Reasons for our decision
Care on 19 October 2022
35. Miss W told us that following removal of the retained placenta she continued to experience heavy bleeding and significant pain. She complains that this was only investigated with an ultrasound scan, and no other reassurance was given about her symptoms.
36. In response to the complaint, the Trust advised pelvic ultrasounds are commonly performed on women presenting with PPH to identify any RPOC and determine the steps for management. The Trust considered Miss W had received the correct management, as the RPOC was removed and she was given antibiotics for suspected endometritis (inflammation of the inner lining of the uterus), which led to an improvement in her health.
37. The Trust explained in its view Miss W was clinically stable and fit for discharge with antibiotics and iron supplements.
38. We have considered this part of the complaint with our obstetrics and gynaecology adviser. The relevant guidance which informs what should happen in these circumstances is the RCOG Green-top Guideline No. 52.
39. The guidance says women presenting with secondary PPH should have high vaginal and endocervical swab to assess vaginal microbiology, and that antibiotics should be initiated where endometritis is suspected. It explains that pelvic ultrasounds are commonly performed on women presenting with secondary PPH to identify any RPOC.
40. We have also considered the GMC’s Good Medical Practice guidance, point 15, which says:
“15 – You must provide a good standard of practice and care. If you assess, diagnose or treat patients, you 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”
41. We can see from the medical records that Miss W was referred to the obstetrics and gynaecology team from the ED. The doctor contacted the hospital where Miss W gave birth to gather information about her delivery and also spoke to Miss W to gather details. The previous hospital reported that the placenta was documented as delivered completely, however, our obstetrics and gynaecology adviser explained this does not completely rule out RPOC.
42. The medical records show the doctor carried out a high vaginal swab and an examination, and during the examination the doctor was able to remove the RPOC. As endometritis was suspected, the doctor also prescribed antibiotics. Miss W subsequently underwent an ultrasound scan, and we can see from the scan report that it did not show any further evidence of RPOC.
43. We have also seen evidence that the doctor explained to Miss W what the likely cause of the bleeding was and reassured her about the ultrasound findings. The records indicate that Miss W’s bleeding had settled, and so she was discharged home with antibiotics and iron supplements and was given safety netting advice to return if she had any worsening symptoms.
44. Overall, based on the evidence available to us, we consider Miss W was treated appropriately in line with the RCOG guidance for secondary PPH as the clinical team carried out a thorough examination, removed the RPOC, and provided appropriate follow up care. We also consider upon discharge, Miss W was given suitable advice for any ongoing symptoms she may experience, in line with the GMC’s Good Medical Practice guidance.
45. For these reasons, we do not consider there are any indications of service failure relating to this part of the complaint.
Care on 18 November
46. Miss W tells us she was first assessed by her GP who then contacted the hospital and arranged for her to be seen in the ED. She says she had ongoing pain, continuing blood loss, a raised temperature, fast heart rate and low blood pressure. Miss W recalls that whilst waiting to be seen, her blood loss was uncontrollable, and says she was not reviewed by a consultant for over six hours. Further to this, Miss W felt when she was seen by the consultant her symptoms were dismissed, and she was incorrectly discharged.
47. In response to the complaint, the Trust acknowledged Miss W had to wait 80 minutes to be triaged on this occasion. It recognised this was longer than expected and apologised to Miss W for the distress and upset caused. It also advised it was working on an improvement plan within the ED to reduce the wait between arrival and initial assessment.
48. Further to this, the Trust explained that once Miss W had been triaged, the ED consultant reviewed and examined her and appropriately referred her on to the gynaecology team for further assessment.
49. We have reviewed this part of the complaint in two sections, firstly we will focus on the care in the ED, secondly, we will focus on the examination carried out by the gynaecology team.
• ED
50. The RCoEM guidance says patients should be assessed promptly within 15 minutes of their arrival at the ED. Miss W arrived at the ED at 6:48pm and was triaged at 8:20pm, this is outside of the recommended timeframes within the guidance. The Trust has acknowledged the delay in Miss W being triaged, and so what is left for us to consider is the impact of this delay.
51. We have considered the care Miss W received in the ED with our ED adviser to understand if the delay impacted upon her presentation and/or the care she received.
52. We can see from the medical records that Miss W’s observations were taken at 7:27pm and were within a normal range. The presenting concerns noted at triage were vaginal bleeding and abdominal pain. Miss W was allocated a triage category of three, our ED adviser explained this usually means the patient is for assessment in ED majors within one hour and confirmed this was the most appropriate categorisation based on her presentation.
53. When Miss W was reviewed in the ED at approximately 9:15pm, we can see a detailed history and assessment was undertaken. A blood test and a urine culture test was requested and collected to check for anaemia and showed Miss W had low haemoglobin levels. Following the clinical review in the ED, Miss W was referred to obstetrics and gynaecology for further assessment and was seen at approximately 11:30pm.
54. We understand this referral was appropriate based on her presentation at the time as she had ongoing issues with vaginal bleeding since the birth of her child on 9 October 2022. We consider these actions were in line with the GMC’s Good Medical Practice, point 15, which is quoted above in point 40 of this statement.
