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Selected Investigations Completed August 2001November 2001 > Part II, Case no. E.1596/00-01
Complaint as put by Mrs X
1. The account of the complaint provided by Mrs X was that on 28 May 1999 her mother, Mrs Z, who was 86 and who suffered from an infected right bunion, was seen by a consultant vascular surgeon (the first consultant) at Southend Hospital (the hospital). The hospital is managed by Southend Hospital NHS Trust (the Trust). Mrs Z had a history of circulatory problems, and had had her left leg amputated six years earlier. The first consultant suggested an urgent angiogram (radiological investigation of the blood supply), but that was not carried out until 30 June, and the results were not available for a further two weeks. On 16 July the first consultant said that Mrs Z had a ‘blockage’ in her right upper leg, and an urgent angioplasty (surgery to improve the blood supply) would be carried out. On 26 July Mrs X was told that admission for her mother’s angioplasty had been arranged for 11 August. She asked for that to be brought forward, but her request was refused. Mrs Z’s GP referred her to the accident and emergency (A&E) unit at the hospital that day. She was seen by two doctors, but was sent home. On 11 August Mrs Z was admitted; by that time, one of her toes was gangrenous. On 12 August angioplasty was carried out and amputation of Mrs Z’s toe was scheduled for 16 August. However, the surgery was postponed twice. On 19 August a ‘below knee’ amputation of the right leg was performed. Mrs X believed that if the surgery had taken place sooner, amputation might have been limited to the toe only. Following surgery, Mrs Z developed a chest infection. However, she was not nursed in an upright position, or provided with antibiotics. Mrs Z died on 24 August. Mrs X complained to the Trust about her mother’s care and treatment but she was dissatisfied with their response. On 15 August 2000 she requested an independent review, but that request was refused.
2. The matters subject to investigation were that the Trust:
(a) did not manage Mrs Z’s condition with sufficient urgency; and
(b) did not provide appropriate care and treatment when she developed chest infection.
Investigation
3. The statement of complaint for the investigation was issued on 10 January 2001. Comments were received from the Trust and relevant papers, including Mrs Z’s clinical records, were examined. A professional assessora consultant physicianwas appointed to advise on the clinical aspects of the case. Her report is reproduced in full at paragraph 30. One of the Ombudsman’s investigators took evidence from Mrs X and Trust staff involved. I have not put into this report every detail investigated; but I am satisfied that nothing of significance has been overlooked.
Mrs X’s evidence
4. Mrs X told the investigator that her mother underwent an ‘above knee’ amputation of her left leg in 1993. Mrs Z also suffered from a bunion on her right foot and had three-monthly visits to a chiropodist. In November 1998 the bunion became infected and her GP prescribed antibiotics. The problem persisted and on 9 April 1999 she was referred to the first consultant. At that time Mrs Z’s foot was ‘warm’, which indicated that it had a reasonable blood supply. Mrs Z did not wish to see the vascular surgeon who had performed the amputation six years previously (the second consultant).
5. On 28 May Mrs Z saw the first consultant, who said he would arrange an angiogram as soon as possible. Mrs X expected her mother would have to wait a week or so, and she became increasingly concerned about the condition of her mother’s foot when she learned that the angiogram was not to be carried out until 30 June. After the angiogram, a follow-up appointment was arranged for 16 July to discuss the results. Mrs X asked for an earlier appointment but was told that the radiologist’s report would not be available for two weeks.
6. On 16 July the first consultant explained that the angiogram showed a blockage in Mrs Z’s upper leg, but good blood vessels between the knee and the foot. The first consultant said that he would arrange an angioplasty as urgently as possible. Mrs X believed that if the blockage was removed the circulation to the foot would improve. She expected her mother would be seen within a week and feared that if action was not taken quickly, her mother would lose the right leg also.
