4. Mrs A complains about aspects of the care and treatment her father, Mr B, received from the Trust on 3 and 4 October 2024. She says the Trust did not assess her father properly and should not have allowed him to eat solid food.
5. Mrs A says this led to his deterioration and death. It has left a lasting impact on her and her family.
6. Mrs A seeks service improvements and a financial remedy.
7. Mr B had a medical history of hiatus hernia (part of the stomach moves upwards into the chest by pushing through a small opening in the diaphragm), Barrett's oesophagus (a condition where the lining of the food pipe changes because it has been irritated by stomach acid reflux for a long time), high blood pressure and central retinal vein occlusion (clot in the vein of the eye).
8. He attended A&E on the evening of 3 October after vomiting black vomit for two days. He also had fluctuating nausea and a cough.
9. Blood tests showed Mr B was dehydrated, and a chest X-ray was suggestive of an infection.
10. The Trust arranged a digital rectal examination which did not show black tarry stool. If this was present it would usually be a sign of upper gastro-intestinal (GI) bleed called melaena.
11. The doctors still considered whether there was bleeding, and he was admitted to a medical ward for on-going management of his nausea, vomiting and dehydration. The Trust planned for a review by the gastroenterology team.
12. The Trust gave intra-venous (IV) fluid, anti-sickness medication, antibiotics, and antacid medication to help protect the lining of the stomach.
13. The Trust kept Mr B nil-by-mouth for the first night until the gastroenterology team had reviewed him in case he needed a camera test of the stomach.
14. The gastroenterology team reviewed him on 4 October. They said there was no evidence of an upper GI bleed because there was no melaena or haematemesis (fresh blood in his vomit). They decided he did not need the camera, and he was able to eat and drink.
15. Later that day, Mr B vomited after eating his lunch. He deteriorated with low oxygen saturation level, requiring supplementary oxygen and he had a fast heart rate.
16. A repeat chest X-ray showed marked progression of right lung consolidation, suggestive of aspiration pneumonia.
17. The surgical team reviewed Mr B in the afternoon on 4 October because doctors suspected a bowel obstruction was a cause for the on-going vomiting. He had no immediate surgical plan, and the medical team were continuing treatment for aspiration pneumonia.
18. The Trust arranged a CT scan of the abdomen, but Mr B became too unwell for it to take place. He deteriorated and sadly died.
23. 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 have not found any indications that something has gone wrong.
24. Firstly, we considered whether the Trust assessed Mr B’s condition for vomiting blood as they should have done.
25. The process is set out in NICE guidance. It is designed to quickly identify life-threatening bleeding while safely redirecting low-risk patients to outpatient care. It says a GI bleed should be considered in patients vomiting blood or passing black, tarry, foul-smelling stools. It says to monitor observations and carry out a rectal examination if the diagnosis is uncertain.
26. NICE guidance says to use formal scoring tools to determine the urgency of intervention and whether the patient requires admission. Glasgow-Blatchford Score (GBS) decides if a patient needs admission or can be discharged for outpatient follow-up. It refers to low risk patients scoring zero to one, being suitable for early discharge. Scores above two and six mean a hospital admission and further tests.
27. When the gastroenterology team reviewed Mr B on 4 October, they followed NICE guidance and concluded that he was unlikely to have an upper GI bleed based on his score and his symptoms. Mr B’s GBS was zero and he was considered low risk. They decided that he did not require an in-patient stomach camera test.
28. We also looked at Good Medical Practice. It says doctors must provide a good standard of practice and care, if they assess, diagnose or treat a patient, they must adequately assess the patient’s conditions, taking account of their history, their views and values, where necessary, examine the patient. They must promptly provide or arrange suitable, investigation or treatment.
29. Our adviser helped us understand that vomiting in older male patients, can be caused by a wide range of issues. For example, gastroenteritis, infections, obstructions, inner ear disorders, gastroesophageal reflux, ulcers, and tumours.
30. We have seen evidence the Trust explored the possibility of an infection, and the chest X-ray showed changes compatible with this. It also suspected a gastro-intestinal malignancy and arranged a CT scan.
31. It appears the Trust carried out an appropriate assessment of Mr B’s condition, in line with the relevant guidance.
32. We then considered whether the Trust should have assessed Mr B’s swallow before allowing him to eat solid food.
33. Aspiration pneumonia occurs when gastric contents (food, liquids, or vomit) are inhaled into the airways, leading to inflammation and infection. Solid food increases the risk of choking rather than aspiration.
34. The National library of medicine journal says old age and frailty increases the risk of aspiration, especially if the person is unwell. There are two main ways people aspirate:
• inhaling the food while they are eating when the food goes the wrong way into the trachea (the wind pipe) instead of the oesophagus (the food pipe) • gastric content going up (by vomiting or reflux) then goes down the trachea. You do not need to eat solid food for this to happen.
35. Our adviser helped us understand the timing and necessity of a swallow assessment depends on the patient’s diagnosis and clinical symptoms.
36. The most rigid and time-sensitive requirement is for stroke patients. For others, specific red flags or high-risk conditions would trigger the assessment.
37. RCSLT resources and information about dysphagia refers to patients with the following conditions, who should be assessed for swallowing safety as part of their initial nursing or medical assessment:
• neurological disorders such as Parkinson’s disease, Motor Neurone Disease (MND), Multiple Sclerosis, or Myasthenia Gravis • dementia and delirium • reduced consciousness • head and neck cancers • intubated patients.
38. It also refers to patients who show the following signs during their hospital admission, requiring an urgent referral to Speech and Language Therapy:
• coughing or choking during or immediately after eating or drinking • a wet or gurgly voice after swallowing • recurrent chest infections • food pocketing (holding food in the cheeks or mouth for long periods) • drooling or inability to manage saliva.
39. Our adviser helped us understand that hospitals restrict solid food before surgery, some diagnostic and imaging tests and during some medical emergencies.
40. We know Mr B did not have any signs or symptoms of a stroke or any of the above high-risk conditions. The Trust initially withheld food when it was deciding whether to send Mr B for a camera test, which was solely for the purposes of the imaging test and not because of his condition.
41. We have not seen any indication that the Trust should have assessed Mr B’s swallowing before allowing him to eat.
42. Mr B’s vomiting initially settled after treatment with anti-sickness medication, and there was no indication that he should not have eaten solid food. He did not fit the criteria for any of the reasons set out in the relevant guidance.
43. We know it was distressing for Mrs A finding out that her father had vomited after eating his lunch and deteriorated afterwards. We can see how this led to her concerns.
44. We cannot say, even on the balance of probabilities, that eating food led to the aspiration pneumonia. We know that Mr B vomited, and the National library of medicine journal tells us this is more common in old age and frailty, especially if the person is unwell.
45. We have seen nothing to indicate that the Trust should have carried out a swallow test or not allowed Mr B to eat any food.
46. We recognise the upset and distress these concerns have caused Mrs A. We are mindful of how important her complaint is to her and the difficult experience she has had. We hope our decision on what happened can bring some closure to this sad event.
1. We have carefully considered Mrs A’s complaint about Royal Devon University Healthcare NHS Foundation Trust (the Trust). We are sorry to hear about the events that led to Mrs A’s complaint. We recognise this has been an upsetting time for her.
2. We have seen no indication anything went wrong when the Trust assessed Mr B and allowed him to eat solid food.
3. This means we have decided not to consider this complaint further. We have explained the reasons for our decision within this statement.