Diagnosis
18. Miss Q complains staff at the Trust did not properly examine her mother and missed the early signs of sepsis on 29 August.
19. The Trust’s response explained when Mrs C first attended hospital there were no available consulting rooms or trolleys. The Trust accepted the doctor examined Mrs C in a wheelchair and best practice would have been to lay her flat first.
20. Miss Q disagrees with the Trust’s account and says a trolley was available in the examination area. We can see no reason to doubt Miss Q’s account and accept the facilities to lie Mrs C flat were available.
21. The Trust went onto explain staff reached a reasonable diagnosis of a UTI based on Mrs C’s symptoms and its investigations.
22. NICE guidance sets out a doctor should suspect a patient has a UTI when they have urinary symptoms. For example, pain when urinating, needing the toilet during the night and changes in urine appearance or odour.
23. NICE guidance also says the doctor should investigate symptoms by examining the person. They should check their temperature, blood pressure, heart rate and respiratory rate looking for signs of systemic illness or sepsis. They should also feel the person’s side feeling for tenderness or abdominal masses.
24. Good medical practice says doctors must provide a good standard of practice and care. In doing so, they should adequately assess the patient’s conditions and examine them appropriately.
25. Mrs C attended ED with worsening abdominal pain, nausea, poor appetite, bloating, diarrhoea, and a one-week history of difficulty passing urine. A doctor assessed Mrs C in ED and found she was breathing unusually quickly. She also had low oxygen in her blood but was on long-term treatment for this using a small amount of oxygen at home .
26. Mrs C did not have a fever and her national early warning score (NEWS) was six. NEWS is a system used to identify patients at risk of deteriorating. A score of six shows someone is at medium clinical risk.
27. The doctor investigated Mrs C’s condition with an abdominal CT scan and blood tests. The blood test showed her lactate level was high. Blood lactate refers to the concentration of lactic acid in the bloodstream, and increases when the body does not have enough oxygen. It can be elevated with infections or sepsis.
28. Mrs C’s C-reactive protein was 35mg/L, which is moderately high. This is a substance found in the blood in response to inflammation and can indicate the presence of an infection. A normal level is between 0 and 5mg/L.
29. The doctor also requested a test to detect any bacteria in Mrs C’s blood. The test takes several days to complete because the bacteria need time to grow. After five days the test showed Mrs C’s blood did not have any bacterial growth which would have indicated sepsis. However, this result was not available at the time doctors diagnosed Mrs C with a UTI.
30. Others tests showed Mrs C’s liver and kidneys were not working as they should have been. The abdominal CT scan showed nothing of concern, and the doctor subsequently discharged Mrs C with a suspected diagnosis of a UTI.
31. Our adviser explained examining a patient sat in a wheelchair is not an appropriate way to investigate their condition. However, they also said the diagnosis of a UTI was reasonable based on Mrs C’s symptoms and the investigation results. This diagnosis was based on several findings like blood tests and scans, and not just the physical examination.
32. We are satisfied the UTI diagnosis was made in line with relevant guidelines. However, we have found the examination did not meet the necessary standard.
33. We have considered what the impact of this examination was.
34. We have found there was no impact on Mrs C’s clinical treatment because of the examination. This is because even if it had been done with Mrs C lying flat, the doctor would likely have reached the same diagnosis of a UTI.
35. Nonetheless, something went wrong and we recognise this has understandably been a distressing experience for Miss Q.
36. Our Principles for Remedy are reflected in the NHS Complaint Standards UK Central Government Complaint Standards. These say organisations should offer fair remedies to put things right and identify learning and use it to improve services.
37. As part of the Trust’s response to Miss Q’s complaint the Trust met with her in person. Staff at the meeting apologised for assessing Mrs C in a wheelchair. We are satisfied this apology puts right what the individual impact of happened given there was no clinical impact and the amount of concern this caused.
38. However, there is no indication the Trust has acted on what happened to avoid the same problem happening again. We have made a recommendation with this in mind.
Discharge
39. The Trust’s complaint response acknowledged Mrs C would have benefitted from an admission and observation on 29 August. It also agreed Mrs C would have benefitted from more help obtaining the medicines doctors prescribed when they discharged her from ED.
40. Good medical practice sets out that doctors should provide suitable treatment where necessary.
41. Patient Care in the ED sets out how staff should discharge a patient safely. It says staff should give advice on what to do if problems get worse. They should also make pragmatic considerations. In this instance we consider that means they should ensure prescriptions are provided in an accessible and convenient manner.
