13. 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 found no indications something went wrong.
Diagnosis
14. Mr Z complains the Trust did not diagnose his father with a build-up of fluid in the lungs caused by heart failure (pulmonary oedema) on 18 January. He says his father's symptoms indicated a serious problem, but staff misdiagnosed him with asthma.
15. The Trust explained Mr V did not show any signs of a pulmonary oedema when he first attended hospital, and a chest X-ray did not indicate this was a problem. The Trust said Mr V responded well to the asthma treatment it gave him so concluded he had an acute exacerbation of asthma.
16. The Trust explained Mr V’s health likely deteriorated several days later due to his end-stage heart failure.
17. NICE guideline 106 and Clinical guideline 187 set out that a patient’s history and the findings of examinations are crucial to identifying heart failure. Doctors should investigate these findings further to reach a diagnosis. This includes giving the patient a chest X-ray.
18. When Mr V attended hospital he reported a dry cough and being short of breath for the last three days. He was wheezing and had a history of asthma. Doctors did not record any concerns with Mr V’s heart or symptoms that might have indicated it was not working properly.
19. Doctors investigated Mr V’s symptoms with a chest X-ray on 18 January. It did not show any indication of heart failure or fluid on his lungs. They also performed two peak flow tests. This test measures how quickly someone can breathe out the air in their lungs. They found Mr V could breathe out 350L per minute, which was 87% of his usual best.
20. Blood tests did not show any signs of infection, and when the consultant visited Mr V the next day they found the veins in his neck were not raised. They also recorded his chest was clear and his ankles were not swollen. These symptoms would be present if Mr V had worsening heart failure or pulmonary oedema.
21. Our adviser explained Mr V did not show symptoms of a pulmonary oedema or heart failure on 18 or 19 January. They explained Mr V’s peak flow test results pointed towards an acute worsening of his asthma when he attended hospital.
22. We consider staff at the Trust investigated Mr V’s symptoms in line with guidance. They used the findings to accurately diagnose him with asthma when he visited hospital on 18 January.
23. We recognise this has been an exceptionally upsetting time for Mr Z. We also recognise the devastating loss he has experienced and his unhappiness with the Trust. We hope the explanation above can reassure him about what happened.
Diuretic therapy
24. Mr Z says the Trust should not have stopped giving his father diuretics on 18 January. He says the Trust stopped them too quicky and without appropriate monitoring in place. Diuretics are a medicine that help the body get rid of excess salt and water. They are commonly used to treat problems like heart failure and fluid retention.
25. The Trust explained Mr V showed no signs of fluid build-up when he arrived in hospital. It said the opposite was true, and that Mr V was dehydrated. It explained it stopped diuretics to help resolve this dehydration.
26. NICE guideline 148 says doctors should diagnose an acute kidney injury if the amount of serum creatine in a patient’s blood increases. Serum creatinine is a waste product from protein and muscle breakdown, and high levels can indicate kidney issues.
27. NICE guideline 106 says doctors should give diuretics to treat fluid build-up caused by heart failure. They should adjust the dose according to the patient’s need.
28. A doctor identified Mr V was dehydrated at 7.20am on 19 January and requested blood tests to investigate further. Blood test results showed Mr V had a decrease in sodium, and an increase in his urea and creatine. Urea is also a waste product from the body and increased levels indicate reduced kidney function.
29. The doctor planned to withhold Mr V’s diuretics in response to the findings. They gave him the final diuretic dose at 1.24pm.
30. The following day Mr V’s kidney function was still reduced and he appeared dehydrated. His eGFR was 28 and he had no signs of fluid build-up. Estimated Glomerular Filtration Rate (eGFR) measures how well someone’s kidneys filter waste in the body. An eGFR of less than 30 indicates severely reduced kidney function.
31. Doctors gave him fluids directly into his vein in response. They also requested strict monitoring of Mr V’s fluid input and output.
