13. We carefully considered Miss P’s concern about a delay in identifying her father’s sepsis and anastomotic leak, particularly considering signs of pain, distress and delirium. We hope to assure her the recorded evidence shows her father received reasonable and appropriate care.
14. Surgery was performed on 27 June. In the immediate post-operative period, the recorded evidence does not suggest Mr P had any apparent pain, distress or delirium. Records note he first reported some pain overnight into 29 June. This was appropriately responded to by the Trust, as they provided analgesics (painkillers). This was in line with GMC guidance which says health practitioners must adequately assess the patient’s conditions and promptly provide suitable treatment where necessary.
15. At the clinical ward round later that morning, records note Mr P denied any pain. This indicates the analgesia given to him earlier had been effective in meeting his needs. Our adviser says having undergone a recent surgery, some post-operative pain to this degree is not unexpected.
16. Mr P did not report pain again until notes of him having slight pain on the evening of 30 June. The medication chart shows analgesics were appropriately offered, yet he declined. Records show Mr P did not report pain again until 2.30am on 2 July. We will discuss what happened at that time in more detail, later in our report.
17. In terms of Miss P’s concern of her father’s pain following his surgery, up to 2.30am on 2 July records do not suggest he was presenting with any pain that was not reasonably considered normal post-operative pain. Records show the Trust appropriately responded when pain was reported, by providing analgesics. When these were taken, they appear to have managed Mr P’s pain accordingly. The Trust acted in line with the GMC guidance outlined earlier, and we do not find any evidence regarding pain up to that point to have warranted any alterative or additional action.
18. In terms of Miss P’s concerns of distress and delirium, both before and at the time of admission, there is documentation questioning Mr P’s memory and mental function. Records note he demonstrated some confusion and difficulty in finding words at the pre-operative assessment, and once he arrived for this scheduled surgery. Our adviser says in turn, it was reasonably expected he may demonstrate a similar level of confusion post-operatively.
19. The recorded evidence does not show Mr P had any distress or delirium in the immediate post-operative period. The first entry noting Mr P becoming unsettled, agitated and confused was at 12.40pm on 29 June. Nursing staff requested a clinical review, and this took place promptly at 1.28pm. This was the appropriate action in line with GMC guidance, which says health practitioners must promptly arrange suitable advice and refer a patient to another practitioner when this serves the patient’s needs.
20. The clinical review found Mr P’s white cell count was elevated. As a result, the management plan was to check for a urinary tract infection (UTI) which can cause these signs. Our adviser confirms this was a reasonable course of action, as Mr P received a prompt clinical review with an appropriate forward plan to investigate these newly presenting symptoms, which were reasonably ascribed to a possible UTI.
21. At 3.50pm that day after a board round discussion of Mr P’s care, a plan was made that should he have a temperature spike or show any deterioration, he should have a CT scan of the abdomen and pelvis (CTAP) and be given intravenous (IV) fluids, antibiotics and ongoing monitoring.
22. Our adviser explains this shows the clinical team were considering the possibility of a sepsis infection (when an infection becomes overwhelming and can be life-threatening). Not only that, but pre-emptively, the clinical team put in place plans for treatment for it, should further signs of high temperature and clinical deterioration have presented. These treatment plans were in line with NICE sepsis guidance, which recommends IV fluids, antibiotics and monitoring when sepsis is apparent.
23. Records show when Mr P developed a raised temperature later that day, the treatment plan commenced without delay. Our adviser confirms this was appropriate action, in line with the GMC guidance and NICE sepsis guidance we outlined earlier and above. We do not find anything to suggest any delay in the Trust identifying and then treating Mr P for sepsis.
24. Further clinical assessment and discussion then took place, with the clinical team suspecting an anastomotic leak and arranging for Mr P to have a CTAP, the appropriate investigation to explore this. The CTAP was taken on 30 June, which was reasonable and timely, although described by our adviser as early, just three days following surgery.
25. Our adviser explains most leaks would not occur as quickly as this. They say typically leaks occur around five days to a week following surgery. It is only in retrospect from the post-mortem that we know there was a leak. We must remember this was not known at the time. Whilst appropriate for the clinical team to question the possibility, this was a questioned early leak.
26. The CTAP was not conclusive and did not sufficiently identify that there was a leak. The plan was to continue the treatment in place, to monitor Mr P and re-scan him in a few days’ time. Our adviser says whilst there is no specific guidance for what to do in this situation, the course of action taken by the Trust was reasonable, in the clinical circumstances.
27. This is because without definitive indication of anastomotic leak there was no clinical indication to act upon this basis. It was also very soon after surgery, when leaks are less likely to have occurred, and Mr P’s symptoms were more indicative of a sepsis infection for which he was being treated.
28. Once treatment for a sepsis infection is started, some time is needed to see if the patient will respond. Some time is also needed to wait after surgery, to see whether anastomotic leak is indeed apparent. At this time, we hope to assure Miss P the treatment and onward management plan was clinically appropriate.
29. On 1 July Mr P was clinically reviewed on several occasions, each time with appropriate assessment and a management plan in place, in line with the GMC guidance outlined earlier. Records note he was confused at times however this was not a new symptom nor considered atypical for him, considering his pre- and on admission presentations. Later that day he was deemed not to have capacity, and this also formed part of his pre-admission consideration and was anticipated as a possibility from that earlier assessment.
30. His national early warning score (NEWS) that morning was 0. NEWS is a national tool where six physiological measurements are recorded and given a score, to help identify an acutely unwell or deteriorating patient. NEWS guidance says a score of 5 or higher requires an urgent response. It explains 0 is the lowest score, indicating a low clinical risk, requiring nothing more than continued 12-hourly repeated NEWS checks on the ward. This therefore did not indicate any concern that Mr P was acutely unwell or deteriorating.
