Treatment of heart and liver problems, including low blood pressure
13. Mrs R believes there was a delay in providing appropriate treatment for her father’s liver problem. She also says nobody checked her father’s heart and instead considered he had pneumonia. She says his blood pressure was dangerously low. She questions whether the heart attack could have been prevented.
14. The Clinical Adviser told us there are no specific standards that apply directly to Mr T. This is because he had a complex, multisystem disease, which was individual to him. Mr T was systemically unwell and needed input from many clinicians and specialties. Doctors should, though, have followed Good Medical Practice.
15. 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. They must be satisfied that any medication they prescribe serves the patient’s needs. They must consult colleagues and make referrals to other qualified practitioners when this serves the patient’s needs.
16. The clinical records show Mr T had episodes of orthostatic hypotension (this is a fall in blood pressure when someone stands from a sitting or lying position) before his admission to the Hospital. During the admission there were no initial concerns about blood pressure. There was a significant drop in his blood pressure following the sudden deterioration on 19 February 2024.
17. The Clinical Adviser told us Mr T’s low blood pressure reflected his acute illness. Doctors suspected he had vasculitis (inflammation of blood vessels). When they investigated this issue they found he had liver disease. They managed the low blood pressure using fluids when needed and treated the suspected vasculitis using steroids and antibiotics. This was in line with Good Medical Practice.
18. The records suggest Mr T’s heart problems developed following the sudden deterioration. Doctors considered the deterioration was due to pneumonia. The Clinical Adviser said it seemed this caused a strain on the heart. Tests showed narrowing of blood vessels and suggested heart muscle damage.
19. The Clinical Adviser said the heart issues were not the main cause of Mr T’s problems. There was no need for any specific cardiology management. The focus would have been addressing and managing the cause of deterioration. This is known as Type 2 Myocardial injury. We have seen no evidence of any failings relating to how doctors considered Mr T’s heart problems.
20. The records show doctors found evidence of Mr T’s liver condition when reviewing a CT scan from 14 February 2024. This showed signs of liver cirrhosis (scarring) and he had fluid in his abdomen (ascites). The liver team reviewed him and diagnosed metabolic dysfunction associated steatotic liver disease (MASLD – a condition where fat accumulates in the liver and which can lead to cirrhosis). They considered this had developed due to various long-term issues, including obesity, diabetes and raised cholesterol.
21. The Clinical Adviser told us doctors assessed and managed Mr T’s liver disease appropriately. There was no indication for them to consider liver disease at an earlier stage in his treatment. We have seen no evidence they delayed giving him treatment. They arranged appropriate tests when the CT scan showed evidence of liver problems.
22. We find doctors followed Good Medical Practice when treating Mr T’s low blood pressure and his heart and liver problems. They carried out adequate assessments and arranged the investigations and treatments that were necessary. We recognise Mrs R disputes this. We have seen nothing to suggest that doctors could have prevented his heart attack. We hope she is reassured we have seen no evidence of any failings in this respect.
Procedure on 19 February 2024
23. Mrs R says her father’s sudden deterioration happened after a procedure to remove ascites on 19 February 2024. She believes he had an ascitic tap procedure (paracentesis) that led to a drop in his already low blood pressure.
24. The Ascites Guideline summarises how clinicians should diagnose and manage ascites for patients who have cirrhosis. It recommends using paracentesis to allow testing of a sample for all patients who develop ascites. This should be followed with further testing and antibiotic treatment.
25. Paracentesis is a procedure where a small tube is inserted into the abdomen guided by a radiologist using ultrasound. The clinician then uses the tube to drain the fluid into a bag or bottle.
26. In Mr T’s case doctors wanted to take a sample of fluid they could then analyse.
The radiologist noted 200mls of fluid was ‘easily aspirated’ and there were no complications. This happened around 2.45pm.
27. The Clinical Adviser told us this procedure is very safe and is unlikely to have caused Mr T’s deterioration on 19 February 2024. It could not have caused any damage that resulted in a heart attack. A relatively small amount of fluid was removed, and this would not have had any effect on Mr T’s heart. Observations following the procedure did not indicate signs of a sudden deterioration.
