Diagnosis, discharge and treatment
11. Ms H complains The Royal Wolverhampton NHS Trust (the Trust) incorrectly diagnosed Mrs H on 25 January 2022 with constipation and this diagnosis was not revised prior to discharge on 28 January 2022. The Trust accept she was diagnosed with constipation but maintain the diagnosis was reasonable. They say her vomiting was suggestive of severe constipation, and further to response to treatment she was appropriately discharged. Furthermore, whilst they accept she was later diagnosed with bowel obstruction, they maintain it was an atypical presentation and therefore does not suggest she should have been diagnosed sooner. Our focus therefore is whether the initial diagnosis and later decision to discharge were reasonable.
12. We carefully considered the relevant professional guidelines, reviewed Mrs H’s medical records, and sought clinical advice to decide if the correct process was followed.
13. Mrs H went to New Cross Hospital at around 10.30pm on Tuesday 25 January 2022 with vomiting and abdominal pain.
14. The General Medical Council (GMC) – Good Medical Practice guidance explains the expectation is that practitioners should assess the patient’s condition, which includes examination and their clinical history as well as arranging suitable investigations or treatment.
15. We note the records reflect the clinicians were aware she had presented with vomiting and abdominal pain over the past two days. They noted that she was not tolerating food or drink and the pain was worse on movement. Signs and symptoms of bowel obstruction include abdominal pain, vomiting, bloating and not passing gas. Our adviser explained it is a very common emergency presentation. Bowel obstruction, also known as intestinal obstruction, is a mechanical or functional obstruction of the intestines which prevents the normal movement of the products of digestion. As such, we can see her symptoms would fit with this possibility.
16. Our adviser pointed to the Royal College of Surgeons of England guidance which sets out that bowel obstructions contribute (along with abdominal infections) to the majority of emergency major operations, deaths and complications and as such, promotes timely care to minimise this. Accordingly, it supports urgent clinical review and urgent imaging this to support this.
17. Specifically, we note BMJ Best Practice guidance on small bowel obstruction suggests a CT scan as a first investigation to order to investigate this further. This is because whilst plain film X-rays have been used as a screening tool, they are not sensitive enough to exclude the possibility of an obstruction.
18. The clinical thinking on admission was that she had constipation. Our adviser acknowledged this was also a possibility but explained that the symptoms of abdominal pain and vomiting on the background of previous abdominal surgery (which records show was known) should raise the option of small bowel obstruction when thinking about possible diagnoses. We can see from the medical records it was understood that Mrs H had a significant past surgical history including an incisional hernia, for which she had undergone two previous repairs, the second of which had been complicated by infection and required further surgery to remove a mesh.
19. In this case whilst constipation was a possible answer, and we acknowledge the Trust’s view that this was an atypical presentation of bowel obstruction, we also note that Mrs H’s clinical history of abdominal surgery plus her presenting symptoms have led to the expectation that bowel obstruction should have been considered as a possibility. We are also pleased to note the Root Cause Analysis report (RCA) done by the Trust accepts the diagnosis of bowel obstruction should have been made on first presentation.
20. We appreciate the Trust’s view about the atypical presentation but have not seen basis to suggest her presentation was so atypical as to negate consideration of bowel obstruction. This because she was presenting with symptoms which do suggest bowel obstruction and against a clinical history which would heighten the suspicion. We would therefore expect imaging to explore this further to have taken place urgently. In practice we would expect a CT scan.
21. The records show that an X-ray was instead suggested as part of her initial admission and assessment. The Adult Inpatient SBART transfer checklist (done about 5am) mentions the plan for an abdominal X-ray is to be completed. As such it does appear imaging was initially planned. However, as identified above and in line with guidance, we would have expected this to be a CT scan in the first instance.
22. We can see that when the Surgical Emergency Unit Clerking Proforma at 7.15am on 26 January was completed it refers to a digital rectal exam which indicates faecal loading and refers to an ‘AXR’ which also indicated faecal loading. Faecal loading is where the rectum and lower colon are filled with stool.
