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Selected Investigations Completed April - July 2000 > Part II, Case no. E.1476/99-00
Complaint against: Basildon and Thurrock General Hospitals NHS Trust
Complaint as put by Mrs X
1. The account of the complaint provided by Mrs X was that her husband, Mr X, had a cardiac arrest on 8 April 1998 and was intubated (a tube was passed down his windpipe to assist his breathing). On 13 June Mr X was admitted to Mary Wright ward at Basildon Hospital with a possible upper airway obstruction. Basildon Hospital is managed by Basildon and Thurrock General Hospitals NHS Trust (the Trust). On 15 June a nurse telephoned Mrs X to tell her that Mr X could go home. When Mrs X arrived in the ward a nurse told her that they were not certain what was wrong with Mr X. Mrs X asked to see a doctor and two doctors came. They told her that her husband had an out-patient appointment for 23 June at Orsett Hospital (which is also managed by the Trust) and that he could go home in the meantime. Mrs X was unhappy about that, and at her insistence the doctors agreed that Mr X should remain in the ward. On 17 June Mr X was transferred to Orsett Hospital but on 18 June he was transferred back to Basildon Hospital, where he had a CT scan and an emergency tracheostomy (an operation in which the windpipe is opened from the front of the neck so that air may obtain direct entrance into the lower air passages). Mrs X was concerned that the CT scan was not performed earlier. She raised her concerns with the Trust but was dissatisfied with their response; on 16 November she requested an independent review of her complaints, but that request was refused by the Trust's convener.
2. The matters subject to investigation were that:
(a) the initial decision on 15 June to discharge Mr X was inappropriate; and
(b) the subsequent management of Mr X's condition was unsatisfactory.
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Investigation
3. The statement of complaint for the investigation was issued on 17 January 2000. Comments were received from the Trust and relevant papers, including Mr X's clinical records, were examined. Two independent professional assessors—both consultant ENT surgeons—were appointed to advise on the clinical aspects of the case. Their report is reproduced in full at paragraph 6 of this report.
Complaints (a) the initial decision on 15 June to discharge Mr X was inappropriate and (b) the subsequent management of Mr X's condition was unsatisfactory
Mrs X's evidence
4. In a letter to the Ombudsman, sent in October 1999, Mrs X said that, on 13 June 1998 her husband was admitted to hospital with severe breathing difficulties. On 14 June Mr X was still having difficulty breathing and was making 'terrible noises'. On 15 June Mrs X received a telephone call from the hospital to say that her husband was to be discharged. Mrs X was unhappy about that. She went to the hospital and asked a nurse what was wrong with Mr X but the nurse said that staff were 'not certain'. Mrs X discussed her concerns about her husband's discharge with two doctors, and demanded that something was done that day; the doctors decided to keep Mr X in hospital. Mr X subsequently was transferred to Orsett Hospital, and Mrs X was told that he would have a scan. However, the scan was not carried out until 18 June, after Mr X had been transferred back to Basildon Hospital. Mr X also had an emergency tracheostomy that day. Mrs X believed that the scan should have been done sooner.
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Trust response to the statement of complaint
5. In his formal response of 3 February 2000 to the statement of complaint the Trust's acting chief executive wrote:
'During the ward round conducted by [a medical senior house officer (SHO)] on 15th June, [Mr X's] case was reviewed and it was decided in association with [an ENT (ear, nose and throat) associate specialist] that he could be discharged. It was noted that [Mr X] had an Outpatient appointment with [an ENT consultant] 8 days later on 23 June 1998.
'.... It is recorded that [Mrs X] was unhappy with this decision ....
'The .... decision .... was .... taken jointly, following assessment and agreement by appropriate medical staff. In response to [Mrs X's] anxieties .... [Mr X] .... was re-assessed by the medical team, and it was agreed that [he] should remain in hospital. Whilst [Mrs X's] concern over the original decision to discharge her husband is accepted, the Trust responded positively, in accordance with her wishes.
'During the period of 13-18 June 1998, [Mr X] was frequently assessed by a variety of specialists from many clinical disciplines .... [Mr X] had suffered with a very rare breathing problem .... appropriate care and treatment had been given following a logical diagnostic process to determine the best course of clinical care for [Mr X].
'.... The Trust has .... apologised unreservedly where shortcomings were apparent. .... It was also recognised that lessons could be learnt, and that these will be communicated widely.'
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Assessors' report
6. I reproduce next in its entirety the report prepared by the professional assessors appointed to provide clinical advice on the complaint.
