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.
14. Mrs P complains about how the Trust managed Mr B’s care and treatment when he was admitted with leg pain and swelling on 20 March. She has concerns it caused delays in arranging the appropriate care and treatment regarding his DVT, specifically regarding scans and medications.
15. The venous thromboembolic diseases guidance is applicable here. It says if a patient is suspected to have a DVT to offer a proximal leg vein ultrasound scan (doppler scan).
16. It says if the scan cannot be obtained within four hours, to carry out a D-dimer test (a blood test used to check for blood clots in the body), give interim therapeutic anticoagulation (immediate blood thinning medication), and to perform a doppler scan within 24 hours.
17. Mr B presented at the Trust on 20 March with increased shortness of breath and recent onset left leg pain, with no history of injury of trauma. This was in the context of a diagnosis of lung cancer. Cancer makes you much more prone to blood clots, and these findings would be very concerning for a suspected blood clot in the leg and lung.
18. Based on this, the Trust suspected Mr B had deep vein thrombosis (DVT), which is a blood clot in the vein, usually in the leg. It was also noted he was very anaemic.
19. Mr B was admitted and reviewed on the ward later that day. A computed tomography pulmonary angiogram (CTPA), which is a scan used to look for blood clots on the lungs, and CT of the abdomen and pelvis were requested.
20. These investigations were subsequently cancelled as it was decided they would not alter Mr B’s management or treatment. This is because Mr B was not deemed to be a suitable candidate for further intervention beyond blood thinning medication, due to his frailty and comorbidities.
21. Our adviser agrees this was reasonable, as the investigations would not have changed Mr B’s management or treatment. Regardless of the scans taking place, he was treated with blood thinning medication.
22. When investigations are being considered, it is important to consider what benefit they will bring to the patient, particularly if they are invasive. Our adviser explains a CT scan can be uncomfortable for the patient, and the dye used for a CTPA can upset the kidneys. There is a fine balance between subjecting patients to unnecessary testing and investigations where it will not change the clinical management and confirming a diagnosis.
23. We recognise a doppler scan was then arranged for 25 March. We acknowledge the guidance above suggests it should have been performed sooner than this. We asked our adviser about this, and they have considered this very carefully. Our adviser explains in the context and current climate, generally across hospitals small and large, this is commonplace and not unusual. Our adviser explains in their clinical experience, this is around the average length of time for an inpatient wait for a doppler scan, particularly if the request spans over a weekend.
24. Due to resources and capacity, our adviser explains this recommended target is not achievable for most cases of inpatients. It is important to recognise that whilst this was longer than recommended, Mr B was appropriately covered with anticoagulant medication in the meantime. There was an input from the haematology team to formulate a plan for Mr B, with advice to put him on intravenous heparin (blood thinning medication) and to consider if an inferior vena cava filter (a small device placed into the vein to stop clots travelling) was suitable, if there was any bleeding.
25. Intravenous heparin is a drip of blood thinner, which doesn’t last as long in the body as injections, like enoxaparin. This means if a patient experiences any bleeding, it can be immediately turned off, and the effect will wear off after a few hours. This shows the Trust was weighing up the risks and benefits of the need for anticoagulant treatment, whilst waiting for further information.
26. The Trust took samples including blood cultures to look for signs of infection and referred to the microbiology team for advice on antibiotics. Mr B was actively treated from the beginning of the admission with antibiotics to cover any potential infection.
27. As a result, weighing up all the above, we do not think what happened fell significantly below of what we would expect. We recognise there was a gap in the scan taking place and understand the doppler scan did go on to confirm a diagnosis of a DVT.
28. It remains that Mr B’s management and treatment was not impacted, and the Trust managed this in line with guidance. Mr B was not left without treatment as a result, and the scan outcome would not have altered the management. We understand why Mrs P would have had concerns about this and are mindful of these. We hope our explanations around this have been useful.
29. We understand Mrs P also has concerns the Trust did not appropriately manage Mr B’s comfort as he approached end of life. Our adviser has carefully considered this.
30. The last days of life guidance is applicable here. It sets out what to do if it is thought a person may be entering the last days of their life. It says to gather and document information on: • ‘the person's physiological, psychological, social and spiritual needs • current clinical signs and symptoms • medical history and the clinical context, including underlying diagnoses • the person's goals and wishes • the views of those important to the person about future care’
31. We understand it was identified on 1 April that despite active treatment, Mr B continued to deteriorate, and it was recognised he may be approaching the end of life. He remained on treatment, but the Trust were also thinking about managing his comfort at this stage.
32. Our adviser explains there was a good consideration of measures which would help protect Mr B’s comfort in relation to his catheter, including the consideration of mittens and decoy catheters. This refers to taping a second catheter end to the leg to allow him to tug at that, opposed to his actual indwelling catheter.
33. We acknowledge the Trust says there was a delay in the deprivation of liberty process being initiated and the mittens being in place. This was due to a misunderstanding of the process. The Trust has apologised for this delay of it being implemented and put training in place to prevent this from happening again. Whilst we recognise this delay, we are reassured by this action, and the guidance was followed to try to maintain Mr B’s comfort.
34. Throughout the admission it is documented there were discussions with the family and detailed considerations of the risks and benefits of continuing with active treatment. It was clearly recognised by the medical team that Mr B had deteriorated, and if treatment looked to be causing him more suffering than harm, they would look to focus on his comfort. There are entries throughout to evidence comfort was maintained.
35. Regarding his nutritional intake, at times during the admission, we understand Mr B had been nil by mouth. This is because of the risk of aspiration, which can cause very serious side effects. It is recognised when Mr B was able to eat, his food intake was low. Very sadly when a patient is dying, food intake can generally be low at this point. This was carefully considered by the medical team, and the risks and benefits were weighed up. After consideration, he was deemed allowed to continue eating if he wished, to maintain his comfort at the end of his life.
36. There was close monitoring of his end-of-life symptoms, with appropriate medications being given to manage symptoms such as nausea and secretions.
37. This is supported by the nursing records, which indicate steps were being taken to make Mr B comfortable during his admission. There were episodes where he was confused and agitated at times, and 1:1 supervision was put in place by a registered mental health nurse. This was to help maintain his safety and comfort.
38. We understand Mrs P has concerns Mr B was left dehydrated. Specifically, regarding fluids, the guidance recommends an individualised approach. It is worth recognising it is not always appropriate for all patients to be placed on IV fluids at the end of life. This is a clinical decision where if the burdens or risks of providing clinically assisted nutrition or hydration, outweigh the benefits they are likely to bring, this may not appropriate. Some interventions can be deemed to be unnecessarily invasive and are not routine in each patient. We hope this helps explain why fluids are not always standard practice, particularly when a patient is still attempting eating and drinking.
39. We understand that despite the above, end of life can be very distressing to witness and this is something which varies in each patient. Sadly, sometimes even when patients are receiving interventions to support their comfort, patients can become agitated or distressed, or experience symptoms. We therefore acknowledge the families account and to not wish to detract from what Mr B was experiencing and what the family went through. We recognise how difficult this must have been.
40. Mr B continued to be reviewed by the medical team at regular intervals, including over the weekend, and these reviews show consideration to Mr B’s comfort. There is no suggestion there were any delays in nutrition or medications being given in a timely manner to maintain comfort. Overall, we have not seen any omissions with the end-of-life care or an indication the Trust did not act in line with guidance. We were sorry to learn about Mr B’s subsequent deterioration and hope this information has been helpful.