23. This record suggests a plain film X-ray had been completed by this time. Faecal loading could signify constipation, but we would expect this to be considered along with other symptoms to come to a view. Despite the reference to ‘faecal loading’ related to the X-ray, the Trust have been unable to share a copy of the abdominal X-ray or accompanying report with us. They have shared a chest X-ray from the same date but this does not suggest how ‘faecal loading’ would have been referred to by the clinician in association with this report as the image is of the lung area.
24. At the review (7.15am), Mrs H was seen by a clinician who noted Mrs H had been constipated but took movocol (laxative), had opened her bowels a small amount the day before, was passing wind, but had a reduced appetite due to nausea. We understand that instead of any further investigations, in light of the abdominal exam and abdominal X-ray the working diagnosis was constipation, and a plan was set out for an enema (liquid to clear faecal matter), laxatives, sips of clear fluid and a urine dip.
25. Our adviser noted Mrs H’s overall presentation did still raise the possibility of a small bowel obstruction, nonetheless. Our adviser again indicated it would have been appropriate at this point to do an abdominal CT scan to explore this presentation further. This is because the Royal College of Surgeons guidance requires early diagnosis and intervention. X-rays are generally accepted not to be very sensitive, and a CT scan will allow more information to understand whether there is a blockage. The guidelines suggest due to the high morbidity and mortality associated with this disorder, clinicians should be aware of this possible diagnosis and be alert to the signs and symptoms. Accordingly, we find a failing that as this was not done.
26. At about 9.00am there was senior medical review by a clinician who noted the history, and agreed the plan was to continue treatment as constipation. Later that day we can see an antiemetics (anti sickness medicine) had been given with good effect and an enema given with ‘medium’ amount of output. The plan was for repeat enema and await prescription for regular laxatives. Whilst we can see there was some small positive response to the approach taken, we note this was minimal and concern remained. This was a further opportunity for further imaging to have been considered, which was missed.
27. On 27 January 2022, at about 11.20am, we can see she was reviewed again. The clinician reflected she had opened her bowels the day before further to the enema and if she opened her bowels again on this day she could be planned for discharge. At the end of that entry, we note ‘patient is aware that surgery is not a good option at present’. We have seen no other reference to surgery further to the plan to treat for constipation. The reference to surgery at this point seems at odds with the suggestion of constipation as a working diagnosis. However, it is the only reference. However again there was a further opportunity to consider additional imaging. We do appreciate by this point there has been some positive movement further to the enema. However, on balance, we remain persuaded that further exploration of the possibility of bowel obstruction should have been done as there was no clear resolution of her symptoms.
28. The following day it was noted that she had opened her bowels twice that morning, was feeling well, the pain had settled and her stomach was reported to be ‘soft’ and ‘non-tender’. We note she was still complaining of some nausea but the plan was for discharge on regular laxatives and antiemetics with a plan for her to eat and drink as tolerated.
29. From the records, we can see Ms H was advised by nursing staff that Mrs H was not having a second enema (despite suggestion of such the previous day) and may be home that day. Mrs H was told she could have something to eat at lunchtime, having been on clear liquids since admission. Mrs H had a small amount of a plain omelette but was immediately sick according to the records. That evening, Mrs H was brought soup and tinned fruit, but it was reported in the records she could not face the soup and only ate a very small amount of the fruit. We note however the records suggest Mrs H did open her bowels again on 27 January and it was noted that all observations were stable. Mrs H’s IV fluids were also recorded as normal.
30. Overall whilst there had been some positive response to medication, we can still see signs of sickness and inability to eat along with an absence of excluding an obstruction. Per the above we can see this was another missed opportunity to take the appropriate steps to have had an abdominal CT scan as her symptoms had not improved.
31. We do appreciate the records show it was noted that Mrs H had opened her bowels on two occasions on 28 January 2022 and that the pain had settled. The balance chart showed she was given a small portion of Weetabix for breakfast and a small portion of soup and jelly for lunch; however, we cannot say how much was consumed, and note her family have told us she did not eat this. It also confirmed Mrs H was feeling better and that the plan was to discharge her with laxatives. This suggests improvement. Ms H confirms she was told her mother was doing better, had had a normal bowel motion that day, and had eaten soup the night before. She was led to believe her mother was well enough to go home.