Matters considered
Whether the decision to discharge Mr X on 15 June was appropriate, and whether the subsequent management of Mr X's condition was satisfactory.
Basis of the report
Relevant documents, including Mr X's nursing and medical records, were made available to us by the Ombudsman's Office.
Comments on the actions of medical and nursing staff
The assessors are commenting on the management of Mr X's airway, rather than other aspects of his care with regard to his heart attack.
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i. On 8 April 1998 Mr X was admitted to A&E in a state of cardiac arrest and was intubated. This was an entirely appropriate action in order to secure the airway and allow cardio-pulmonary resuscitation. It is uncertain how long the tube was in position for.
ii. On 13 June Mr X attended A&E. He was noted to have noisy breathing at the time and was seen by the on-call medical team who subsequently called an ENT surgeon to see Mr X. The medical SHO who saw the patient some hours after admission was concerned that the breathing difficulty might have been the result of the previous intubation of the airway at the time of the cardiac arrest and resuscitation. This concern is documented in the hand-written clinical notes. The ENT surgeon who saw the patient made a thorough examination of the airway and was able to see as far as the level of the vocal cords and did not detect any abnormality to this level. It would appear from his notes that the patient was breathing quietly and was not in stridor (noisy breathing when breathing in, indicating an upper airway obstruction). This change in symptoms is quite possible due to decreasing of inflammatory oedema (swelling from inflammatory leakage of fluid into the tissues). The notes do indicate that the pharynx (throat) was congested and the medical SHO had questioned in his notes whether inflammatory swelling of the epiglottis (part of the throat which prevents food and fluids entering the windpipe) was the cause of Mr X's symptoms. The latter was ruled out by the ENT surgeon. Unfortunately he did not consider a stricture (narrowing of the gullet) below the cords at this time. The case notes are clear and well written and the examination seems to have been thorough.
iii. On 14 June there appears to have been a period of noisy breathing which did not distress the patient and this apparently settled on nebulisers. Early in the morning of 15 June the nursing notes state that the patient suddenly developed stridor and was appropriately given Ventolin nebuliser and oxygen. Later on 15 June, the medical SHO carried out a ward round and, according to the acting chief executive's response to the statement of complaint 'in association with' the ENT associate specialist, decided Mr X could be discharged. We are uncertain exactly at what level this ENT opinion was given, as the hand-written notes make no mention of the associate specialist, only 'S/B (seen by) ENT SHO'. Later on the page there is an ENT note saying 'home today' with an illegible signature, and a nursing note 'seen by ENT doctors'. Mr X was to have an out-patient appointment to see an ENT consultant on 23 June. The sudden onset of stridor and subsequent resolution could have been due to a plug of mucus lodging temporarily in the area of the stricture.
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iv. Mrs X was unhappy at this decision by both medical and ENT SHOs to discharge the patient, and the notes indicate that the emphasis was on the ENT opinion in coming to that decision. In view of Mrs X's strong feelings on the matter, her husband was kept in and seemed to have a comfortable night. However, he still seemed to go in and out of stridor and on 16 June the medical team correctly decided, as a result of a study of lung air flow, that he should have a bronchoscopy (a procedure for viewing inside the windpipe) on 17 June. This bronchoscopy showed a severe tracheal stenosis (abnormal narrowing of the windpipe) and quite correctly an urgent ENT referral was requested.
v. As the problem with Mr X's airway was now clearly an ENT problem, the patient was transferred to the nearest ENT department which was in the neighbouring Orsett Hospital, where he arrived later that day. There is a hand-written note stating 'even the slightest increase in shortness of breath should be taken seriously and pulse oximetry done'. These instructions were entirely appropriate and underlined the precarious state of Mr X's airway. On arrival at Orsett Hospital instructions were given that Hydrocortisone (a steroid with anti-inflammatory action) should be administered if there was any increase in stridor. This would have had the effect of reducing the tissue fluid causing swelling (oedema) and was entirely appropriate.
vi. The patient had a comfortable night and the following day (18 June) an urgent MRI (magnetic resonance imaging—a non-invasive method of imaging the body) scan was requested. Because the scanner was at Basildon Hospital the patient had to be transferred again for his scan. While at Basildon Hospital an emergency tracheostomy was performed, presumably because it was felt unwise to transfer him yet again with an unprotected airway. Stenosis was found to be at the level of the second and third tracheal rings and the tracheostomy therefore had to be made particularly low to get below this. This seems to have been performed very satisfactorily and the airway was secured and made safe before his transfer back to Orsett Hospital. This was all entirely appropriate and correct.