55. Whilst we have not seen any indications that Miss W became more unwell in the time she was waiting for her triage and subsequent reviews or that the delay impacted upon her treatment pathway, we recognise that the delay in being triaged and reviewed when feeling so unwell must have been concerning for Miss W, and we recognise this may have caused her distress and frustration at the time, and when reflecting on the care she received.
56. We consider the Trust has responded proportionately to the impact the delays had, in line with our NHS Complaint Standards with regards to giving fair and accountable responses and promoting a learning culture to ensure services are continuously improving. For these reasons, we will not be taking any further action in relation to this aspect of the complaint.
• Gynaecology
57. We have reviewed this part of the complaint with our obstetrics and gynaecology adviser.
58. We can see from the medical records that the doctor took a detailed history of Miss W’s symptoms and previous admissions. The doctor carried out a thorough examination of Miss W’s abdomen and uterus, and noted there were no signs of active bleeding, no obvious source of bleeding, and that the cervix looked healthy.
59. Miss W’s recorded observations were all within a normal range, which indicates there were no immediate causes for concern. Our obstetrics and gynaecology adviser explained that Miss W’s haemoglobin level was also stable, at 104, which had improved from her previous admission and was within a reasonable range post-birth. Miss W’s inflammatory markers were also within the normal range, indicating that established infection was unlikely.
60. The doctor requested a urine sample, and this indicated a potential diagnosis of urinary tract infection (UTI). Miss W was prescribed antibiotics to treat the UTI and was discharged home with safety netting advice.
61. Overall, based on the evidence available to us, Miss W was treated appropriately in line with GMC guidance (see point 40 of this statement) for her presenting symptoms and suspected UTI. For this reason, we have not identified any indications of service failure that require further investigation.
Care on 21 November
62. Miss W complains that despite being significantly unwell, she had to wait for hours to be seen. She tells us as time went on her pain worsened, and she recalls a urine sample being taken but being left next to her in a bed pain untested.
63. In response to the complaint, the Trust apologised for Miss W’s wait. It explained it was a very busy day in the department, which led to an extended wait to be seen by a doctor. It has apologised for any distress that was caused and recognised this was a poor experience.
64. The Trust said it was disappointing to read the experience around a full bedpan being left in the room. It said the nurse who supplied the bedpan should have removed it immediately once she had finished and apologised this does not appear to have happened on this occasion. It explained it had discussed this with staff in the daily safety brief, focusing on how it is not an acceptable level of practice.
65. Further to this, the Trust confirmed regular checks are now carried out every couple of hours by the nursing team leader on shift to ensure the general cleanliness of the department is maintained, and that patients personal care and hygiene needs are met.
66. We have considered the care Miss W received in the ED with our ED adviser.
67. Miss W attended the ED at 3:58pm, was triaged at 4:25pm and was seen by a doctor at 8:45pm. The RCoEM guidance says patients should be assessed promptly within 15 minutes of their arrival at the ED.
68. We can see on this occasion Miss W was triaged 27 minutes after her arrival at the ED. We do not consider this fell so short of the expected standard to be considered a service failure. However, we recognise Miss W waited a further four hours and 20 minutes for a review, and so we have considered if Miss W should have been seen sooner following triage.
69. We first reviewed Miss W’s observations taken at the point of triage and our ED adviser confirmed they were within a normal range. There were no indications that Miss W met any of the high risk or moderate risk criteria set out in NICEG51 and in this situation, the guidance recommends that a review by a clinician is arranged, and that clinical judgement should be used to manage decisions on further management (point 1.6.15).
70. Following triage, Miss W was allocated a triage category of three. Our ED adviser explained this usually means the patient is for assessment in ED majors within one hour and confirmed this was the most appropriate categorisation based on her presentation.
71. Whilst Miss W was triaged correctly, there was a further delay in her being seen by a doctor. We acknowledge Miss W tells us that during this time she was in pain, which was increasing, and that she felt significantly unwell. This must have been concerning for her, and we recognise it likely caused her further distress and frustration.
72. When Miss W was reviewed by the doctor it was noted she had increasing left loin pain, fever, and nausea. A provisional diagnosis of pyelonephritis (kidney infection) was made based on her symptoms and a positive urine culture from 18 November 2022.
73. Miss W was prescribed antibiotic and referred to the surgeons for review. We consider this was in line with the NG51, as the clinician used their clinical judgement to manage their decision. We also consider it was in line with GMC’s Good Medical Practice point 15, as Miss W was assessed, provided with treatment (antibiotics) and referred on for further review by the surgeons.
74. Overall, whilst there was a delay in clinical assessment, we consider Miss W received the appropriate treatment whilst in the ED. With regards to the urine sample, (urinalysis), we understand this not being done would not have had an impact on the clinical work up of Miss W’s diagnosis and treatment as a decision was made to treat Miss W’s presentation as a diagnosis of pyelonephritis.
