15. Mrs C first attended hospital on 7 November with upper abdominal pains. An ultrasound took place, and this showed an abnormality in Mrs C’s gallbladder. Our Adviser has explained that this can represent a polyp (benign growth) or a gall stone. Blood tests indicated possible stones in the common bile duct and an MRCP scan showed that she had three gall stones.
16. The relevant guidance here is Gallstone disease, diagnosis and management, NICE, CG188. With regard to diagnosing gall stones this guidance says that patients should have blood tests and an ultrasound scan and that an MRCP should also be considered. The actions of the Trust in assessing and diagnosing Mrs C were in line with this guidance.
17. Mrs C was discharged from hospital on 9 November, and the plan was for her to have an ERCP as an outpatient and laparoscopic cholecystectomy (a surgical procedure to remove the gall bladder). The consultant colorectal surgeon wrote to Mrs C on 10 November to explain that they had booked her ERCP procedure as an outpatient and that a referral had been made for the gallbladder removal. This referral was sent the same day.
18. Mrs C was seen as an outpatient on 23 November to discuss the next steps. It was agreed that an ERCP was required and then a view would be taken on whether the laparoscopic cholecystectomy was required, depending on the outcome of the ERCP procedure to clear the stones.
19. The NICE guidance says that to manage gallbladder stones patients should be offered day case laparoscopic cholecystectomy, but that it should be offered within one week to patients with acute cholecystitis, which is inflammation of the gallbladder.
20. Acute cholecystitis can have a number of symptoms including a high temperature, sickness, sweating, loss of appetite, jaundice and stomach swelling but the main problem is sudden sharp pain in the abdomen that does not go away. Our Adviser has commented that Mrs C did not have the relevant signs of acute cholecystitis, and it was recorded that her symptoms had settled with conservative treatment. Mrs C did not report any further abdominal pains at the time of her outpatient appointment on 23 November, further indicating that she did not have acute cholecystitis, as the pain associated with this condition was not present.
21. Taking into account Mrs C’s presenting condition it was therefore in line with the NICE guidance that her ERCP and potential laparoscopic cholecystectomy were planned as an outpatient appointment in the future, and this was appropriately followed up with the initial appointment on 23 November.
22. We recognise Mr C’s concerns about Mrs C having a potential infection. Our Adviser has commented that Mrs C’s clinical symptoms had improved by the time she was discharged, but we cannot say with any certainty whether there was any infection present. Our Adviser has explained there was no evidence of sepsis in the bile ducts and the fact that Mrs C’s symptoms resolved, and she was well when she attended the appointment on 23 November, indicates that any infection did not have any impact.
23. We understand that Mr C feels the surgery should have taken place at the time of Mrs C’s initial hospital admission. Based on the evidence we have seen it was appropriate that Mrs C was referred for further treatment as an outpatient and the assessment, diagnosis and decisions made were in line with the relevant guidance.
24. We are sorry to read that Mr C feels decisions were negatively influenced by Mrs C’s age, that she was dismissed and that communication was poor. As we consider the decisions made to have been appropriate, we hope we are able to offer some reassurance that decisions were made based on Mrs C’s condition, and in her best interests, rather than her age.
25. We cannot say what discussions took place while Mrs C was in hospital, although it was recorded that Mrs C wanted to return home, indicating that discussions about her care had taken place. The surgeon wrote to Mrs C on 10 November detailing the results of her tests and the next steps.
26. GMC good medical practice guidance sets out the expectations of good communication and says that patients must be given the information they need in a way they can understand. We have seen evidence of conversations with Miss C and the detailed letter after discharge provided her with all the relevant details about her condition. We are satisfied Mrs C was provided with appropriate information that was in line with the GMC guidance.
27. Mrs C returned to hospital on 26 November with severe abdominal pains. Our Adviser has explained that further episodes of pain as Mrs C experienced are a recognised problem while patients wait for an ERCP procedure. This must have been very distressing for Mrs C, and she received relevant pain relief which eased her symptoms. When Mrs C was admitted, it was recorded that she had an ERCP procedure already booked on 30 November.
28. On 27 November Mrs C was reported to be in less pain, and it was decided that she would remain in hospital until her planned ERCP procedure. Mrs C’s observations remained normal with a NEWS score of zero on 29 November. NEWS is the National Early Warning Score and determines the level of illness of a patient.
29. We recognise it must have been difficult and upsetting for Mrs C to be back in hospital with further pain. There is no specific guidance which sets out the required urgency of an ERCP procedure. Mrs C was in a stable condition whilst in hospital from 26 to 30 November and our Adviser has commented there was no evidence of cholangitis (infection of the biliary tree) or jaundice. Bearing this in mind, it was appropriate that Mrs C’s ERCP procedure went ahead on the previously planned date.