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Comments
vii. Fortunately, post-intubation stenosis of the trachea is a rare event. Nonetheless, the ENT associate specialist should have been aware of this possibility, and in view of the history of Mr X going in and out of stridor the situation should have been taken more seriously and a more senior ENT opinion obtained on admission on 13 June. It was inappropriate to attempt to discharge Mr X on 15 June unless there had been a definite diagnosis of a cardio-pulmonary cause of shortness of breath and noisy breathing. Unfortunately it would appear that when the junior ENT surgeon (possibly only the SHO, though the associate specialist was at least consulted) saw the patient, Mr X was not having problems at the time and the junior ENT surgeon therefore was probably lulled into a false sense of security. This is understandable, given the level of his experience. If the associate specialist had seen the patient as well at this time, he too may well have come to the same conclusion. However, it is the history of the patient going in and out of stridor that should have alerted the ENT team to the instability of the situation; with the benefit of hindsight, a more appropriate decision would have been to admit Mr X to the ENT ward for observation. Perhaps a more senior opinion at this stage would have come to this decision. It is always easier to err on the side of caution in theoretical analysis, but much more difficult on the spot at the time. However, Mrs X should reasonably have expected staff to err on the side of caution.
viii. Once a diagnosis had been established by bronchoscopy on 17 June, appropriate and rapid action seems to have been taken. However, there were unnecessary delays in Mr X's management, not because of staff failings, but due to the need to transfer him from one hospital to another for investigations and hospitalisation in the appropriate department. This must add considerable risk to any patient in a similar condition to Mr X in the future. It is fortunate that the diligence of both nursing and medical staff involved in this case avoided any disaster arising and that the final outcome was satisfactory under the circumstances.
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Conclusion
ix. The decision to discharge Mr X on 15 June was inappropriate given the history, and fell below a standard which the patient could reasonably have expected in the circumstances. Mr X's upper airway problem was undiagnosed and its seriousness not adequately appreciated by junior medical and intermediate grade ENT staff by the time of the decision being made to discharge him on 15 June. The decision was probably appropriate to their experience. However, a more senior opinion should have been sought.
x. Bronchoscopy by a senior member of the medical team was entirely appropriate and a correct diagnosis rapidly made. The management subsequent to that was only unsatisfactory because of the lack of rationalisation of hospital services in the area, but the nursing and surgical teams carried out their tasks with an entirely appropriate sense of urgency and proficiency and prevented Mr X coming to grief under these difficult circumstances. A full and complete explanation and appropriate apologies have been given to Mrs X from the highest level in the Trust.
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Findings (a)
7. Mrs X complained that on 15 June she was told that her husband was to be discharged from hospital. She was concerned about that because he had severe breathing problems and staff did not appear to know the cause of his symptoms. Mrs X spoke to medical staff and it was agreed that Mr X should remain in hospital. In reaching my findings I have taken into account the assessors' report at paragraph 6. In his response to the statement of complaint, the acting chief executive accepted that Mrs X had been concerned about the discharge, and he said that staff had responded positively to her wishes. However, the assessors have advised me that the decision to discharge Mr X was inappropriate. They have said that Mr X's history of going in and out of stridor should have alerted the ENT team to the instability of the situation; Mr X's upper airway problem went undiagnosed, and the junior staff who attended him failed to appreciate the seriousness of the situation. The assessors concluded that a senior opinion should have been sought, and that the care provided fell below a standard that the patient could reasonably have expected. I uphold the complaint.
Findings (b)
8. The matter to consider here is whether or not Mr X's subsequent care was satisfactory. Mrs X was concerned that, despite her husband's symptoms, the decision to carry out a scan was not made until 18 June. The assessors have noted that on 16 June, following the results of a study of Mr X's lung airflow, the medical team correctly decided that he should have a bronchoscopy. That was performed on 17 June, and once it became clear that Mr X's problem required ENT treatment, he was transferred to the nearest ENT department. The assessors have said that Mr X's subsequent care was entirely appropriate. They have noted the potential risk posed by the transfer of patients between departments; I leave that matter for the Trust to consider. However, the assessors have noted that, despite such difficulties, the final outcome was satisfactory. In their opinion, the nursing and surgical teams carried out their tasks with an entirely appropriate sense of urgency and proficiency. I hope that Mrs X is reassured by that. I do not uphold the complaint.
Conclusions
9. I have set out my findings in paragraphs 7 and 8. The Trust have agreed to convey through my report—as I do—their apology to Mrs X for the shortcoming I have identified. Previous < Contents > Next
Short text of this investigation
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