75. We can see the Trust has acknowledged the delays on this occasion and for the upset and distress it caused. It has also acknowledged the issue of the bedpan/urine sample being left in the room. It has explained what should have happened, and what action it has taken to ensure staff are aware of their responsibilities in this regard. We are reassured the Trust has put measures in place to ensure the cleanliness of the department is maintained.
76. In conclusion, we consider the Trust has responded proportionately to the impact of the delays in the ED and the concern caused by the urine sample being left by the bedside, in line with the NHS Complaint Standards with regards to giving fair and accountable responses and promoting a learning culture. For this reason, we will not be taking any further action on this part of the complaint.
Care on 1 December
• Catheter care
77. Whilst in the ED on 1 December, Miss W recalls being told not to empty her catheter bag as the nursing team needed to measure her urine. She explains it was halfway full when she got to the ED, and she asked that it was emptied as it was getting full and causing her pain. Miss W recalls this was emptied just before lunchtime the following day when she was moved to a ward, which means it had been left for over 17 hours.
78. In response to the complaint, the Trust explained that the nurse would have advised Miss W not to empty the bag initially so they could check how much urine she was passing, and that they would do this for her. It stated it is expected this would be done in a timely manner, and the bag would not be allowed to get full. The Trust reviewed the medical records and identified nursing documentation in the early hours of the morning that whilst Miss W was in the ED, her catheter was drained.
79. We have reviewed this part of the complaint with our nursing adviser. We have also considered NICE QS61, which says urinary draining bags should be emptied frequently enough to maintain urine flow and prevent reflux, and should be changed when clinically indicated, and the NMC’s Code, which says nurses must provide the fundamentals of care effectively. The fundamentals of care include but are not limited to nutrition, hydration, bladder and bowel care, physical handling and making sure that those receiving care are kept in clean and hygienic conditions (point 1.2).
80. The records do not state how full the catheter bag was upon admission, however, Miss W was admitted with abdominal pain and her observations were stable, so we understand there were no indications she required fluid balance monitoring, which means there was no requirement to record how full it was.
81. We can see from the medical records that the catheter bag was drained at 03:33am on 2 December. We recognise this was four and a half hours after Miss W presented to the ED, and it is possible her catheter bag could have been full by this point.
82. At 09:16am the following day, Miss W was reviewed by the urology SHO. The records indicate they had reviewed her urine output, noting there had been no blood clots in the urine, and a catheter was in situ. The plan included admission under urology, and instructions to carry out a urine dip and culture, and to attach a bag to the catheter to monitor urine output and colour.
83. Our nursing adviser explained that as Miss W was already catheterised when she came in, it is likely she had a leg bag attached. These bags hold much less urine than a hospital catheter bag. To carry out the urine dip and culture and change the bag, the medical/nursing team would have needed to assess the leg bag to review the colour of the urine and if there was any blood. Therefore, is most likely at this point they would have changed from the leg bag to a hospital catheter bag.
84. Whilst the leg bag was not changed to a catheter bag until Miss W was moved to the ward, there are indications that the bag was drained within a reasonable timeframe following her presentation to the ED.
85. The nursing notes do not indicate there were any issues at this time with the catheter. We recognise Miss W was in pain upon her admission and this persisted over the period of time we are focusing on here. We have taken into consideration the other active causes of pain at the time, which were likely contributing to this.
86. There is no evidence there were any issues with the catheter between the point of admission and the transfer to the ward. This is because there is evidence the catheter was drained, and there are no indications of urine reflux at that time which may suggest it was not being emptied frequently enough.
87. For these reasons, we have not identified any indications further investigation is required for this part of the complaint.
• Cannula care
88. Miss W says when she was taken to hospital by ambulance, one of the paramedics inserted a cannula into her arm. She says a couple of days later, her arm was swollen, and she asked for the cannula to be removed or replaced several times. Miss W tells us it was painful when medication was being administered through the cannula, and eventually her whole arm became swollen. Miss W complains that despite this, the cannula was not removed until 8 December, seven days later.
89. In the Trust’s response to the complaint, it says the cannula was inserted on 1 December and removed on 4 December. However, during the Trust’s investigation it identified there was a lack of knowledge amongst the nursing team on appropriate documentation of adult assessment for lines and tubes. The Trust has confirmed this has now been brought in to clearly identify and document when patients have cannulas in situ. The Trust says the ward has now received further training, and the Practice Education Facilitator is working closely with the Infection Prevention Control team to roll out further education for staff to improve documentation.
90. The Trust has said since Miss W’s admission, the Trust electronic patient record system ‘Cerner’ now has visual infusion phlebitis scores and cannula assessment documentation to be used by staff to better document cannula care provided to patients. The VIP scale is used for the assessment of the early signs of phlebitis.
91. Further to this, the Trust apologised for Miss W’s poor experience, and that it did not meet the required record keeping standards.
92. We have reviewed this part of the complaint with our nursing adviser. We have also considered NICE QS61, which says peripheral vascular catheter insertion sites should be inspected during every shift at a minimum, and a visual phlebitis score should be recorded, as well as the DoH guidance which advises removal of a cannula should be considered if it has been in place for 72-96 hours, as the risk of complications increases over time.