7. On 26 July Mrs Z learned that she was to be admitted to the hospital on 11 August. Mrs X complained to her mother’s GP about the delay and he arranged for Mrs Z to be seen in A&E that day. When Mrs X and Mrs Z attended A&E they waited four hours to be seen by a doctor (an A&E senior house officerthe first SHO) and a further hour to be seen by another doctor (an on-call surgical senior house officerthe second SHO). At some point that evening a test showed that foot pulses were present. The second SHO decided that Mrs Z should go home pending her angioplasty on 11 August. On 30 July Mrs Z visited her pain specialist (the pain consultant), as she had regularly done since her amputation. He looked at her foot and recorded that gangrene was present.
8. On 11 August Mrs Z was admitted to the hospital. The angioplasty was carried out the next day but the condition of Mrs Z’s foot deteriorated subsequently. A doctor (a surgical registrarthe registrar) suggested that Mrs Z’s toe should be amputated. Mrs Z refused at first, but Mrs X managed to persuade her otherwise. Another doctor (a house officerthe first HO) spoke to Mrs Z several times over the weekend of 14 and 15 August but the possibility of a more extensive operation was not mentioned. Mrs X was told that the toe amputation would be performed on 16 or 18 August. Mrs Z was fasted for her operation on 16 and 17 August but on both occasions the surgery was postponed. On 18 August Mrs X was informed that her mother’s operation was scheduled for 23 August. She complained to the Trust’s complaints manager about the delays and Mrs Z’s operation was brought forward to 19 August; surgery was carried out on that day.
9. On 20 August Mrs Z seemed to be recovering well, but on 21 August her breathing became laboured. Mrs X reported that to a nurse, who seemed uninterested, although Mrs X acknowledged that observations and oxygen therapy might have been carried out that afternoon. On 22 August Mrs X found her mother lying flat in bed with only one pillow in place. A sister helped Mrs X to sit Mrs Z up and agreed that a pillow could be brought from home. Mrs X was concerned to hear another doctor (the third SHO) tell a nurse, during a ward round, that oxygen was being administered through the wrong type of mask. The nurse said there was a shortage of masks; the mask was not changed until four hours later, after the nurse was reminded again. Mrs X felt that her mother’s chest infection might have been associated with that episode and with lying flat. Mrs X was also told that her mother was anaemic and ‘losing blood from somewhere’. Mrs Z deteriorated further and died in the early hours of 24 August. Mrs X felt that if her mother’s case been taken more seriously, the outcome might have been different.
Trust response to the statement of complaint
10. In his formal response of 1 February 2001 to the statement of complaint the Trust’s chief executive wrote:
‘…. [During the Trust’s investigation of [Mrs X’s] complaint the clinical assessor to the convener acknowledged] that there were one or two aspects to [Mrs Z’s] management which were less than ideal, [but] judged that by and large there were no major shortcomings in her care. [However, although] the delays prior to surgery should not have occurred, it is unlikely that these made any difference to the clinical outcome. [Mrs Z] did have a serious chronic condition and indeed in the referral letter from her [GP] dated 9 April, mention was made that the outcome of [Mrs Z’s] foot problem would probably be an amputation.
‘The Trust has accepted that, with the benefit of hindsight, [Mrs Z’s] referral by her [GP] on 26 July 1999 should have resulted in her admission. An apology has been given to [Mrs X] that this did not happen as there was no bed available.
‘It was very unfortunate that it was necessary to cancel the proposed surgery in August because of an emergency which required immediate attention. I understand that surgery did not proceed on Monday 16 August because [Mrs Z] had earlier decided that she did not wish to have her toe amputated.
‘I am very sorry [Mrs X] feels that her mother did not receive appropriate care and treatment when she developed chest problems. Following the surgery on 19 August [Mrs Z] made a fair recovery, taking into account her general poor health and the fact that she had undergone a major procedure. On 21 August she was well enough to sit out in a chair for two hours. Unfortunately [Mrs Z] became somewhat unwell with gastric symptoms later that evening and sustained an accompanying fall in her blood oxygen levels. She was seen by a senior house officer at this time, was sat up and given oxygen and reviewed again later. The oxygen saturation levels had risen to 100% by this time.
