University Hospitals of North Midlands NHS Trust

4. Mrs G complains the circumstances of Mr G’s discharge from the emergency department (ED) caused or contributed to his cardiac arrest on 24 November 2023. She says the Trust should not have discharged Mr G because he was still very short of breath and had not taken a medication used to manage his breathlessness in nearly 24 hours.

5. Mrs G says she feels guilty for taking Mr G to hospital. She says the Trust's actions meant she lost the opportunity to prepare for Mr G’s death and remains distressed at the pain he suffered while being resuscitated.

6. Mrs G would like the Trust to make service improvements and pay a financial remedy.

7. Mr G was in his mid-fifties at the time of the events complained about. He had severe chronic obstructive pulmonary disorder (COPD) and emphysema.

8. Mrs G brought Mr G to the Trust’s ED on 23 November 2023 with an infective exacerbation of COPD, causing him to feel short of breath. The Trust took a chest X-ray and found Mr G to have a small pneumothorax. This means air had leaked out of Mr G’s lung into the space between the lung and the chest wall. Trapped air stops the lung from fully expanding, so the lung partly collapses.

9. Mr G was discharged from ED at about 5:30pm on 24 November. At about 7pm, Mrs G brought Mr G in a wheelchair to the front entrance of ED. She told us it was extremely cold (below freezing) and the shock of the cold took Mr G’s breath away. Unfortunately, he suffered a cardiac arrest. He was resuscitated and taken into the Trust’s intensive care unit (ICU).

10. Mr G was transferred from ICU to a respiratory ward on 25 November. He sadly died in hospital on 28 November.

Decision to discharge Mr G

14. Before we decide if we should conduct a detailed investigation of a complaint, we look at whether there are signs the organisation has got something wrong. We do this by comparing what should have happened with what did happen. We have done this and have not found any indications that something has gone wrong.

15. The British Thoracic Society (BTS) pleural disease guideline sets out how doctors should manage conditions affecting the lining of the lungs and chest wall, including pneumothorax. The guideline is designed to make sure patients receive the right level of treatment based on how unwell they are. It takes into account the size of the pneumothorax (how much air is trapped between their lung and chest wall).

16. The BTS guideline says if a patient has mild symptoms and a small pneumothorax, doctors should monitor their symptoms and ‘consider discharge’ with a plan to follow-up.

17. Our ED adviser explained the symptoms Mr G initially went into hospital with were more likely to be related to the infective exacerbation of COPD than the pneumothorax. Our ED adviser said the records show Mr G had responded to treatment with nebulisers (a machine that turns liquid medicine into a fine mist so it can be breathed in) and oral steroids, to help open his airways.

18. The records show after the Trust identified Mr G had a small pneumothorax, it continued to monitor his symptoms throughout 24 November. At about 4pm, a doctor noted Mr G’s breathing was at his ‘baseline’. This means his breathing had returned to what was typical for him. Our respiratory consultant adviser noted the Trust recorded Mr G had no chest pain, and his clinical observations (including heart rate, pulse, and temperature) were stable.

19. Before it discharged Mr G, the Trust arranged to see him again in the pleural clinic. It also advised Mr G to return to hospital should he experience worsening shortness of breath, chest pain or feeling faint.

20. We can see the Trust’s actions were in line with the BTS guideline for the size of the pneumothorax Mr G had. It monitored his symptoms and discharged him when he was stable with plans to follow-up and advice about what to do if his symptoms worsened. Our respiratory consultant adviser said it was appropriate for the Trust to discharge Mr G after taking these actions.

21. We recognise that Mr G deteriorated significantly and suddenly after he was discharged. We can understand why Mrs G was deeply concerned that the Trust might have missed something that could have prevented this. We hope through our work, we have been able to reassure her that the evidence shows the Trust acted in line with the relevant guideline.

Oramorph

22. Mrs G complains the Trust did not prescribe Mr G Oramorph while he was in hospital. She explains Mr G took Oramorph regularly at home to manage his breathlessness, but by the time of his cardiac arrest on 24 November, he had gone without it for nearly 24 hours.

23. The GMC ‘Good Medical Practice’ guidance sets out the duties of doctors and tells them what they must do to provide good clinical care. It says doctors must prescribe drugs only when they are ‘satisfied they serve the patient’s needs’. It also says doctors must check the treatment they provide is ‘compatible with any other treatments the patient is receiving’.

24. Both our respiratory consultant adviser and our ED adviser acknowledged that some patients with COPD may be prescribed morphine or other opioid drugs to manage the sensation of breathlessness. However, they explained a well-recognised side effect of morphine is respiratory depression, meaning it can slow breathing.

25. While Mr G was in the ED, doctors took a blood gas test. This allowed them to determine how well his lungs were working by measuring the levels of oxygen and carbon dioxide in his blood. The records show ED doctors were concerned by these results, which was one of the reasons why they referred him to the respiratory team.

26. We understand from our ED adviser that given these factors, it was reasonable for the doctors in the ED not to prescribe Mr G Oramorph. While we acknowledge Mrs G’s account, we do not think there is sufficient clinical evidence to show Oramorph would have served Mr G’s needs at that time. This means we consider the ED doctors acted in line with the GMC Good Medical Practice guidance.

27. Our ED adviser said Mr G’s cardiac arrest could not have been caused by him not having Oramorph. A cardiac arrest happens when the heart suddenly stops pumping blood around the body. Oramorph does not treat the underlying causes of breathlessness or protect the heart from cardiac arrest. We therefore do not see a link between what Mrs G complains about and Mr G’s sudden cardiac arrest.

28. We fully empathise with how Mrs G’s life has been affected by the shocking events of 24 November and Mr G’s sad death. We can see how much work she has put into understanding what happened and raising her complaint. Our decision is not intended in any way to diminish this or her experience. We hope our statement clearly explains the reason why we cannot consider the complaint further.

1. We thank Mrs G for her complaint about the care the Trust provided her husband, Mr G. We recognise how important the complaint is to her and the effort she has made to share her experience with us. We would like to offer our sincere condolences to Mrs G for her sad loss.

2. After careful consideration, we consider the Trust acted in line with relevant guidance when it discharged Mr G on 24 November 2023. We can understand why Mrs G had serious concerns and we hope our explanation is helpful.

3. We also consider the Trust acted in line with relevant guidance by not prescribing Mr G Oramorph (morphine in liquid form) during his time in hospital. We want to assure Mrs G we have seen no indication that not having Oramorph could have caused or contributed to his cardiac arrest.