93. As the Trust has acknowledged, the documentation available with regards to cannula care is poor. There is no explicit evidence that the cannula site was inspected daily, or that VIP scores were recorded.
94. The medication administration records show medications were being given through the cannula between 1 and 3 December, which would suggest the cannula would have been observed by the nursing team when administering medication despite this not being recorded. Medication on 4 December all seems to have been given orally, and the medical records from this date say “no cannulas in situ at the time of writing”.
95. The medical records indicate that the swelling of Miss W’s arm began on 5 December 2022. Nursing notes from 5 December at 11:53am state a cannula was in place with no swelling to the area, and a later entry at 3:15pm states the cannula was checked as Miss W complained of soreness and was subsequently removed due to swelling and warmth around the area.
96. Our nursing adviser said it is likely the entry on 4 December was incorrect, as it is unlikely phlebitis would develop so quickly on 5 December. Further to this, pictures provided by Miss W seem to show the cannula in the same place on her arm when comparing images from 2 December to 5 December. Therefore, on the balance of probabilities, we consider it most likely the same cannula was in place over this period.
97. This would be approximately 120 hours since it was inserted. Our nursing adviser explained that a cannula can be left in for up to seven days if it is difficult to gain IV access in a particular patient. Additionally, nurses can rely on their clinical judgement if the cannula site remains clean, dry, and free of redness or swelling and is still functioning well and needed for ongoing treatment. Cannula insertion can be painful and cause distress for patients and frequent re-siting can increase the risk of infection because skin integrity is breached more frequently.
98. We have not seen any evidence which would indicate the swelling on Miss W’s arm began before 5 December. We can see that when Miss W complained of pain from the cannula site on 5 December, the nursing team took appropriate action in removing the cannula and escalating this to the doctor for review. This led to the cannula being removed and replaced, and treatment being started to address the pain and swelling. We consider this was in line with the NMC’s Code with regards to ensuring a patient’s physical needs are assessed and responded too (point 3) and referring matters to colleagues when appropriate (point 8.1).
99. Overall, we consider there are indications of service failure with regards to cannula care and record keeping as the cannula site was not inspected daily, and VIP scores were not recorded.
100. We have not identified any indications this had a negative impact on Miss W. Whilst the cannula was in for a prolonged period, there are indications the nursing team took appropriate action to remove the cannula and escalate Miss W for review by the doctors as soon as she reported swelling in the area. Miss W was promptly started on antibiotics to treat the phlebitis.
101. We consider the Trust has provided a proportionate remedy to this part of the complaint, in line with the NHS Complaint Standards, as it has provided Miss W with an explanation of what went wrong, an apology, and has explained what steps will be taken to ensure service improvements take place.
Care on 9 December
102. Miss W says she started feeling very unwell on 9 December. She raised concerns with those treating her, but recalls being told she would be discharged as her observations and blood tests were stable. Miss W tells us as time went on, she became breathless and had worsening pain, and she was shivering and confused. Miss W says a member of the ED team eventually took her observations and advised her she would be treated for sepsis. Miss W also recalls being told she may have had a heart attack but says no-one discussed this further with her.
103. In response to the complaint, the Trust says Miss W was seen by the cardiology, gynaecology, and critical care teams several times on 9 December as her observations had triggered the need for reviews. The Trust states the medical records also show she had hourly observations due to her National Early Warning Score (NEWS).
104. NEWS is a tool used to improve the detection of, and response to, clinical deterioration in patients with an acute illness. It is an aggregate scoring system which allocates a score to six physiological measurements: respiration rate, oxygen saturation, systolic blood pressure, pulse rate, level of consciousness or new confusion, and temperature. A higher NEWS score indicates the patient’s observations are outside of the norm and indicates their care requires escalation and more frequent monitoring (RCP – NEWS 2).
105. The response also details that a urology review took place mid-morning on 9 December, and following this, a referral to cardiology was made due to Miss W’s rapid heart rate. An electrocardiogram ECG (a test that measures and records the electrical activity of the heart) was carried out, which showed sinus tachycardia (characterised by a heart rate exceeding 100 beats per minute) and a working diagnosis of pulmonary embolism (PE – a blood clot which blocks blood flow to the lungs) or pleurisy (an inflammation in the areas surrounding the lungs) was made. An urgent CTPA (computed tomography pulmonary angiography – a test used to detect blood clots in the lungs) was carried out to look for blood clots in the lungs.
106. The Trust explains the results of the CTPA were inconclusive for a PE, but Miss W was prescribed dalteparin (an anticoagulant to thin the blood) for precautionary measures. The critical care outreach team also recommended Miss W have a cardiology review, ECG, and a troponin blood test to rule out acute coronary syndrome (ACS – sudden reduced blood flow to the heart) and cardiomyopathy (disease of the heart muscle). The cardiology team reviewed Miss W in the afternoon and determined that Miss W’s clinical picture was not in-keeping with a cardiac problem.
107. The Trust has apologised if the treatment plan was not discussed with Miss W and has recognised this may have caused her some distress and worry.