‘[Mrs Z] remained unwell the following day with continuing gastric symptoms, however she was haemodynamically [her circulatory system was] stable. I am afraid I cannot comment formally on [Mrs X’s] report that [Mrs Z] was not nursed in an upright position as there is no specific documentation in the nursing notes. I understand from a verbal report that it was difficult to ensure that [Mrs Z] remained in a sitting position at all times since she did frequently slip down the bed in spite of the nurses’ best efforts. I note [Mrs X’s] reference to the improved nursing position once her mother was transferred to the HDU [high dependency unit], and feel that this was probably facilitated by the electronic bed which would have made the positioning of the patient much easier. [Note: the nursing records show that [Mrs Z] was actually transferred to the Coronary Care Unit (CCU) and not to the HDU.]
‘There is good documentation in [Mrs Z’s] medical records of regular visits by the doctors and the initiation of appropriate treatment. [Mrs Z] showed signs of fluid overload on 23 August and was given intravenous frusemide [medication to reduce fluid retention] to good effect; this drug to be continued [twice daily]. A chest X-ray was performed. When [Mrs Z] was reviewed by a doctor later at 14.30 hours it is recorded that she was “much better” than in the morning.
‘In respect of antibiotic cover [Mrs Z] was prescribed erythromycin from 18 August, before her surgery, until 22 August. The patient was reviewed by a house officer [the second HO] at 6.15 am on 23 August when it was recognised that there might be a chest problem. Intravenous Augmentin was given and later Cefuroxin and Metronidazole were prescribed.
‘In conclusion; the Trust accepts that it would have been preferable had [Mrs Z] been admitted following her GP’s referral to the on-call surgical team in July. However, it is not felt that [Mrs Z’s] post-operative care and treatment was inappropriate. It is a matter for regret that [Mrs X] has ongoing concerns with regard to these two matters.’
Written evidence of Trust staff
11. In his response of 14 June 2001 to the Ombudsman’s Office the first consultant stated that when he received the GP’s referral letter of 9 April 1999 he referred Mrs Z to the second consultant, who had looked after her previously. It was correct in his experience for specialist consultant care to be provided by a single individual where possible. The first consultant then received a further GP referral letter on 30 April and decided he would see Mrs Z at the next available out-patient appointment. The decision when to see a patient depended upon the sense of urgency in the GP letter; if potentially limb-threatening symptoms were indicated the patient would be seen in the next urgent slot, usually within two to three weeks. If necessary he could add an urgent patient to his next clinic; usually the following Friday. A non-urgent referral might wait several weeks.
12. The first consultant saw Mrs Z on 28 May. If it had been necessary, he could have admitted her to hospital that day, but given the clinical situation, the subsequent four-week wait for an angiogram was not unreasonable. It was unlikely that the prognosis would have changed while she waited. It was also routine after an angiogram for patients to wait for two weeks for the results; the first and second consultants and the radiologist having met to discuss results and treatment options at the interim routine Friday meeting.
13. When the first consultant saw Mrs Z on 16 July he made a note that a ‘salvage angioplasty’ was to be carried out. That meant that it might have been possible to improve the blood supply to the limb, but he also noted that an above knee amputation might be necessary. He wrote to Mrs Z’s GP on 20 July indicating that there was little change in the foot. It would have been improper to inform Mrs Z, ‘an elderly lady’, about the possibility of an amputation unless absolutely necessary, because of the fear that that might cause.
14. Mrs Z attended A&E on 26 July. However, there was nothing in the notes to suggest that the second SHO sought a senior view on that occasion. The first consultant did not recall being informed about the situation. The first consultant then became ill on 11 August. His workload would have been taken over by his consultant colleagues and coordinated initially by the registrar. The first consultant did not think that a major amputation could have been avoided in this case; only in a perfect medical world with unlimited access to consultants could delays be avoided.