31. That evening Mr P was seen to be shivering with a high temperature. Appropriately in response, and in line with GMC guidance, nursing staff bleeped the clinical coordinator who discussed the possibility of changing the type of antibiotic Mr P was receiving.
32. Whilst he was already receiving the appropriate treatment for a sepsis infection throughout this time, discussion to potentially change antibiotic type was the appropriate course of action considering this new presentation. Our adviser confirms this was in line with NICE sepsis and GMC guidance. Notably Mr P’s NEWS remained between a 0 and a 4, which did not require any alternative or additional action in line with NEWS guidance.
33. At 2.30am on 2 July Mr P suddenly became distressed, with severe and visible signs of pain, and his NEWS was 5. Under NEWS guidance, this required an urgent response, for nursing staff to inform a clinician to attend for review. Records show this happened. The clinical coordinator was contacted, stronger analgesics were given in response to his distress and pain, and a clinician attended to review Mr P at 3.46am. Our adviser confirms this was within an appropriate timeframe for such a response.
34. The clinician planned for Mr P to receive IV morphine (a strong analgesic) and lorazepam (used to treat agitation), to have blood tests repeated, observation frequency increased and for a later further review. Our adviser says there is no specific guidance for what to do in this situation, yet the course of action taken here was reasonable in the clinical circumstances.
35. This is because treatment was already being given to Mr P for a sepsis infection and tests had already been taken to explore whether this was due to a UTI. An anastomotic leak had already been questioned, a scan to investigate this had already been taken 24 hours earlier, and a plan was in place to continue to monitor Mr P and to re-scan to explore this again in the coming days. Stronger analgesics were given without delay to try and address his immediate pain, with a plan for review after some time to see its effect.
36. When Mr P still complained of some pain at 4.30am, additional IV morphine was given appropriately in response. The clinician called the ward at 5.55am for an update, and escalated Mr P’s care for a day team review which took place just 90 minutes later. This was appropriate and timely, in line with the GMC guidance outlined earlier.
37. At 7.10am Mr P’s NEWS was 1 and he was more settled and had a normal temperature. This further indicates that the actions and interventions taken overnight were effective and provided improvement.
38. When reviewed by the day team at 7.40am discussion was for the re-scan to take place that day. This was further discussed, and a plan was in place at 9am to make the necessary arrangements. Our adviser confirms this was appropriate, as it accounted for the events overnight and followed the course of the earlier management plan.
39. Unfortunately, just under 90 minutes later and before the scan took place, Mr P went into PEA, and he sadly died.
In summary 40. We know Miss P is concerned about whether signs were missed and action delayed, which might have avoided her father’s death that morning. We can assure her that from the recorded evidence, there were no immediate post-operative signs or symptoms to suggest any concern.
41. Our adviser explains Mr P’s NEWS chart across the admission did not suggest any apparent concern. His bloods were reasonably normal except for a raised white cell count and inflammation markers. These findings were reasonably ascribed to post-operative changes and then an infection. His confusion and distress was not felt to be atypical considering his pre-admission assessment and presentation on admission. When this presented post-operatively, the Trust responded by considering the possibility of it being exacerbated by a UTI infection.
42. From 29 June an infection was assumed, as this was at the first increase in temperature alongside other symptoms. The appropriate treatment for a sepsis infection commenced without delay. Our adviser confirms there was no clinical indication to have commenced sepsis treatment sooner than it started.
43. An anastomotic leak was suspected at an early stage, and the appropriate investigation was performed. As this was not indicative of a leak, and Mr P’s symptoms were indicative of a sepsis infection from possible UTI for which he was being treated, the Trust’s plan was for continued medical management and monitoring, and to re-scan after some days. This was reasonable.
44. Mr P’s reported pain from surgery up to 2.30am on 2 July did not indicate anything other than typical post-operative pain, and it was responded to and treated accordingly. His pain at 2.30am was different, however the Trust acted upon it without delay, amending treatment to better meet his needs and obtaining clinical review. Appropriately, the clinician called for an update just over two hours later, at which time they arranged the day team review which took place 90 minutes later. This was all appropriate and timely.
45. Because of the events from 2.30am, the plan for re-scan was expedited and arrangements began to be made for another CTAP that morning. Very sadly, the PEA overtook that plan. Our adviser explains this was a sudden and unexpected event that could not have been predicted nor prevented.
46. They confirm there was no clinical indication for an earlier repeat scan. The Trust provided appropriate medical management overnight into the morning of 2 July, when the decision for re-scanning was then made and being processed. There was nothing to indicate any urgent or emergent need for this scan, any sooner than the arrangements that were being made.
47. Lastly to address Miss P’s concern, there is no indication Mr P should have been returned to theatre any sooner. Our adviser explains he would not have been returned before a repeat CT, and we do not find anything to suggest this was delayed. Additionally, our adviser explains even where a leak is clearly seen, it does not always require a return to theatre to resolve. These can be resolved conservatively, with antibiotic treatment and a radiological drain.
Conclusion 48. As we have explained, we do not find any evidence of delays in the Trust identifying or treating Mr P’s sepsis, nor any delays in it identifying the anastomotic leak. We find early consideration for both a sepsis infection and an early leak, with plans in place so as the circumstance evolved and the clinical signs were then apparent, those plans could be enacted without undue delay.
49. We very much hope our decision can provide Miss P assurance about the care her father received, and that our report has fully explained the reasons for the outcome.