108. We have reviewed this part of the complaint with our urology adviser. We have also considered the GMC’s Good Medical Practice guidance, in particular, the following points:
• Point 15 a-c with regards to adequately assessing the patient’s condition, examining them, providing and arranging suitable advice, investigations or treatment, and referring the patient to another practitioner when indicated.
• Points 31 and 32 with regards to listening to patients, taking account of their views, and responding honestly to their questions and giving them the information they want or need to know in a way they can understand,
• Points 48 and 49 with regards to treating patients with dignity and respect, and working in partnership with patients, sharing key information they need to make decisions about their care including their condition, options for treatment, risks and uncertainties, and the progress of their care.
109. In reviewing Miss W’s medical records, we have not identified any indications of delay in providing care on 9 December. The Trust’s response is supported by the information in the medical records, as we can see Miss W was appropriately reviewed by each team and escalated for further review and investigation when her NEWS increased. Our urology adviser confirmed there are no indications Miss W had severe sepsis at this time.
110. There is evidence to show each team was investigating Miss W’s symptoms to find a cause, and that appropriate plans were put in place for ongoing monitoring and treatment, in line with the GMC’s guidance quoted above. For this reason, we will not be investigating this part of the complaint further.
111. With regards to communication regarding a possible heart attack, we can see the cardiology review took place between 2-2:30pm. It is noted Miss W’s presentation was not in keeping with a cardiology issue. The notes also indicate Miss W had made the team aware of a possible finding of an ‘aortic click’ at a different hospital, and it was agreed Miss W would ask her mother to bring in the latest correspondence detailing this. The cardiology team noted they would compare the findings of their investigations to the ones previously undertaken at the other hospital. We consider indicates the cardiology team discussed the results of their investigations on 9 December with Miss W.
112. For this reason, we consider there are indications the cardiology team acted in line with the GMC’s Good Medical Practice guidance and provided Miss W with information about her condition, as well as taking account of her views.
113. We acknowledge we were not present at the time to independently know what, and how, things were said. It is possible Miss W may have still felt unclear about her treatment plan and what was happening, and we recognise this may have caused her distress and uncertainty. We can see the Trust has acknowledged and apologised for any shortcomings in the standard of communication and the impact this had on Miss W. We consider this is a proportionate response to this part of the complaint, in line with the NHS Complaint Standards.
114. Overall, we do not consider there are any indications of service failure that would require further investigation in relation to this part of the complaint.
Care on 13 and 14 December
115. Miss W says she felt she had deteriorated further on 13 and 14 December and requested a doctor reviewed her, but nobody came and she felt she was being ignored.
116. In response to the complaint, the Trust explained it had reviewed Miss W’s medical records from 13 and 14 December and noted her observations were stable and within normal parameters. It also noted a plan was in place for her to be followed up with the gynaecology and respiratory teams in outpatient appointments once she had been discharged.
117. We have reviewed this part of the complaint with our urology adviser. We have also considered the GMC’s Good Medical Practice guidance, in particular, the recommendations listed in point 108 above.
118. In reviewing Miss W’s medical records from 13 and 14 December, we have not identified any indications she was becoming more unwell at any point. Miss W’s nursing observations are stable, and do not show a deterioration on either day. We can also see evidence of onward planning for Miss W’s follow-up care after discharge.
119. For this reason, we have not identified any indications of service failure and have not identified any indications this part of the complaint requires further investigation.
Discharge on 14 December
120. Miss W says she received a call from the DVT clinic on 15 December asking if she had been discharged the day prior with blood thinning medication (dalteparin). She says she was not given any dalteparin on discharge, despite questioning the nurses about this at the time. We understand Miss W returned to the hospital on 15 December, one day after her discharge, to collect the medication.
121. In response to the complaint, the Trust explained that on 15 December the DVT nurse contacted Miss W to arrange to see her in the DVT clinic. An appointment was offered for 16 December, but as Miss W was unable to attend, it was booked for 19 December. During the call, the nurse told Miss W to keep taking the dalteparin injections, and Miss W advised she did not have any. Therefore, the nurse advised Miss W to return to the hospital for the injections.
122. The Trust also explained that it is usual practice to treat patients as if they have a DVT until the scan confirms otherwise. It acknowledged this was a stressful situation for Miss W and apologised it did not offer sufficient reassurance to support her better.
123. We have reviewed this part of the complaint with our urology adviser. We have also considered NG158, which says patients should be treated as if they have a DVT until a scan confirms otherwise.
124. We understand that Miss W should have been discharged with the dalteparin injections to ensure she did not miss a dose. We consider this was a shortcoming, rather than a service failure, as the nursing team got in touch with Miss W promptly after her discharge to arrange collection of the required medication.
125. Despite this, we understand this must have been a concerning time for Miss W and we do not wish to diminish the impact it had. We can see the Trust also acknowledged this and provided an apology accordingly.
126. We also now know that Miss W did not have a PE, and our urology adviser confirmed there would not have been any impact on Miss W from missing one dose in these circumstances. We hope Miss W is reassured by this information.
