RDUH Trust
Response to contacts between 28 and 31 March 2023
18. Mr E complains that the nurses who handled the calls he and Mrs L made at the end of March 2023 should have arranged for a hospital admission because of her worsening condition.
19. The Nursing Adviser told us Mrs L needed an indwelling catheter (PleurX) to carry out the paracentesis procedure (draining ascites). This has to be done using ultrasound scanning to ensure there are no vital organs affected by the drainage. This type of catheter is recommended in RCOG Guideline for patients with persistent ascites to reduce the need for repeated procedures to reinsert ascitic drains.
20. The evidence clearly shows Mr E called the oncology team three times between 28 and 31 March 2023. The Nursing Adviser told us the registered nurse who took the first call correctly assessed that Mrs L did not need urgent treatment. By the time of the second call Mrs L’s situation had changed, and her abdomen was more swollen. The nurse rightly arranged for a doctor to schedule drainage.
21. The third call to the oncology team was answered by a support worker. They made a very detailed assessment of Mrs L’s symptoms and gave advice on managing these while waiting for the appointment.
22. The Nursing Adviser said, on each occasion, the nurses handling the calls ensured Mr E was ware that if Mrs L’s condition worsened he could take her to the emergency department. This is what happened. The evidence does not suggest there were any ‘red flags’ to suggest emergency care was needed.
23. We have seen no indications that the nurses who handled the calls from Mr E and Mrs L between 28 and 31 March 2023 fell below the required standards. They appear to have followed the RCOG Guideline.
Drain insertion
24. Mr E complains that Mrs L was left to wait for five days from her arrival at Hospital A for clinicians to drain the ascites. He says this left Mrs L in pain and distress for longer than was necessary.
25. The Oncology Adviser told us there are no specific guidelines about the timeliness of paracentesis. Good Medical Practice says doctors must provide a good standard of care. This includes carrying out adequate assessments, taking account of the patient’s history and examining them if necessary. Doctors should also arrange timely treatment and appropriate investigations or referrals if needed.
26. The clinical records clearly show Mr E raised concerns with staff about the need for a drain on Monday 3 April 2023. Mrs L’s drain was planned to be inserted on Wednesday 5 April. A senior nurse noted they had spoken with Mr E to say the drain was not an emergency treatment and Mrs L could wait until it was scheduled. The nurse said the team would try and bring the procedure forward, but this could not be guaranteed.
27. The Oncology Adviser reiterated what the Nursing Adviser told us earlier in this report. Mrs L needed a PleurX drain, which would require specialist insertion by an interventional radiologist. There is a limited number of clinicians who would be able to complete this procedure in most UK hospitals. It also needs to be noted that the request was made immediately before a weekend. The Oncology Adviser said it would not be unusual for someone to wait three working days for this procedure to take place.
28. Clearly, Mr E was concerned that it took time to arrange for the procedure Mrs L needed and we appreciate how distressing he found this period. The evidence does not suggest that clinicians failed to provide timely treatment. Doctors appear to have followed Good Medical Practice. There are no indications of failings in this respect.
Pain, nutrition and hydration
29. Mr E says the clinical records are incorrect when they refer to Mrs L eating well. He says she returned every meal uneaten. He says she was given insufficient nutrition and hydration while waiting for the drain to be inserted. He also says Mrs L was in exceptional pain and this was not addressed.
30. The NMC Code says nurses must deliver the fundamentals of care effectively and this includes helping with food and drink if necessary. The Nursing Adviser also told us that pain management is a fundamental aspect of nursing care.
31. We recognise that Mr E disputes the clinical records relating to nutrition, hydration and pain. We are persuaded that the clinical records are an accurate reflection of the care clinicians gave to Mrs L during her admission to hospital. They were completed promptly after the events by several different healthcare professionals and are consistent.