32. However, Ms H says on arriving on the ward, Mrs H was brought out in her wheelchair with a sick bowl. Ms H asked the nurse what investigations had been done and was told none other than the abdominal plain X-ray in A&E and the enema on Wednesday. She says she asked the nurse whether Mrs H was well enough to go home but all the nurse did was turn to Mrs H and ask ‘Catherine, do you feel well enough to go home?’. Ms H says she was not entirely happy, but assumed medical staff knew best.
33. We can see from the records that a clinical review took place which stated that Mrs H was medically fit for discharge and to be discharged with regular laxatives. We appreciate that Mrs H had had some positive effect from medication, but we have also seen this was with the benefit of laxatives and anti-sickness medication. As such, this was managing the symptoms rather than understanding any underlying cause, or being confident Mrs H’s clinical position had changed. Similarly, we appreciate she had started to take a little food and drink, but we appreciate this was minimal.
34. We also understand the ward was concerned enough about nausea to have placed a sick bowel with Mrs H. There is no evidence that a follow up was planned for Mrs H. The Trust acknowledged within their RCA report that there were lapses in the clinical decision-making and discharge process in this case. Accordingly, we are persuaded Mrs Whorton was discharged inappropriately, without further investigation, and find a failing in this.
35. Mrs H was sick in the car on the way home and continued to vomit during the evening and was unable to eat anything. Her daughter describes her as being clearly unwell and not really able to have a proper conversation.
36. Whilst we do not disagree with the Trust’s position that Mrs H’s was not a typical presentation of bowel obstruction in that she did have some bowel function and was able to tolerate small amounts of food and drink; we remain persuaded there were symptoms which suggested bowel obstruction from the start which should have been explored.
37. Ms H says appropriate checks were not done whilst her mother was an inpatient. We have already identified where interventions failed to identify signs of bowel obstruction. However, we have considered the records on whether they were monitoring her, and we are satisfied that appropriate surgical and nursing observations were done throughout the admission.
38. If the CT scan had been done the diagnosis of constipation could have been revisited, and in line with the Trust’s own reflection it is likely a small bowel obstruction may have been identified. This is because when she was readmitted a large amount of feculent material was drained from the stomach, and a CT completed about three days after the initial admission. The CT scan did show a bowel obstruction. As there was a large amount of feculent material, we are confident the bowel obstruction had been in place for some time and therefore more detailed imaging would have been likely to flag this up.
39. If bowel obstruction had been identified at the first admission, we would have expected conservative treatment to be considered. Treatment involves a combination of nasogastric decompression (emptying the stomach by removing its contents) for between 24 – 48 hours, and intravenous fluids. This is set out within the guidelines from the National Library of Medicine.
40. The intravenous fluids would have replaced the lost fluid, prevent dehydration and AKI. This would have allowed monitoring of the obstruction and given it a chance to settle with these conservative measures. If there had been no improvement, then discussions about surgery could have taken place. With prompt diagnosis and management, it is accepted that the prognosis for most patients with small bowel obstruction is good.
41. We cannot say now whether conservative management would have been successful in Mrs H’s case as a positive response is not guaranteed. Research has indicated that this is successful in many cases, but this depends on what approach is used and the health of the person concerned.
42. From the records, we know Mrs H was 80 years old. She was able to walk short distances with a frame and lived in a retirement village. The widely used clinical frailty scale would have likely said Mrs H was mildly to moderately frail (CFS score 5-6). Her co-morbidities included heart problems for which she was taking tablets for heart failure, previous bypass, high blood pressure and diabetes.
43. For this reason, even with optimal care we cannot say that conservative treatment would have been successful during her first admission. We can say more timely conservative treatment was likely to mitigate the deterioration in her condition as it is likely that IV fluids would have helped prevent dehydration. We have seen the CT scan on readmission showed ischaemia (lack of blood supply). Due to the lack of food and drink on the previous admission, Mrs H was suffering from dehydration which in combination with the AKI meant she had narrowed blood vessels. Overall, this resulted in blood supply to the stomach to be inadequate. Earlier treatment may have avoided some of this deterioration.