127. For these reasons, we will not be taking any further action on this part of the complaint.
Care during appointment on 19 December
128. Miss W tells us in the lead up to her appointment, she began to feel unwell again and had concerns she may have sepsis again. Miss W says during the appointment the DVT nurse contacted the urology and gynaecology departments to see if someone would examine her but was told both departments would not be able to review her. Miss W recalls being told to go to the ED if she felt she had deteriorated.
129. In response to the complaint, the Trust explains Miss W was reviewed in the DVT clinic, and whilst there had her observations taken and reported that she had pain on both sides of her abdomen, as well as an intermittent high pulse rate. It says the DVT nurse contacted the AMAC consultants, as well as the urology and gynaecology teams to voice Miss W’s concerns, and the gynaecology team provided appropriate advice on management at home.
130. We have reviewed this part of the complaint with our obstetrics and gynaecology adviser.
131. It appears Miss W had complained of abdominal pain and ongoing vaginal bleeding during her appointment in the DVT clinic. The DVT nurse spoke with the urology team, as they had referred her to the clinic, and they advised the DVT nurse to contact the gynaecology team due to the ongoing vaginal bleeding. We understand the gynaecology team were the most appropriate team to signpost to, due to Miss W’s symptoms.
132. From the medical records we can see the gynaecology team were aware Miss W was already taking antibiotics and subsequently provided safety netting advice on when to represent to the gynaecology team/ED should her symptoms worsen, or the bleeding increased. It had already been established that it was unlikely that there were any further RPOC, and so we understand further investigations were not needed in this regard. We consider there are indications the gynaecology team provided appropriate advice in line with the GMC’s Good Medical Practice guidance point 15 (see points 40 and 108 of this statement).
133. For these reasons, we do not consider there are any indications of service failure that require further investigation.
Care on 23 December
134. Miss W tells us she presented to the ED on 23 December following a telephone consultation with a doctor from the ACU clinic. She says she felt week and was having pains in her chest and stomach. Miss W says she spoke to a nurse who advised she could bypass the ED, but when she arrived, she realised there had been a miscommunication regarding a bed being ready for her and because of this there was a delay in treating her for sepsis.
135. In response to the complaint, the Trust said during the telephone consultation with the doctor from the ACU clinic, Miss W was advised to attend the ED if she felt unwell. Otherwise, they would refer her to the urology team for a review, and they would contact her directly.
136. It explained that by the time discussions had been had and a referral for a bed had been made, Miss W had already self-presented to the ED and the teams were not yet aware of this. The Trust noted that Miss W was triaged within 20 minutes of her arrival and started treatment for infection within an hour of arrival.
• ACU clinic
137. We first considered the actions of the doctor in the ACU clinic with our urology adviser. We understand that based on the symptoms Miss W described, there were no indications she required a direct admission to urology or gynaecology. We can see from the records that the ACU doctor asked if the teams would be able to offer a review for Miss W.
138. Our urology adviser explained that in this situation if a patient is feeling unwell, it would be appropriate for them present to the ED to undergo a review, and any onward referrals could be made at that point.
139. For these reasons, we consider the advice given and actions taken by the ACU clinic were in line with the GMC’s Good Medical Practice point 15, with regards to assessing a patients’ condition, referring to another practitioner when indicated, and providing and arranging suitable advice.
• ED
140. We will now consider the actions taken in the ED department. The relevant guidance here is NG51. This guidance says where a patient presents with signs or symptoms that indicate possible infection, NG51 says clinicians should consider if the patient has sepsis (1.1.1). If sepsis is suspected, the clinical team should carry out observations during the initial assessment and examination (1.3, 1.3.1).
141. The guidance advises clinicians to use the patient’s history and physical examination results to determine the risk of severe illness or death from sepsis (section 1.4).
142. The guidance recommends the following actions for adults with suspected sepsis who meet 1 or more high risk criteria:
• arrange an immediate review by the ‘senior clinical decision maker’ • carry out a venous blood test • give a broad-spectrum antibiotic without delay (within one hour of identifying the patient meets any of the high-risk criteria) • discuss with a consultant
143. Further to this, for those with suspected sepsis and any high-risk criteria and lactate below 2 mmol/litre (Miss W’s blood results show it was 1.16), consideration should be given to giving an IV fluid bolus (1.6.4).
144. The guidance goes on to explain that clinicians should carry out a thorough examination should be carried out to look for sources of infection. This can include urine analysis and chest X-rays to identify the source of infection (points 1.10.1, 1.10.13).
145. Lastly, NG51 also says oxygen should be given to achieve a target saturation of 94-98 in adult patients (1.9.1).
146. Miss W presented to ED at 3:50pm with shortness of breath and a fever, as well as pain in her chest and stomach. It is noted she was already on antibiotic treatment to treat an ongoing infection.
147. A sepsis screen was commenced at approximately 4pm. Observations were taken, and Miss W’s NEWS was 6, as sepsis was suspected she was escalated to the consultant. Miss W was then triaged at approximately 4:21pm.