28. We find that clinicians followed the Ascites Guideline. We can appreciate why Mrs R has linked the procedure to her father’s sudden deterioration shortly afterwards. We have seen no evidence paracentesis had a detrimental effect on Mr T’s health.
Response to deterioration on 19 February 2024
29. Mrs R says there was a delay in responding to her father’s heart attack. She questions whether he should have been transferred to intensive care.
30. The NICE Guideline explains how patients in hospital should be monitored to identify those whose health may become worse suddenly and the care they receive.
31. The clinical records show Mr T was waiting for a nurse to attend to his personal care around 7.50pm when he vomited and became acutely unwell. When the nurse attended she contacted the Patient Emergency Response and Resuscitation Team (PERRT). Mr T’s blood pressure had dropped and he had lost consciousness.
32. Doctors suggested Mr T’s deterioration was due to an underlying infection. They continued to give him antibiotics and fluids to stabilise his blood pressure. It was clear to doctors that Mr T was unlikely to survive, but they continued to provide active treatment. Unfortunately, they established he was too unwell to have surgery or any further investigations.
33. The Clinical Adviser told us the response from clinicians was appropriate. They said it is good practice to provide such patients with urgent medical support when it is acutely needed. Intensive care was not deemed appropriate because of Mr T’s significant poor health and frailty. The Clinical Adviser agreed with this approach.
34. We recognise how distressing it was for Mrs R when her father’s health rapidly worsened on 19 February 2024. We have seen no evidence that clinicians delayed their response or that it would have been appropriate for them to transfer Mr T to intensive care. We find that clinicians followed the NICE Guideline.
Consent
35. Mrs R says her father was asked to consent to several procedures without any consideration of his cognitive impairments and visual difficulties. She specifically mentioned paracentesis and a skin biopsy procedure.
36. The Consent Guideline says medical professionals must start from the presumption that all adult patients have capacity to make decisions about their treatment and care. A patient can only be judged to lack capacity to make a specific decision at a specific time. The choice of treatment or care for patients who lack capacity must be of overall benefit to them, and decisions should be made in consultation with those who are close to them or advocating for them.
37. The clinical records show healthcare professionals obtained Mr T’s consent several times for the care they provided for him. There was no suggestion he lacked capacity to give his consent before his sudden deterioration on 19 February 2024. It is not necessary in such circumstances to obtain consent from relatives. There is evidence that some clinicians also discussed planned procedures or interventions with Mrs R. This was in line with the Consent Guideline which is clear that capacity relates to a specific decision at a specific time.
38. On 12 February 2024 a dermatology doctor assessed Mr T. They noted his macular degeneration and dementia. The doctor also spoke to Mrs R by phone and noted they explained a planned biopsy procedure to her and the risks associated with it. Both Mrs R and her father agreed with the proposed skin biopsy.
39. On 19 February 2024 a nurse noted Mr T consented to the ultrasound guided paracentesis procedure. They noted they explained the procedure to Mr T beforehand and discussed what would happen next.
40. The Trust apologised in its complaint responses that clinicians did not consult Mrs R regarding consent for the skin biopsy and paracentesis. We can see evidence that clearly shows a clinician obtained appropriate consent from Mrs R and her father for the skin biopsy.
41. There is less information relating to consent for the paracentesis procedure. The Clinical Adviser told us the clinician felt Mr T had capacity to give his consent. It was not necessary to gain consent from Mrs R or another family member if that was the case. Ideally, doctors should have made the family aware of the need for the procedure and the potential risks associated with it. We cannot conclude that the clinician fell below the standard explained in the Consent Guideline.
42. We find that healthcare professionals followed the Consent Guideline when providing care and treatment for Mr T. We can see no evidence to suggest they did not take his cognitive impairment or visual difficulties into account.
Communication
43. Mrs R says clinicians at the Hospital failed to communicate with her about her father’s treatment plan, test results and decisions about his care. She says this left her feeling uninformed and anxious.
44. Good Medical Practice says doctors must communicate effectively with patients and their relatives. It says they must be considerate to those close to the patient and be sensitive and responsive when giving them information and support.
45. The clinical records show clinicians had several conversations with Mrs R and other family members. The clinicians included doctors, nurses, occupational therapists, speech and language therapists and physiotherapists.