44. We appreciate that when conservative management was attempted when she was readmitted it was not successful. However, as we have indicated above, more timely treatment would have been likely to mean her condition was not as poor when it was attempted. As such, it seems likely that earlier treatment would have allowed her to have been in a better clinical condition for the attempt. This means that she may have been more responsive to conservative management if this had been tried earlier. As such, we cannot say that the later failure of conservative measures would have been the same if they had been tried on the first admission. However, we also are unable to say it would have been successful.
45. If conservative treatment had been tried earlier and not been successful, it is possible that surgery would have been an option at the earlier stage (which it was not here as her overall condition was not such that she would have been considered able to tolerate it). In order to consider her position regarding possible earlier surgery we have had regard to the Portsmouth Physiological and Operative Severity Score for the enumeration of Mortality and morbidity (P-POSSUM). This methodology is a way of predicting mortality ahead of surgery. Our adviser suggested that on the first admission there was a predicted mortality rate of about 10%. By the second admission this had jumped to 51%. As such, whilst we can see why surgery was not considered appropriate on her second admission, it may have been a possibility on her first admission.
46. However, we cannot say that even at that earlier stage surgery would have been considered a viable option. This would have been a clinical decision based on a consideration of her overall health, and more detailed imaging.
47. As we have indicated above, she would have been about 5 -6 on the clinical frailty scale. Research from National Library of Medicine shows the Clinical Frailty Scale (CFS) is a rapid assessment tool to identify vulnerable and frail patients. They evaluated the association between preoperative CFS scores and outcomes following emergency laparotomy. For those considered to be frail (a CFS score of 4 or over) noted that they were significantly more likely to die than those considered to be fit (84.8% vs 39.2%). This is therefore a helpful tool to predict mortality and morbidity after surgery.
48. Furthermore, our adviser noted her history of heart disease and previous bypass as ‘significant co-morbidities.’ We have seen an early clinical review suggested surgery was not considered an option before discharge, albeit we do not know what context that statement was in.
49. As a result, we appreciate clinicians would have been likely to be cautious about a decision to proceed with surgery. We cannot say now she would have been considered suitable, even if she had been in a better clinical condition, as she may have been with an earlier diagnosis.
50. As such, we cannot say now that earlier intervention would have saved her life. We can however say that earlier intervention may have given her more options.
51. As a result, we are persuaded there were multiple missed opportunities for appropriate imaging to be completed, which would have likely allowed the diagnosis of a small bowel obstruction, and conservative treatment would have been attempted. Further to that, surgery could have been considered. We appreciate Ms H is confident the outcome would have been different. We cannot say now that treatment for bowel obstruction would have been successful however there was a missed opportunity to allow this to take place.
52. We have seen above that more timely conservative treatment was likely to mitigate the deterioration in her condition as it is likely that IV fluids would have helped prevent dehydration. The CT scan on readmission showed ischaemia. It is probable that the dehydration and AKI caused by the small bowel obstruction in combination with narrowed blood vessels to the stomach caused the blood supply to the stomach to be inadequate and it is this that ultimately led to her death. Whilst our adviser confirmed that earlier identification and treatment would have meant the risk of developing gastric ischaemia would have been less, we cannot say that it would have been avoided if conservative treatment had been undertaken.
53. Overall, whilst we have seen multiple missed opportunities for earlier intervention and management, we cannot say now whether conservative treatment would have been successful, or if not, surgery would have been either appropriate or survivable. However, we can say that that there was a missed opportunities here which lost her the opportunity for a fair chance of survival. By saying ‘fair chance of survival’ we mean where there was a real chance of survival but that we are unable to say on balance of probabilities she would have survived.
54. Whilst we have not been able to find Mrs H’s death was avoidable, we have found there was a fair chance of survival through earlier investigation, diagnosis and treatment, which was missed. This has not been fully acknowledged by the Trust albeit they have acknowledged failings in care. As a result, we have partly upheld this complaint.