Complaint about timing of MRI scan
20. The suspected cancer guidance says that where adults have a sub-acute loss of central neurological function, doctors should consider an urgent MRI scan of the brain to be done within two weeks.
21. On 27 September, Mr B was experiencing loss of neurological function, as he had been unsteady on feet, forgetful and bumping into things. This must have been very worrying for Mr and Mrs B so soon after his lung cancer diagnosis. In line with the guidance, he should have had an MRI scan within two weeks.
22. On that date, the doctor planned for him to have an urgent MRI scan of his brain. They requested the scan using the Trust computer system which has three prioritisation categories. These are routine, urgent, and 2ww/FDS.
23. The Trust told us the doctor made this referral for a scan using the ‘urgent’ category. The Trust explained this category is for referrals it aims to book in about three to four weeks.
24. The highest priority category on its system was 2ww/FDS. 2ww is two week wait and FDS is faster diagnosis standard. They relate to the target for patients with suspected cancer to be seen within two weeks of urgent referral and to have cancer diagnosed or ruled out within 28 days.
25. The Trust has confirmed the doctor selected the ‘urgent’ option as they were not fully aware of the different priority categories at that time. They requested the MRI scan as urgent, under the impression this was the most urgent form of request.
26. Considering the titles given to the prioritisation options, we can understand how this error happened. The options on the system are not clear as regards their urgency.
27. Making a referral for a scan to be completed within three to four weeks, was not in line with the suspected cancer guidance. This is a failing.
28. In line with the suspected cancer guidance, if the MRI scan had been requested with the correct level of prioritisation, the scan should have been completed by 11 October.
29. Sadly, Mr B was admitted to the ED with a brain haemorrhage, experienced a seizure and died on a day in October. As this admission was before the scan should have taken place, we cannot link the failing with those events. This means we have not found the failing had any clinical impact on Mr B.
30. We recognise how stressful and upsetting this period was for Mr and Mrs B, knowing he had advanced lung cancer and waiting to hear if this had spread to his brain. As we have not found the failure in selecting the scan prioritisation led to any delays, we cannot say it caused any additional distress to Mr and Mrs B over and above what they were already experiencing.
31. We are pleased to see the Trust are making changes to its priority request selections to make these clearer.
Complaints about the ED visit
Timing of assessment/review:
32. RCEM initial assessment guidance says triaging of patients should usually be done within 15 minutes of arrival at the ED. RCEM best practice guideline says there should be a process for rapid treatment of time critical conditions. It says Trusts should consider a process for rapid management of specific conditions such as stroke.
33. It says patients should be assessed according to two main factors, their suspected diagnosis and acuity. Acuity is a measure of the severity of the patient’s condition and the urgency with which they need to be seen and assessed by a suitably qualified clinician.
34. Mr B arrived at the ED at 1.16am and was triaged eight minutes later. Due to having right sided weakness and difficulty communicating. A CT scan was completed shortly after, and a stroke specialist assessed him approximately half an hour after triage. These were timely assessments and in line with the guidance.
35. On assessing him at 2am, the stroke specialist considered a stroke was unlikely and that Mr B had likely experienced a brain bleed. From the records, it appears the radiology team had telephoned the ED to report the brain bleed on the CT scan. However, it is not clear if the severity of this had been communicated at that stage. The report of the CT scan was not available until 3.09am.
36. Following their assessment, the stroke specialist referred Mr B to the medical team for further management. This was in line with GMC good medical practice which says to refer a patient to another practitioner when this serves their needs.
37. Our ED adviser said that if someone has a bleed on the brain, their acuity is very high. This means they have a life-threatening condition and are at risk of rapid deterioration. Due to the nature of Mr B’s condition, a doctor should have seen him within no more than 30 minutes.
38. Due to their need for immediate emergency care, patients with a bleed on the brain should be transferred to the ‘Resus’ area of the ED. This is the resuscitation area where patients receive a higher level of monitoring and have intervention from a senior doctor.
39. The records show the medical team accepted the referral from the stroke specialist at 2.30am. Despite this, they did not review Mr B for almost two hours and only when the family pressed the emergency call bell as Mr B began having a seizure.
40. This is not in line with the RCEM best practice guidance and is failing.
Monitoring of condition
41. There are two ways the Trust were monitoring Mr B during his attendance at ED. These are:
• level of consciousness, using the GCS which gives a total score out of 15 when considering eye, verbal and motor responses.
• physiological observations (breathing rate, oxygen saturation level, blood pressure, pulse rate, level of consciousness and temperature)
42. The Trust GCS policy says that where the GCS is below 15, they should be performed and recorded on a half hourly basis until a score of 15 is achieved. There should be urgent reappraisal by the supervising doctor when there is a drop of 2 or more points in the motor response.
43. RCP guidance says NEWS is based on a scoring system using physiological observations. The total score indicates the risk of a patient deteriorating and the level of response required.
44. It says where a patient scores 3 in a single parameter, nursing staff should inform the medical team who will review the patient and decide if escalation of care is required. NEWS should be repeated hourly.
45. At 1.24am, a nurse calculated Mr B’s GCS score as 13. This was due to a reduced verbal response. At 2am when assessing Mr B, the stroke specialist repeated the GCS with the score remaining at 13.