15. In his written response of 7 July 2001 to the Ombudsman’s Office, the second SHO stated that he could only assume that when Mrs Z attended A&E on 26 July, her wait to see him was due to pressure of work and the low triage priority assigned to her. He did not recall the GP referral. His notes showed that there was no recent change in the level of pain; Mrs Z was not taking antibiotics at the time. He discharged her after increasing her treatment for pain and prescribing first-line antibiotics. Admission might have expedited Mrs Z’s angioplasty but from his experience that was usually difficult, and Mrs Z was already booked for angioplasty in two weeks time. The second consultant was on-call that day, but the second SHO did not recall contacting him about Mrs Z’s case and there was no record of that in the notes. He did not think it was inappropriate to discharge Mrs Z that evening as she lived with her daughter and the social set-up was adequate. However, the bed-state of the hospital or the observation ward might also have influenced his decision. He felt he had acted appropriately providing suitable treatment; he did his best within the constraints of the NHS.
Oral evidence of Trust staff
16. The pain consultant told the investigator that he could not remember the precise details of the consultation on 30 July. He had noted ‘gangrene’ in the records, but he did not know for certain whether Mrs Z had reported that to him, or whether he had examined the foot and seen skin discolouration himself. If he had had any concerns he would have called one of the on-call surgical team to examine the foot. However, as he had not done that, he must have been satisfied that Mrs Z’s proposed admission for 11 August was appropriate.
17. The second consultant told the investigator that he had not been involved in Mrs Z’s care and treatment prior to the right leg amputation on 19 August. He had known the first consultant for seven years and was confident that he would never allow a leg to deteriorate. However, in view of Mrs Z’s age, widespread arterial disease, and prior amputation it was always possible that a second amputation would be necessary, even after active intervention. The aim at the time would have been to try to avoid that and consider what could be done. The wait for angioplasty did seem a long time, but that would depend on the appearance of the foot and the whole clinical picture. Mrs Z should have been detained in hospital on 26 July, given the clinical description of the foot, her age, pain and the fact that the GP had expressed concern. If a senior review had taken place, earlier intervention might have followed.
18. On 12 August the angioplasty was carried out with reasonable results. Angioplasty patients were normally discharged home the same day but it was clear that Mrs Z should not be discharged. The note of 13 August to discharge Mrs Z on 16 August was probably entered routinely and erroneously. No medical notes were made between the first HO’s entries of 13 and 16 August, but Mrs Z would have been monitored over the weekend. There was no record that amputation was discussed with Mrs Z before 16 August. There also appeared to be some confusion about whether the operation was to take place that day. It appeared from the nurses’ notes that Mrs Z had been fasted, but the medical notes indicated that the operation was not to take place until the next day, or later in the week.
19. The second consultant said that it was ‘chaotic’ when the first consultant became ill suddenly, creating direct pressure on him as he was the only remaining vascular specialist. He was pushed to the limit, and additional pressures were caused by general waiting list targets. The registrar was involved in Mrs Z’s care and the second consultant would not question his ability to supervise it. However, there had been concern at the time about the pressures on medical staff when colleagues were away. It was probably because of those pressures that a retired consultant general surgeon (the third consultant) became involved with Mrs Z’s care on 18 August. The second consultant was uncertain who was in charge of Mrs Z’s care because the rota was not amended to show who was covering in the absence of the first consultant but he felt sure that it would have been made clear to the nurses which consultant was covering Mrs Z’s care. Since then the Trust had introduced a more organised structure.
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20. The second consultant saw Mrs Z for the first time on 19 August. He thought that her operation had been delayed because more urgent cases had been prioritised. Also, it was preferable to undertake a below knee amputation on an elective, rather than an emergency list. He believed that the decision to schedule the operation for 23 August might have been made because that was a ‘spare’ list following the first consultant’s absence. In the event, the surgery was carried out sooner as a space was found on his elective list of 19 August.
21. The 21 and 22 August was a weekend, and the second consultant would not routinely have been called out to review Mrs Z after her amputation. The registrar saw Mrs Z on 23 August before she was transferred to the CCU. It would have been preferable for Mrs Z to have had HDU care at an earlier stage, but such facilities were not always available. It remained a worry to him that the post-operative care of critically ill patients still took place on general wards.
