Discharge from ED
17. On 24 November 2024 Miss E attended the Trust’s ED. Miss E was presenting with pain when passing urine, for which she had been taking nitrofurantoin (an antibiotic). She informed staff she was experiencing pain in her left abdomen and lower back and feeling unwell with nausea and vomiting.
18. Staff examined Miss E. They acknowledged Miss E’s pulse was slightly raised at 105 beats per minute (the normal range for an adult’s pulse is 60 to 100 beats per minute). The Trust also noted she was said to be tender on her left side.
19. As such, the Trust recorded Miss E to have a NEWS2 score of one. The NEWS2 scoring system is used in hospitals to assess how unwell a patient is based on their vital signs. A score of one indicates very low clinical risk.
20. The ED staff performed a urine dipstick, a pregnancy test, and took Miss E’s bloods.
21. The Trust suspected possible urinary tract infection (UTI) and staff administered oral paracetamol, oral cyclizine (anti-sickness medicine), intra-venous gentamycin (antibiotics), intravenous ondansetron (anti-sickness medicine) and Buscopan (medication used to soothe cramps and spasm).
22. ED staff discussed Miss E’s care with the urology registrar (a senior doctor), who advised contacting the GP to expedite her urology outpatient referral. The Trust then discharged Miss E from the ED with a short course of trimethoprim (antibiotics).
23. In discharging Miss E, staff gave her advice regarding ‘red flag signs’, making her aware to return if necessary. Red flag signs are symptoms that may indicate someone has a serious underlying condition.
24. On 28 November Miss E attended her GP after one week with UTI symptoms and pain in her left side. She said she was vomiting and clammy. Staff recorded her pulse to be 115-130 beats per minute and that her urine was cloudy and concentrated.
25. Staff performed a urine dip, which indicated an infection with the presence of leucocytes (white blood cells that the body produces as part of an immune response to infection). At this stage the GP suspected Miss E may have pyelonephritis. This is a type of kidney infection and as such, the GP referred Miss E back to the Trust’s ED for further tests.
26. Within 15 minutes of her arrival to ED, Miss E was assessed by the triage nurse who noted Miss E’s recent UTI diagnosis and use of antibiotics. Given her vital signs, ED staff considered Miss E to be a NEWS2 score of three (still a low score with medium clinical risk).
27. A doctor assessed Miss E in the ED. The doctor reviewed Miss E’s background of repeated UTI’s, recent ED attendance details and GP referral. Miss E reiterated the symptoms she had been experiencing to the doctor and said the antibiotics had not seemed to make much difference.
28. Miss E made the doctor aware she was waiting for a gynaecology appointment for a cyst on her left ovary, which was attached to her uterus, as well as a left renal cyst identified on CT scan earlier in the year.
29. The ED notes show the doctor assessed Miss E as well with no active vomiting. The Trust performed a second urine dip. It showed no leucocytes, nitrites (a substance that can indicate urine infection) or blood. The Trust noted the GP letter reporting cloudy urine with leucocytes.
30. The Trust further investigated Miss E’s symptoms with blood tests and a bladder scan.
31. Staff administered Miss E with intravenous fluids, intravenous ondansetron (anti-sickness medicine) and per-rectum diclofenac (potent pain relief and anti-inflammatory drug).
32. The ED staff discussed Miss E with the urology registrar on call, with a review of her history, urinalysis, blood results, scans and imaging. The registrar did not feel further imaging or antibiotics would be useful at this point.
33. Staff explained this to Miss E who was upset that she had not got any further with identifying a cause for her symptoms. The Trust gave her tramadol (painkiller) and cyclizine (anti-sickness medicine) to take at home if this was required.
34. The Trust discharged Miss E with an outpatient pelvic ultrasound scan booked and advice to return if her symptoms worsened.
35. In determining what the Trust’s actions should have been in this situation, we have taken on board clinical advice from our adviser.
Our adviser directed us to the relevant guidance. GMC Good Medical Practice says at section 7:
In providing clinical care doctors must:
a)adequately assess a patient’s condition(s), taking account of their history, including I.symptoms II.relevant psychological, spiritual, social, economic, and cultural factors III.the patient’s views, needs, and values b)carry out a physical examination where necessary c)promptly provide (or arrange) suitable advice, investigation or treatment where necessary d)propose, provide or prescribe drugs or treatment (including repeat prescriptions) only when you have adequate knowledge of the patient’s health and are satisfied that the drugs or treatment will meet their needs e) propose, provide or prescribe effective treatment based on the best available evidence
36. Our adviser explained that in accordance with these guidelines, the Trust investigated Miss E’s symptoms appropriately. On 28 November Miss E presented with pain on passing urine, nausea and worsening pain in her left flank. From the records we can see the Trust considered her medical history, took her temperature and bloods, performed a urine dip and a bladder scan.
37. Having obtained the available evidence, our adviser confirmed the Trust provided reasonable treatment in pain relief and anti-sickness medication. The doctor also arranged for suitable advice and investigation in referring Miss E for a pelvic ultrasound following her discharge.