46. Nurses repeated this at 2.30am and it had reduced to 11. This was due to a two-point drop in the motor response. In line with the Trust’s GCS policy, this should have prompted the nurse to urgently request a supervising doctor review Mr B. The GCS should have been repeated 30 minutes later.
47. We have seen no evidence the GCS was repeated when it should have been or that the reduced GCS was escalated to doctors.
48. Turning to the monitoring of his physiological observations, at triage Mr B’s NEWS was one. This was repeated at 2.20am when it was four. This included a score of three for confusion.
49. In line with the RCP guidance, due to this score of three in one parameter, the nurse should have informed the medical team. We know that around the same time, the stroke specialist was reviewing Mr B and had referred him to the medical team.
50. This NEWS was a further opportunity for the medical team to have been made aware of Mr B’s clinical picture and his need for urgent review. Nursing staff should also have repeated the NEWS within an hour.
51. We have seen no evidence staff did either of these things until the family pressed the emergency call bell almost two hours later. This is a failing in the Trust’s monitoring of Mr B.
Seeking specialist input from another hospital
52. GMC guidance says doctors should consult colleagues where appropriate. They should promptly provide or arrange suitable advice, investigations or treatment where necessary.
53. Our ED adviser said there are some brain bleeds which can be solved by neurosurgery and others which cannot. A patient with a bleed needs urgent neurosurgical input to assess this. This should be done almost immediately at the time of the medical review. We consider this would be in line with the GMC guidance.
54. On reviewing Mr B, the stroke specialist identified there may be a need for neurosurgical referral once the CT scan report was received. The CT report was provided at 3.09am and this also indicated he needed an urgent neurosurgical referral.
55. As set out above, Mr B should have been reviewed by a doctor by around 3am. This would have coincided with the CT scan report being available. A referral should have been made to neurosurgery almost immediately at that time, following the Trust’s usual pathway.
56. However, as doctors did not review Mr B until 4.15am when he had a seizure, they did not make this referral until 4.40am. This is a failing which is associated with the delay in reviewing Mr B.
Treatment
57. Mrs B is concerned there were delays in her husband receiving Keppra and dexamethasone medications.
58. GMC guidance says doctors should promptly provide or arrange suitable advice, investigations or treatment where necessary. They should prescribe drugs or treatment only when they are satisfied the drugs or treatment serves the patient’s needs.
59. Our ED adviser said dexamethasone is given to a patient if there is oedema (swelling) in the brain. It helps to reduce the swelling, which along with the bleed, is causing pressure in the skull.
60. The CT scan identified Mr B had oedema as well as the bleed in the brain. This means, in line with the GMC guidance, he should have received dexamethasone. We have already set out how there were delays in doctors reviewing Mr B.
61. Due to this delayed review by doctors, there was also a delay in him receiving dexamethasone. This was not in line with the GMC guidance and is a failing.
62. Turning to Mrs B’s concern about Keppra. Our ED adviser said it would not be standard practice to give Keppra to someone experiencing a haemorrhage to prevent them potentially having a seizure. Our physician adviser said most people with brain bleeds, even significant ones, do not go on to have seizures.
63. The records show doctors administered Keppra to Mr B once he began having a seizure. This was in line with the GMC guidance. We have seen nothing to indicate he should have been prescribed it prior to having the seizure.
Impact of the failings
64. As set out above, we have found found failings in the timing of medical review, monitoring of Mr B, administering of dexamethasone and referral to neurosurgeons.
65. We can see that if doctors had reviewed Mr B earlier, at around 2.30am to 3am, they would have referred him to neurosurgeons and administered dexamethasone. Our ED adviser said they may also have taken steps such as blood pressure management and body positioning to try to optimise the situation. These are steps to try to reduce the pressure within the skull.
66. Although dexamethasone reduces swelling, it does not work instantly. Our ED adviser said it begins to work after approximately an hour. This means it may have started to have some effect on the swelling by about 4am. However, even with the other possible measures outlined above, it would not have prevented the build-up of pressure. This is because it could not prevent the continued bleeding which was still happening.
67. Mr B was taking blood thinning medication. This meant that once the bleed began prior to his admission, it would have continued. This added to the pressure within his skull causing further damage to his brain.
68. The CT scan was completed shortly after arrival at the ED and showed his brain was already herniating due to the pressure within the skull. This is where brain tissue is displaced from its normal position due to increased pressure within the skull. This leads to compression of vital structures within the brain.
69. Our physician adviser said this situation was not salvageable with surgery. Due to the herniation of the brain which had already occurred, his advanced lung cancer, the neurological symptoms, and his risk of uncontrollable bleeding during surgery, neurosurgeons would not have operated on him.
70. Mr B’s condition was not treatable or reversible. It was a catastrophic final event which was most likely related to cancer. Sadly, he would have died during this attendance at ED even if these failings had not happened.
71. Sadly, the bleed Mr B experienced before his admission meant he died quite suddenly and without the opportunity to make plans and decisions about the last period of his life. We recognise how distressing this was for his family. Although we have not found these events were in any way avoidable, we recognise the failings have had a significant emotional impact on the family.
72. Seeing Mr B so unwell at the ED and without timely medical review, monitoring or treatment was distressing for his family, at a time they should have felt supported. The failings have contributed to their loss of confidence in the NHS.