148. We consider this is in line with NG51 as sepsis was appropriately suspected based on Miss W’s presentation and observations, and when sepsis was suspected, the clinical team promptly carried out appropriate observations in the initial assessment and examination.
149. Based on the criteria in the guidance, we understand Miss W met one moderate to high-risk criteria (due to her blood pressure), and one high risk criteria (due to her increased heart rate).
150. We can see from the observations done at 4:02pm, Miss W’s oxygen saturation was 99% and therefore oxygen was not required. The records show Miss W underwent blood tests and cultures (results logged at 5:13pm), received IV fluids (5:22pm), had urine cultures taken (6:25pm), had a chest X-ray (6:27pm) and was admitted under the medical team (7:54pm). We can see that antibiotics were first administered at 5:58pm, and further antibiotics were given at 8:22pm.
151. Overall, we consider the ED team treated Miss W appropriately for suspected sepsis in line with NG51 except for the provision of antibiotics. This is because there was a delay of approximately 45 minutes in administering antibiotics on this occasion.
152. We have considered this delay with our ED adviser. At the point Miss W presented to the ED, she was taking three different antibiotics at home (co-amoxiclav, nitrofurantoin, and teicoplanin). It also recorded she had an allergy to gentamicin and penicillin. We understand this can make it more difficult to co-ordinate antibiotic treatment, along with Miss W’s longstanding issues with infection and sepsis.
153. Based on the evidence we have reviewed, we consider it was appropriate for the team to choose the correct antibiotic given the complexity of her medical history and previous results, rather than to give Miss W a generic antibiotic immediately, to ensure she received the most effective treatment.
154. For these reasons, we do not consider this indicates there was a service failure. Despite this, we recognise it will be concerning for Miss W to learn there was a delay in receiving antibiotics. We hope it is reassuring to know that upon reviewing the care provided, our ED adviser commented that it is unlikely this delay would have had an impact on Miss W’s presentation on this occasion.
Care on 16 January
155. Miss W complains that despite an ultrasound scan on 16 January showing she had signs of gallstones, the clinician would not remove her gallbladder. Miss W says she was in extreme pain and was taking a combination of strong painkillers.
156. In response to the complaint, the Trust explained Miss W was seen by the consultant surgeon for a review of her symptoms and the findings of the ultrasound. The results suggested Miss W may have gallstones but noted there was no evidence of acute cholecystitis. Acute cholecystitis is a sudden inflammation of the gallbladder, often caused by a gallstone blocking the cystic duct which can lead to severe abdominal pain.
157. The consultant surgeon recommended an MRCP to exclude ductal stones. This was carried out on 17 January and did not suggest any abnormal findings, only ‘tiny gallbladder calculi (stones)’ were found. The consultant surgeon recommended contacting the pain management team to help with Miss W’s symptoms.
158. The Trust explained it was sorry to learn Miss W’s pain levels remained high during this time period. It is documented throughout the period she was provided with regular analgesia and anti-emetics to help manage her symptoms.
159. We note that following the MRCP, the endocrinology team made a plan to continue providing Miss W with pain relief and to monitor her urinary symptoms. If symptoms continued, the plan was for a renal tract ultrasound. Miss W was also due to undergo a PET CT scan to further investigate the cause of her symptoms and had an outpatient clinic booked in for follow-up with the results.
160. We have reviewed this aspect of the complaint with our general surgery adviser. We have also considered NICE CG188. For patients with suspected gallstone disease, the guidance recommends carrying out liver function tests and an ultrasound (point 1.1.1). It says where an ultrasound has not detected common bile duct gallstones but liver function tests are abnormal, an MRCP should be considered (1.1.2).
161. The guidance also says laparoscopic cholecystectomy (gallbladder removal) is to be offered in those diagnosed with symptomatic gallbladder stones. Lastly, it recommends onward referral for further investigations if conditions other than gallstone disease are suspected (1.1.4).
162. We consider there are indications the appropriate investigations for gallbladder disease were carried out in line with NICE CG188 for Miss W’s symptoms and presentation.
163. The results of the scans did not identify symptomatic gallbladder stones, and therefore in line with the NICE guidance there were no indications for surgery. Following the MRCP, recommendations were made for input from the pain management team, and the endocrinology team had a plan for further investigations into Miss W’s pain symptoms, in line with the NICE guidance.
164. In conclusion, we have not identified any indications Miss W required surgery to remove her gallbladder on this occasion, and we will not be investigating this part of the complaint further.
Care on 5 May
165. Miss W complains she was discharged on 5 May following surgery without passing urine and with her incision site bleeding. Miss W says she was asked to urinate after her surgery before she could go home. She says she advised the clinical team she had not done so, and recalls being told it was normal and would pass. She also tells us her wound bled following surgery.
166. Miss W says her mother called 111 on 6 and 7 May as her temperature was spiking and she did not urinate. She was then readmitted to the ED on 8 May with urinary retention and required catheterisation. The ED summary from 8 May says Miss W was complaining of abdominal pain, vomiting, difficulty passing urine, episodes of fever, and green discharge from her operation site.