42. Our adviser explained Mrs C would have benefitted from being admitted given her extensive past medical history and how these symptoms were managed.
43. They added there is no documentation staff explained to Mrs C what she should do if her condition got worse outside of hospital. Furthermore, the prescribed medicines were not available for Mrs C on discharge. She was visiting the area and unfamiliar with local pharmacies or where she could collect the medicines late at night.
44. We consider the Trust should have admitted Mrs C to hospital. We also consider the discharge process was not followed properly as she was unable to collect the prescription and unaware of what to do if things got worse. We have looked at the impact of this.
45. Miss Q feels her mother might not have died if she was kept in hospital overnight, and that getting the prescription would have improved her chances of survival.
46. Mrs C had significant long-term health problems. This included type 2 diabetes, chronic obstructive pulmonary disorder, congestive heart failure, ischaemic heart disease and pulmonary hypertension. These underlying issues were recorded as contributing to her death.
47. Further to these chronic problems, her condition got significantly worse between the two hospital attendances. Specifically, her symptoms became more severe and blood tests showed her condition had worsened.
48. Our adviser explained Mrs C’s deterioration was not predictable. They said the combination of her long-term health conditions and short-term deterioration meant a different course of action was unlikely to have prevented her death.
49. We cannot link the failings we have identified to the most serious impact Miss Q has claimed.
50. Nonetheless, we recognise the distress Miss Q has experienced due to these sad events. We also understand the inconvenience and worry of Mrs C returning to hospital by ambulance as an emergency, and the distress of witnessing the excruciating pain her mother went through. This would likely have been avoided if the Trust had admitted Mrs C on 29 August.
51. We have considered what the Trust has done to put things right. Its medical examiner investigated what happened and identified the Trust should have admitted Mrs C. The consultant also discussed what happened with the pharmacy department to avoid similar problems in the future.
52. Our adviser explained the Trust has accurately identified what went wrong and taken appropriate learning from what happened. We consider it is unlikely these problems will happen again and the Trust has sufficiently improved its service for others in similar circumstances.
53. We are pleased to see the Trust’s proactive approach to identifying failings. We also recognise the underlying difficulties it was facing at the time, such as an overcrowded department and stretched resources. We appreciate the pressures this placed on staff.
54. However, we are conscious of the individual impacts on Miss Q. She has told us her mental health has been impacted by what happened, and this continues to affect her everyday life. She has had help from a bereavement counsellor because of the trauma she has experienced.
55. We understand why these events were so distressing for Miss Q, and why they have had a lasting impact on her.
56. The Trust has expressed its sincere regret for the events and apologised to her for what happened. We do not believe the Trust’s apology alone goes far enough. We have made a recommendation with this in mind.
Resuscitation
57. Miss Q says the Trust did not prepare a resuscitation suite for her mother despite paramedics asking it to do so. A resuscitation suite is a specialised area for the assessment, resuscitation, and treatment of patients with critical conditions, like sepsis.
58. The UK NHS Ambulance Services & Emergency Department pre-alert guideline says paramedics can use a pre-alert call to tell doctors at the receiving hospital about the patient. It should be used so the doctors can prepare immediate clinical interventions.
59. However, the decision to implement any such response is made at the discretion of the senior clinical staff at the receiving hospital. There may be valid reasons for them to provide an alternative response based on clinical triage and available resources in their department.
60. Although this guidance postdates the event, our adviser explained it is relevant to the issues raised. This is because the basic concept of pre-alerts has remained unchanged since the events complained about.
61. The Trust explained that although paramedics requested a resuscitation bay, the final decision on assessment is made by the doctor and nurse in charge of the department. The complaint response added that although resuscitation has more ‘elbow room’, the assessment Mrs C received was the same regardless of where it took place.
62. Paramedics sent a pre-alert to the hospital explaining Mrs C had warning signs of sepsis and needed resuscitation. An ED consultant saw Mrs C within ten minutes of her arrival in hospital, and staff transferred her to the resuscitation suite immediately after the consultant’s assessment.
63. A pre-alert allows ambulance clinicians to share information with the receiving hospital. This enables hospital staff to prepare care the patient might need on arrival.
64. Although ambulance staff recommended a resuscitation suite, Mrs C still needed triage to diagnose the problems and decide treatment. This is what happened, and the paramedic’s pre-alert helped it happen sooner.
65. We consider nothing went wrong when senior clinical staff at the Trust decided what treatment it would provide and where.