32. Our adviser explained because Mr V’s kidney injury was caused by dehydration the doctors withheld the diuretic on 19 January. The next day his kidneys were still not working properly and an examination showed he was still dehydrated. In response they gave him fluids and monitored this closely.
33. We recognise Mr Z’s concern and why he feels it was wrong for staff to withhold his father’s diuretic.
34. As there was no indication Mr V had fluid build-up he did not need a diuretic. His dehydration meant it was appropriate for staff to withhold them on 19 January to avoid worsening this. Staff did this as part of a series of steps to manage Mr V’s hydration and monitored it accordingly.
Weight monitoring
35. Mr Z says the Trust did not properly monitor his father’s weight whilst in hospital. He says this was a direct departure from established standards in managing heart failure patients. He says it meant staff missed clear red flag warnings of his father’s fluid overload.
36. The Trust said the clinicians did not request a daily weight chart and therefore one was not completed. However, Mr V's weight was measured on arrival and recorded at 62.5 kilograms.
37. Clinical guideline 187 says weight monitoring should be part of initial treatment in acute heart failure. Weight monitoring is used to identify if someone’s body is retaining too much fluid.
38. However, NICE guideline 148 does not indicate the need for daily weight monitoring for an acute kidney injury.
39. Our adviser explained when Mr V first arrived at hospital he had no symptoms to indicate acute heart failure or fluid overload. Therefore, daily weight monitoring was not needed to manage his condition at that point. They said monitoring Mr V’s weight would not have changed how doctors managed his illness.
40. When a doctor saw Mr V in the afternoon of 21 January there were no findings to suggest his body was retaining too much fluid. The fluid balance chart between 1am and 8pm indicated he had a total intake of 1300ml of fluids and an output of 1200ml of urine. The 100ml difference of urine was insignificant.
41. Mr V became critically unwell just before midnight on 21 January and fluid started to accumulate on his lungs. Monitoring his weight would not have identified this any earlier or changed the course of his treatment. Based on relevant guidance, we consider there was no indication to monitor Mr V’s weight throughout his time in hospital.
42. The impact of this issue has been understandably concerning for Mr Z. We understand why he feels staff at the Trust should have monitored his father’s weight.
Escalation
43. Mr Z complains the Trust did not escalate his father’s care when he started to deteriorate on 19 January. He says the deterioration continued for several days with increasing respiratory distress and worsening blood test results. He says the Trust should have got further cardiology input and monitored his father more intensively.
44. The Trust said Mr V was stable over the weekend with no indication of symptoms or signs of acute heart failure. It explained appropriate and timely investigations were carried out with regular monitoring of Mr V's National Early Warning Score 2 (NEWS).
45. NEWS is the standard way of assessing acute illness. It is calculated using clinical observations like heart rate, body temperature and consciousness level. Scoring four or less means the patient is categorised as low risk.
46. It said staff altered medications accordingly to treat Mr V’s most pressing symptoms and diagnosis, although it noted this can be a difficult balance considering his comorbidities. It also said there was timely escalation to the appropriate teams and specialists, but Mr V was too unwell and treatment was not successful.
47. The Trust’s escalation policy sets out what should happen when a patient’s condition declines. It says staff should monitor a patient using NEWS. If a patient’s NEWS is 5 or 6 then their care should be escalated to appropriate emergency doctors.
48. Staff recorded Mr V’s NEWS regularly throughout his admission. There is no indication he was in a critical condition on 19 January. Our adviser explained Mr V’s NEWS first showed an acute deterioration late on 21 January. Therefore, there was no need for escalation before this.
49. They went on to explain staff referred Mr V to emergency care staff when his condition deteriorated. The relevant teams then took over caring for Mr V.
50. Therefore, we consider staff monitored Mr V appropriately. When they identified his condition was getting worse they referred him to the right staff at the right time in line with guidance.
51. We understand the worry these events have caused Mr Z. We recognise how upsetting they have been and why these issues have meant so much to him.