32. Records from 31 March 2023 refer to clinicians giving Mrs L pain relief (oramorph and paracetamol) and fluids (drinking water). They established that she had mild pain. Staff offered her food, which she declined. This was understandable given her vomiting and ascites.
33. On 1 April 2023 the records show that Mrs L was receiving intravenous fluids. A consultant noted she ‘remains a little dehydrated’ and that intravenous fluids would continue. By the next day a doctor noted Mrs L’s condition had improved ‘with some fluids.’ There are also references to Mrs L drinking water. On 3 April Mr E complained that she was dehydrated. But the records suggest she continued to be given fluids.
34. The clinical records show Mrs L was eating and drinking on 3 April 2023. But the next day a doctor noted she ‘had not been eating much during the past week due to discomfort.’ They then said she should not eat from midnight on 5 April because of the planned paracentesis.
35. The Nursing Adviser told us there is little evidence that Mrs L had uncontrolled pain during her hospital admission. There were several references to Mrs L denying that she was in pain. On one occasion she asked for stronger pain relief and a nurse provided this for her.
36. The Nursing Adviser noted that by the time Mrs L left the hospital she was eating a normal diet and had a good oral intake. They said this is the pattern you would expect to see when a patient had ascites that has resolved. Ideally, clinicians should have recorded Mrs L’s fluid balance more accurately, but it is clear she was not dehydrated.
37. The evidence does not suggest that nurses left Mrs L in pain. Nurses also gave her appropriate nutrition and hydration. There is no evidence to suggest nurses failed to provide the fundamentals of nursing care for Mrs L. They appear to have followed the NMC Code.
Staff attitude
38. Mr E complains about the attitude and professionalism of several clinicians who attended Mrs L during her admission to Hospital A.
39. We have decided to focus on the more serious complaints that people bring to us, where they may have faced a big impact. For example, these may be about a potentially avoidable death or where someone has suffered prolonged pain. These types of complaints are where we can often make the biggest difference. This will allow us to provide the right level of service to those people, as quickly as possible. This means we are not looking into complaints where we can see there has been a smaller impact.
40. Clearly, Mr E’s interactions with clinicians at Hospital A were upsetting for him. But we cannot see that they could have had any significant impact on Mrs L’s health. We have decided not to investigate this aspect of the complaint further.
Safeguarding concern
41. Mr E recalled an incident on 3 April 2023 when he overheard two healthcare professionals laughing. He believed this was because of the delays in arranging the drain for Mrs L. He says this should have led to a safeguarding referral.
42. The NMC Code says nurses must put the interests of people needing their services first. They must make care and safety their main concern. They must act without delay if they believe there is a risk to patient safety. Good Medical Practice says doctors must act promptly if they think patient safety may be seriously compromised.
43. RDUH Trust explained that one of the clinicians had since left its employment. The other individuals on the ward had no recollection of the incident.
44. The Nursing Adviser told us the situation described by Mr E would not usually be considered a safeguarding matter. If clinicians had been laughing this would be inappropriate behaviour and would normally be addressed by speaking to them to ensure they learnt from what had happened.
45. The Oncology Adviser told us the purpose of safeguarding is to keep people safe. There is no suggestion that the incident Mr E recalled put Mrs L at risk. It was right that clinicians did not consider this to be a safeguarding issue.
46. We recognise that Mr E has strong views that what happened on 3 April 2023 put Mrs L at risk. Based on the clinical advice we have received we do not consider that this should have led to a safeguarding referral.
47. There are no indications that nurses or doctors fell below the standards required in the NMC Code and Good Medical Practice regarding the alleged incident.
Medical decisions
48. Mr E says doctors were wrong to refuse chemotherapy for Mrs L. Instead, he says they cancelled scheduled appointments and decided not to treat her. He says they left her to die. Mr E believes Mrs L could have lived longer.
49. Doctors should have followed Good Medical Practice as explained earlier in this report. Doctors must propose investigations or treatments based on their own assessment and their clinical judgment about the likely effectiveness of treatment options.