38. Having seen the records, our adviser explained that the appropriate tests were performed given the suspected pyelonephritis. They explained that Miss E did not report symptoms of a fever, and her temperature was measured twice as normal in ED. They explained, according to the Oxford Handbook of Emergency Medicine, it is appropriate to diagnose pyelonephritis if there is evidence of UTI with loin pain and temperature.
39. Miss E’s urine dip was negative for blood, leucocytes and nitrites when staff tested this in ED, although staff noted the earlier results collected by the GP with cloudy urine and leucocytes. Our adviser explained that Miss E’s blood tests were appropriately performed by ED staff, and these showed normal white cell count and normal kidney function.
40. Given these results and her presentation, our adviser explained that it was reasonable for the Trust to assume Miss E did not have pyelonephritis.
41. Our adviser recognised that Miss E had a raised pulse during her time in the ED, which contributed to ED staff considering Miss E to have a NEWS2 score of three. However, they explained that there were several possible causes for this. They suggested that it was appropriate to consider Miss E of low clinical risk at this stage, meaning that the Trust’s decision to discharge her was acceptable.
42. We appreciate that this experience was stressful for Miss E and that not knowing the cause of her pain and symptoms must have been very frustrating. We have found no indications that the Trust did anything wrong in discharging her from ED. This is because there was no indication Miss E had a problem that required urgent treatment, and she could wait for further outpatient tests.
43. We appreciate Miss E felt unsafe to go home as she was in a lot of pain. We note the Trust prescribed pain relief to help her manage her pain at home. The Trust also gave appropriate advice for Miss E to come back to ED if she became more unwell.
Internal pelvic scan
44. As we have already outlined, in attending the Trust’s ED Miss E presented with pain when passing urine, pain in her left side and feeling generally unwell. Following the various tests for a UTI and the failed use of antibiotics, the Trust ruled this out.
45. The ED staff discussed Miss E’s case with the urology registrar, with the recorded conversation detailing a review of her history, urinalysis, blood results, scans and imaging. The urology doctor did not feel that further imaging of the bladder was needed. The ED doctor therefore followed this advice, planning further investigation with a pelvic ultrasound scan.
46. Following the referral made by the ED doctor, on 5 December Miss E attended the Trust, and staff performed the scan. This was preformed using a transvaginal probe and it showed a likely bicornate uterus with ovaries appearing normal in size, shape and texture.
47. We see a note in the records from the ultra-sonographer (a healthcare professional who uses ultrasound equipment to create images of patients’ internal organs) that following the scan, Miss E told her that she expected a urinary bladder scan instead of a transvaginal scan.
48. We see from the sonographer’s notes she explained the procedure to Miss E prior to performing it and explained to Miss E how the request and symptoms indicated a transvaginal scan was appropriate.
49. We see the records confirm this, as the doctor who discharged Miss E on 28 November noted that he had requested an outpatient ultrasound scan of Miss E’s pelvis. The doctor detailed Miss E’s clinical history as part of this request, stating Miss E had a known ovarian cyst and that antibiotics for a UTI and its symptoms had not helped.
50. We understand that Miss E states that this was an error as she was not known to have an ovarian cyst, rather a renal cyst identified on CT scan earlier that year. However, we do see from the records on 28 November Miss E described awaiting a gynaecology appointment for a cyst on her left ovary.
51. Having considered Miss E’s symptoms and presentation in ED on 28 November, our adviser explained in ordering and performing the pelvic ultrasound the Trust made appropriate steps to further investigate Miss E’s ongoing symptoms.
52. As the cause of Miss E’s symptoms were unknown, it was in line with GMC guidance to arrange suitable advice and investigation in the form of a pelvic ultrasound scan.
53. Our adviser acknowledged that the ED doctor appropriately took on board the opinion of a urology specialist in not undertaking a scan of Miss E’s bladder. Our adviser also noted the ultra-sonographer acted in line with the referral made by the ED in carrying out a pelvic ultrasound scan.
54. The adviser highlighted that NHS guidance on ovarian cysts says they are observed by ultrasound scans, carried out by using a probe placed in the vagina. This indicates the Trust requested the right type of scan.
55. We do recognise Miss E’s concerns about the need for this type of ultrasound being communicated to her effectively. We appreciate it was stressful having such an invasive procedure when she was not expecting this.
56. The clinical records say the doctor had a discussion with Miss E about the plan going forward from her discharge on the 28 November, prescribing pain relief and clearly documenting the need for a pelvic ultrasound. However, it is unclear what was said exactly between the doctor and Miss E. It is unclear if the doctor clearly explained that the pelvic ultrasound would be carried out using a transvaginal probe.
57. For this reason, it would be impossible for us to determine whether there were indications of failings in the communication of the doctor to Miss E at this point. We do see that the sonographer explained the procedure to Miss E prior to it taking place.
58. We see no indications that a went wrong in referring and performing a pelvic ultrasound. We recognise we cannot give a view on whether the doctor adequately communicated to
59. Miss E about what the scan would entail. There is no evidence we could obtain to allow us to make an independent decision. We recognise Miss E was not expecting an internal scan with a transvaginal probe and this was stressful for her. We are reassured the sonographer took appropriate steps to explain what the scan entailed before performing it.
60. Overall, we have seen no indications of failings and so we will take no further action on this complaint.