30. Mrs C had the ERCP on 30 November. Our adviser has explained that the complication she experienced was a perforation of the duodenum. This is an uncommon but recognised serious complication of ERCP which includes a range of situations from perforation of the duodenum with a wire to a full tear of the duodenum. Our Adviser has commented that it was most likely to have been a wire perforation as it was not noted at the time of the procedure, and major tears are more likely to be seen. The complication occurs because of mechanical trauma from the scope, wire or instruments passed through the scope.
31. It was extremely unfortunate that Mrs C experienced this complication. Our Adviser has commented that anatomically, it is more likely than not, that Mrs C would have been in the same position had the ERCP taken place earlier, and therefore we are not able to say that having the procedure earlier in the admission, would have made any difference, as the same complication could have occurred.
32. Mrs C’s condition deteriorated the day after her surgery. Further investigations and blood tests took place, and it was recorded that Mrs C had a possible perforation. A CT scan was completed early on 2 December followed by an urgent laparotomy (abdominal surgery) the same morning.
33. GMC good medical practice sets out the expectations when treating a patient in these circumstances and says that doctors should adequately assess a patient’s condition, promptly provide or arrange suitable advice, investigations or treatment and refer patients to another doctor when this serves their needs.
34. Mrs C deteriorated after her ERCP procedure and appropriate action was promptly taken to identify the problem, which ultimately led to the surgical team undertaking a laparotomy. Based on the evidence we have seen we are satisfied that Mrs C received appropriate treatment to try and resolve the problems caused by the duodenal perforation and that this treatment was in line with the relevant guidance. We are sorry to hear how traumatic this time was for Mr C.
35. Regarding the surgery itself our Adviser has explained there was a concern that Miss C would have a hostile abdomen because she had previously undergone a midline laparotomy and this wound had been reopened two more times. A hostile abdomen is where a patient has extensive internal scarring because of previous surgery and/or inflammation, and it makes further surgery more difficult and riskier.
36. Our Adviser went on to explain that in Mrs C’s case she did indeed have a hostile abdomen which made dealing with her duodenal perforation more difficult than normal. The surgeon undertaking her laparotomy was unable to remove her gall bladder and all he was able to do was try and achieve effective drainage at the site of her duodenal perforation. In limiting what he did the surgeon would have considered the risk of creating further injuries to Mrs C, the stability or instability of her condition under anaesthetic and the possibility of getting her safely through the operation and on to a recovery pathway.
37. As explained above, we are satisfied that the decisions made were appropriate and in line with the relevant guidance and therefore we are not persuaded that Mrs C’s age negatively influenced these decisions.
38. Mr C has said that staff spoke with his brother rather than himself as the next of kin. It is recorded that Mr C’s brother called the hospital on 2 December for an update on Mrs C’s condition and checked that the hospital had the relevant telephone numbers for both brothers. On 10 December, a conversation took place with Mr C’s brother at the hospital about Mrs C’s ongoing prognosis and details about ongoing treatment were discussed with both brothers by telephone on 13 December before and after a tracheostomy (an opening in the neck to aid breathing). Mr C discussed Mrs C’s condition with the hospital team again on 16 December and it was noted on 22 December that both sons had been updated.
39. GMC good medical practice guidance says that doctors must be considerate to those close to the patient and be sensitive and responsive in giving them information.
40. Whilst we have reviewed the medical records to understand the contact with Mrs C’s family, there are likely to be further interactions which are not recorded. We appreciate Mr C’s strength of feeling about being the recorded next of kin for Mrs C and the notes confirm that he was recorded as the next of kin.
41. It was reasonable for staff to update Mr C’s brother when he was at the hospital, and we have not seen any evidence to suggest that Mr C’s brother received different or prioritised information. Based on the evidence we have seen we are satisfied that communication with Mr C was appropriate, was in line with the GMC guidance, and that he was involved in important discussions.
42. Mr C has also said he is unhappy with the Trust’s handling of his complaint and that he felt dismissed. We are sorry to hear that Mr C felt this way, as this must have been a very difficult time for him.
43. Mr C initially complained in January 2024 and received a response in July 2024. He complained again and the Trust provided its final response in November 2024.
44. The NHS complaints standards say that when investigating complaints NHS organisations should give an open and honest answer as quickly as possible and give fair and accountable responses that set out what happened and whether mistakes were made. We acknowledge that the responses from the Trust took time, but the responses were a detailed and accurate account of the events and answered all of Mr C’s questions. The responses provided were in line with the expectations of the NHS complaints standards and suitably addressed Mr C’s concerns within a reasonable timescale.