50. By 3 April 2023 it was apparent to the oncology team that Mrs L’s illness was progressing. This meant that chemotherapy treatment was no longer working for her. A doctor explained this to Mrs L and noted she was ‘not for further chemotherapy.’
51. The Oncology Adviser told us Mrs L was clearly approaching the end of her life. They said it would have been wholly inappropriate to provide her with active chemotherapy treatment. There would have been a significant risk of her developing unpleasant side effects that would have affected her quality of life.
52. We appreciate how distressing it must have been for Mr E and Mrs L to receive the news that further chemotherapy would not have been beneficial. We consider doctors made this decision based on their assessments and clinical judgments. We can see no indication they fell below the standard expected in Good Medical Practice.
RCH Trust
Medical decisions
53. Mr E says Dr G was biased in favour of consultants at RDUH Trust. He was unhappy that Dr G praised those consultants when giving his second opinion. He says Dr G contacted the team at Hospital A despite being instructed not to do so. Mr E considered this to be a breach of confidentiality. He believes Dr G should have arranged further chemotherapy for Mrs L.
54. Dr G should have followed Good Medical Practice. This also says doctors should only prescribe drugs or treatment when they have an adequate knowledge of the patient’s health and are satisfied they will meet their needs. Doctors should consult with colleagues where appropriate.
55. Mr E shared copies of Dr G’s emails to and from doctors at Hospital A with us. These clearly show that Dr G knew the doctors at Hospital A. We can see that Dr G asked for information from RDUH Trust. He said ‘I don’t think I will have anything to add – or maybe she just needs to hear that.’ A doctor from Hospital A noted that Mrs L had done reasonably well in the five years since her diagnosis. The emails clearly show that both Dr G and the doctor from Hospital A had the same view that further chemotherapy would not be beneficial for Mrs L.
56. Dr G sent a letter to Mrs L’s GP following the consultation on 2 May 2023. He stated he agreed with the team at Hospital A that chemotherapy should not be prescribed. This was because of Mrs L’s frailty and the risks that the treatment ‘could cause more problems than the disease.’ Dr G recommended palliative care rather than active treatment.
57. The Oncology Adviser told us that a doctor cannot give a second opinion without considering the patient's history. This meant it was appropriate for Dr G to request this information from the team at Hospital A. This is not a breach of patient confidentiality. The Oncology Adviser said Dr G would have fallen below the standards expected in Good Medical Practice if he had provided treatment without taking account of Mrs L’s history.
58. We have already explained our view that the decision made at Hospital A was in line with Good Medical Practice. We have the same view about Dr G’s decision at Hospital D.
59. We have seen no indication of failings by Dr G relating to his contacts with clinicians at Hospital A and the outcome of his second opinion.
Identification
60. Mr E says Dr G failed to wear his identification. He also says he refused to provide his GMC registration number.
61. This is another issue where we have decided not to investigate further because it would not be proportionate to do so. We recognise this could have caused some irritation for Mr E, but we cannot say it would have had any impact on Mrs L’s health. Our focus is on investigating matters that could have had a serious effect as we have explained above.
Complaint handling
62. Mr E was unhappy that the employees who carried out the complaints investigations for both organisations were not impartial.
63. As with the previous issue, we do not consider it would be appropriate for us to investigate the impartiality of complaint handling by the organisations. Again, this is because of the relatively small impact this would have had on Mr E. We recognise that, if there was poor complaint handling, this could have led to him experiencing distress and frustration that could have been avoided. But it is not proportionate for us to investigate further.
Conclusion
64. We have decided not to start a detailed investigation of Mr E’s complaints about Mrs L’s care and treatment and complaint handling. We hope he is reassured that we have seen no indication of failings relating to the specific aspects of nursing and medical care he complained to us about. We have also explained why we have decided not to look at some of his concerns that could only have had a relatively small impact.