• Discharge/urine retention
167. We have reviewed this part of the complaint with our general surgery adviser.
168. The medical records following surgery indicate Miss W was observed post-operatively for around seven hours and her observations remained stable. There are two entries within the nursing notes which state Miss W had been able to mobilise to the toilet, and that she had passed urine.
169. There are no indications within the medical records that Miss W was not fit for discharge, and she was discharged with post-operative advice and pain relief. We consider this is in line with the GMC’s Good Medical Practice guidance (see points 40 and 108 of this statement).
170. We recognise Miss W’s recollection differs to what is recorded in the records. We hope it is reassuring for Miss W that the AoA guidelines which say voiding is not always necessary before discharge, and therefore even if she had not passed urine at this time, it would still have been appropriate for the team to go ahead with her discharge given she was medically stable.
• Wound care
171. We have reviewed this part of the complaint with our nursing adviser.
172. In reviewing Miss W’s medical records, we can see an instance of bleeding from the incision site at approximately 4:37pm. The notes say the nursing staff applied sterile dressing gauze, secured it with mipore dressing, and that no further concerns were noted. The nursing notes prior to discharge say the wound site was intact, and extra dressings were given to take home.
173. The NMC’s Code says nurses should make sure any treatment, assistance, or care is delivered without undue delay and ensure a patient’s physical needs are assessed and responded to (points 1.4 and 3).
174. When the wound bled on 5 May, we consider the nursing team took appropriate action in line with the NMC’s Code by assessing the wound and the level of bleeding, and re-dressing it. There are no indications an infection was starting in the wound prior to discharge. For this reason, we will not be taking any further action on this part of the complaint. We were sorry to learn Miss W’s wound later became infected and understand her concerns regarding this.
Care between 9 and 17 May
175. Miss W had attended the ED on 8 May with urinary retention and was discharged with a catheter in place. She re-attended on 9 May with pain, stating it was the worst pain she had ever experienced. Miss W complains her pain was not well managed during her hospital admission, and that she was told everything was normal despite her significant levels of pain.
176. In response to the complaint, the Trust explained Miss W was reviewed by the doctors on 9 May and by the anaesthetist on 10 May. Following this, she was referred to the pain nurse specialists who reviewed her in person from 10 to 17 May.
177. The analgesia that was provided during this time was tramadol, diclofenac PR, IV paracetamol, and buscopan. On review of the documentation, the Trust concluded there was correct and timely escalation by the nursing team with regards to pain management, as well as good management by the same pain specialist nurse each day during the admission.
178. We have reviewed this part of the complaint with our nursing adviser. We have also considered NG138, which says if a patient is unable to manage their own pain relief: • Do not assume that pain relief is adequate • Ask them regularly about pain • Assess using a pain scale if necessary • Provide pain relief and adjust as needed (1.2.8)
179. We can see that during the admission, Miss W was receiving both PCA and oral pain relief and she was reviewed on a daily basis by the specialist pain nurses. Whilst we have not identified any pain scores within the medical records, the daily nursing notes indicate Miss W was asked about her pain levels on a regular basis.
180. There is evidence that Miss W’s pain relief was reviewed and adjusted in line with the severe pain Miss W was reporting. It is recorded that Miss W intermittently said she felt her pain was well controlled and there was some improvement.
181. Overall, we consider there are indications that Miss W’s pain was managed in line with NG138, and that efforts were made to try and ensure Miss W’s pain was managed appropriately during this admission. Despite this, we recognise the significant levels of pain Miss W was experiencing and do not wish for our decision to diminish her experience or the impact this had on her.
Discharge on 18 May
182. Miss W complains she was discharged on 18 May despite continuing to be in pain. She feels she should not have been discharged until her pain was under control.
183. In response to the, the Trust explained from its review of the medical records, Miss W was reviewed, and the plan of care was discussed with her. It apologised if Miss W felt staff were not attentive to her concerns and also apologised if Miss W’s pain levels remained high, and for any distress this caused for her.
184. We reviewed this part of the complaint with our general surgery adviser.
185. As we have outlined above, Miss W was reviewed on a daily basis by the specialist pain nurses. In addition to this, the medical records show she underwent a CT scan of her abdomen and pelvis and an MRCP to rule out any potential complications from her surgery. The results of these investigations did not show any abnormal or concerning features.
186. Miss W was also reviewed by the surgical team, who made a plan for discharge with a follow up in the outpatient clinic the following week.
187. Furthermore, in our review of the medical records we can see at the point of discharge Miss W’s observations were normal and stable, and her pain was reportedly under control with oral painkillers. We can also see she was given safety netting advice by the nursing team upon discharge regarding her pain management and medication she needed to collect from the hospital.
188. We consider this was in line with GMC’s Good Medical Practice guidance point 15 a and b (outlined in points 40 and 108 of this statement) as she underwent the relevant investigations to assess her condition, was given safety netting advice during the admission and upon discharge and had a plan for follow up review in the outpatient clinic.
189. For these reasons, we have not identified any indications that Miss W was not fit for discharge on 18 May and will not be taking any further action on this part of the complaint.