46. On 11 February 2024 a doctor met Mr T’s daughter and grandson and noted they ‘discussed the plan.’ Mrs R recalled that the initial management plan was to use steroids and antibiotics to treat any inflammatory condition and possible infection.
47. On 16 February 2024 a doctor recorded meeting Mr T’s daughter. They discussed the scan which showed evidence of cirrhosis. They explained how this showed advanced liver disease. Doctors said they planned to discharge Mr T from the Hospital in three days.
48. Mrs R was present at the doctor’s ward round on the morning of 19 February 2024. The doctor explained that the liver team was to take over Mr T’s care. They planned to arrange further investigations before discharging Mr T.
49. A doctor had another discussion with Mr T’s family following his sudden deterioration later that day. They explained that he was then critically unwell and the reasons why they would not be arranging intensive care for him. The doctor noted the family was upset with what they were saying and raised several concerns which they discussed with them. The doctor stressed they were doing what they thought was best for Mr T.
50. On 20 February 2020 a consultant met Mr T’s son and grandson at the bedside. The consultant said they did not know the cause of the underlying liver disease. They said it was likely the deterioration was due to an infection, and they were giving antibiotics to cover all possible sources. The consultant said Mr Artermi was unlikely to survive.
51. Later that day a different doctor met with Mrs R and other family members. They said there were signs that Mr Artermi’s body was shutting down. They said it was likely Mr T would die in the next three days. The family asked several questions and the records show that doctors attempted to answer these.
52. On 21 February 2024 a junior doctor had a discussion with family members at the bedside. They acknowledged the shock of Mr T’s sudden deterioration and explained that he appeared to be in organ failure. They said Mr T appeared to be dying but they could not say when that would happen. The doctor discussed symptoms and medication.
53. The Clinical Adviser told us they had no concerns with the extent of communication from the doctors with Mr T’s family. They said the records show doctors kept them updated appropriately throughout the admission.
54. We can see how it must have been distressing for Mr T’s family that doctors could not provide definitive answers about what was happening to him early in the admission. The records we have seen show doctors were sensitive and responsive in giving the family information. We find they followed Good Medical Practice.
Resuscitation
55. Mrs R says she was put under pressure to agree to a DNA-CPR (do not attempt cardiopulmonary resuscitation) decision about her father.
56. The Resuscitation Guideline explains that healthcare professionals are aware that decisions about whether or not CPR will be attempted raise very sensitive and potentially distressing issues for patients and those emotionally close to them. It says if the healthcare team is a certain as it can be that a person is dying as an inevitable result of underlying disease or a catastrophic health event, and CPR would not restart the heart and breathing for a sustained period, CPR should not be attempted.
57. The Resuscitation Guideline says it is not necessary to obtain the consent of the patient or those close to a patient when deciding that CPR has no realistic prospect of success. People do not have the right to demand treatment that is clinically inappropriate, and healthcare professionals have no obligation to deliver such treatment. But there should be clear and honest communication with the patient and those close to the patient and their views should be considered as part of the decision-making process.
58. Mr T’s clinical records show that a doctor first completed a DNA-CPR form on 19 February 2024. At that point Mr T lacked capacity to make decisions about resuscitation. The doctor noted they had discussed their view with the family, which was that CPR was unlikely to be successful and would not be in Mr T’s best interests.
59. Another doctor completed an end-of-life care form on 20 February 2024. They noted there had been multiple conversations with family members since the events of the previous day. They noted their decision that Mr T would not be resuscitated in the event that his heart or breathing stopped.
60. The Clinical Adviser said the rationale for the DNA-CPR was clearly documented and he agreed the decision was in Mr T’s best interests.
61. The evidence suggests doctors followed the Resuscitation Guidelines when making a DNA-CPR decision. They clearly involved the family in their decision making. There was no requirement on them to get agreement from the family, because it was a medical decision. We find the doctors followed the relevant standards in this respect.
Conclusion
62. We appreciate how distressing it must have been for Mrs R and her family when her father became seriously unwell during his admission to the Hospital. We have carefully considered her views, and we have seen no evidence that clinicians fell below the relevant standards relating to the issues we have investigated. We do not uphold her complaint.