionist for an appointment because she was still bleeding heavily and there had been no change since her last appointment.
58. The Practice’s guidance says when it is contacted by a patient, they should be asked what problems they are experiencing. If they meet ‘red flag’ criteria, for example chest pain, stroke, or broken bones, they would be advised to go the ED or phone 999. If they do not meet those criteria and ask for a same day face to face appointment and none are available, the patient should be asked if they want to make a future face to face appointment. If that is refused, the receptionist should tell the patient they can attend a local walk-in centre or offer to ask a GP for advice.
59. The receptionist noted Ms K was unwilling to wait until Monday 11 December, which was the next available appointment. They made a referral to the Practice’s GPs asking for advice.
60. Ms K went to the ED at midday on 7 December and complained of heavy vaginal bleeding. She was told to increase the dosage of norethisterone and prescribed tranexamic acid (which helps blood to clot and is used for heavy periods). She was also told to contact her GP if the bleeding continued after five days.
61. A Practice GP recorded they made an unsuccessful attempt to contact Ms K at about 5.00pm that afternoon. They noted they could see Ms K had been to the ED and had been given medication.
62. We acknowledge Ms K was frustrated when she was not given a same day appointment with a GP on 7 December. Her symptoms did not meet the red flag criteria, and we can see she was offered appropriate alternatives. We have seen no indications of failings by the Practice in the way it dealt with Ms K’s request. The Practice acted in line with both the NHS England GP guidance and its own internal process when it offered her an appointment on 11 December, and asked GPs for advice. Ms K decided to seek alternative support by going to the ED where she received treatment for the symptoms she described. For these reasons we will not be considering this matter further.
Vocare Group (NHS111)
63. Mrs K complains that when Ms K called NHS111 on 2 January 2024 it did not consider the symptoms Ms K described, nor access Ms K’s GP and hospital records when it triaged the call. She also says it failed to call Ms K back to complete the call after it was cut off prematurely.
64. NHS 111 is a free healthcare assessment service for people who need medical help or advice fast but are not in an emergency. A trained adviser assesses the patient’s needs and directs them to the best local service, such as an out-of-hours GP, urgent treatment centre, pharmacist, or arranges a nurse callback or ambulance if necessary.
65. The NHS Pathways guidance explains NHS 111 services use NHS Pathways which is a telephone triage system. It is used for assessing, triaging and directing the public to urgent and emergency care services. Calls using NHS Pathways are managed by non-clinical specially trained health advisers who refer the patient into suitable services based on their health needs at the time of the call. The health advisers are supported by clinicians who can provide advice and guidance or who can take over the call if the situation requires it.
66. The NHS Pathways guidance says life-threatening symptoms are assessed at the start of the call, triggering ambulance responses if appropriate, progressing through to less urgent symptoms which require a less urgent response. The response the adviser decides on is known as a disposition. A disposition will specify the skill set and time frame that a patient requires. NHS Pathways is not a diagnostic system and only assesses symptoms presented at the time of the call and signposts to the next level of care.
67. Ms K called NHS111 at 11.04pm on 2 January. We listened to a recording of this call. Ms K told the adviser she had a bad migraine, felt really unwell and was vomiting. She said she had high blood pressure, was lightheaded, had no loss or disturbance of vision and took medication for regular migraines. The adviser asked if Ms K had taken her blood pressure and she said she had not.
68. Ms K could be heard vomiting during the call, and the adviser transferred the call to a clinical adviser. Ms K told the clinical adviser: • her landlady was with her • she had not lost any blood • the migraine and vomiting started the previous day • she had not lost consciousness • she had no stroke-like symptoms, for example she could lift both arms into the air • had a similar migraine in December and had gone to hospital.
69. NICE headache guidance says red flags suggesting a potentially serious cause of secondary headache requiring emergency admission include new severe or unexpected headache, such as a sudden onset, or ‘thunderclap’ headache reaching maximum intensity within five minutes. This might indicate malignant hypertension.
70. The clinical adviser asked if the headache started suddenly. Ms K said it had and had got worse since it started. They asked Ms K if it felt like she had been ‘hit by a brick’ when the headache started. Ms K did not answer. The clinical adviser asked if Ms K was there. Ms K did not answer. Before the clinical adviser disconnected the call, they said they would try to call back. If Ms K had any concerns she could call NHS111 again.
71. Section 5.8 of the NHS111 contract explains what action should be taken if a call disconnects during triage with a clinical adviser. The clinical adviser must attempt to contact the patient on two separate occasions. When two separate attempts have been made by a clinician and there is no significant clinical concern or risk identified regarding the case, the clinical adviser selects ‘early exit’ and the call can be closed with no further action required. If the case is tagged as an emergency priority and the clinician has been unsuccessful at contacting the patient, advice must be sought from team leader immediately for them to listen to the call to check the severity of the patient’s symptoms. In these cases, an assessment is not completed, and no disposition is reached.
72. The clinical adviser selected ‘early exit’. They recorded: • the assessment ended because the line went dead, and a disposition was not reached • they made unsuccessful attempts to call Ms K back • Ms K was not on her own • Ms K had seen her GP on 15 December and was given red flag advice.
73. We can see this indicates the NHS111 clinical adviser accessed Ms K’s GP records before they decided to close the call. The GP records the clinical adviser looked at are the ones of Ms K’s last face to face appointment with her GP on 15 December which we referred to earlier. The notes said Ms K had a week-long headache, her blood pressure was 130/80mmHg which, from the NICE hypertension guidance, means it did not reach the level of stage one hypertension, and Practice staff had advised her to go to the ED.
74. Having discussed the NHS111 call with our NHS111 adviser, we can see it was handled in line with the standards and guidance we have referred to. Both the NHS111 initial adviser and clinical adviser asked questions in line with the NHS Pathways triage. We can also see the appropriate guidelines were followed when Ms K’s call with the clinical adviser disconnected. We can see the clinical adviser made attempts to call Ms K back and documented why they decided to close the call with no further action required. They also accessed Ms K’s GP records for further information to support their decision, although we can see this is not a requirement.
75. We also thought about whether the clinical adviser completed an appropriate risk assessment before deciding the call could be closed. With the help of our NHS111 adviser we can see with the information available to them, Ms K would not have been considered a significant clinical concern or at risk in line with Section 5.8 of the NHS111 contract we explained earlier. This is because she told the clinical adviser she had someone with her, and the GP records suggested she had recently been given red flag signs by her GP. We can see Ms K said she had high blood pressure but did not specifically say she had previously been diagnosed with malignant hypertension. Our NHS111 adviser explains that high blood pressure is very common and, on its own, and without an answer to the question about how the headache felt, we understand the clinical adviser would not consider that to be a significant clinical concern when the call ended.
76. In our view, Ms K’s symptoms were properly considered during the call for as long as it went on, her GP records were accessed after the call cut out, and attempts were made to call her back. This means NHS111 acted in line with guidance and standards when dealing with Ms K’s call.
77. We acknowledge Mrs K’s concerns about this call and why she might think her daughter’s death could have been avoided if a disposition had been reached and an ambulance been dispatched, or Ms K had been told to go to the ED. We hope to reassure Mrs K that we have not identified any indications of errors by NHS111 which contributed to Ms K’s death. For this reason, we will take no further action.