22. A ward sister (the first sister) told the investigator that she had little recollection of Mrs Z’s admission. She was on early duty on 13 August but could not recall whether amputation was discussed with Mrs Z that day, or whether Mrs Z refused it. Such important matters would have been recorded in the patient’s notes and there was no record of such discussion. Mrs Z had an uneventful recovery up to 16 August. The nursing notes showed that the proposed amputation was discussed with Mrs Z and Mrs X before Mrs Z was fasted for surgery later that day. Nursing staff would not have fasted her unless they had been told specifically by medical staff that she was to have her operation. The nurses must have been informed later about the cancellation, because that was recorded in the notes at 7.30pm. On 17 August Mrs Z’s surgery was planned for 7pm and she was fasted in preparation. However, at 6pm the operation was cancelled again; the registrar spoke to the family. Mrs Z’s below knee amputation was performed on 19 August.
23. On 21 August Mrs Z had an episode of coffee ground (partly digested blood) vomiting. The first sister did not recall Mrs X complaining about her mother’s breathing problems that day and could not say whether oxygen was provided in response to Mrs X’s observations. However, if Mrs X had complained, it would have been recorded and a doctor would have been called. The medical notes showed that an SHO and a HO reviewed Mrs Z, but there was no nursing note about that. Mrs Z’s oxygen saturation levels were recorded that evening and at intervals throughout the following two days. The first sister had no recollection of any discussion about the availability of oxygen masks. The ward usually had a wide selection but if there was a shortage they would obtain supplies from another ward.
24. There was ‘no way’ that a nurse would intentionally have nursed Mrs Z in a flat position. Staff were especially aware of Mrs Z’s position because they were monitoring her oxygen saturation levels. She might have slipped down the bed, and that might have been a recurrent problem, considering the amputations. Patients normally had three pillows, but sometimes there was a shortage. Relatives often liked to bring pillows from home, and the nurses did not object to that.
25. Another ward sister (the second sister) could not recall who took over Mrs Z’s care when the first consultant became ill, but the third consultant was brought out of retirement to help. Mrs Z was seen during the ward round of 13 August and it was planned to review her condition on Monday 16 August. There was no record in either the medical or nursing notes that she had been seen by any of the on-call team over the weekend of 14 and 15 August. It was likely that Mrs Z would have been seen routinely during the weekend ward round. However, it was possible that she was not reviewed by a consultant for the first six days after her admission. The second sister did not recall that Mrs X made any complaints that weekend, or that Mrs Z had been offered or refused surgery.
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26. On 16 August the registrar decided that amputation of Mrs Z’s toe should be performed. The second sister telephoned Mrs X who was very unhappy, believing that amputation could have been avoided if the angioplasty had been carried out at an earlier date. The second sister recorded that discussion and that Mrs Z was for theatre later that day, probably on the emergency list. Mrs Z was then fasted. The second sister could not explain why the medical notes of 16 August did not state that Mrs Z was to have her operation that day because the nurses had been informed that that was the case. Mrs Z was very reasonable about the cancelled operation, but understandably concerned that she had been prepared for theatre and fasted; Mrs X seemed to be more concerned than her mother. The following day the nurses were informed that Mrs Z was to be prepared for theatre, but the operation was cancelled again. Cancellations were a source of frustration for staff and patients.
27. The second sister said that the third consultant saw Mrs Z on 18 August and referred her to the second consultant who then saw her on 19 August; a below knee amputation was performed that day. The second sister did not recall the details of Mrs Z’s subsequent deterioration but medical staff were informed that Mrs Z vomited ‘coffee grounds’ on 21 August. There was no record in the nurses’ notes of doctors’ visits to Mrs Z on 21, 22 and 23 August. The nurses should have recorded those. (Note: the medical records show that Mrs Z was reviewed at least 12 times by medical staff during those three days.)
28. The second sister had no recollection of a shortage of oxygen masks. Oxygen saturation levels were regularly recorded and she was aware that patients with chest problems needed special consideration. The doctors or physiotherapists specified what type of mask was to be used and doctors would be involved if there was concern about oxygen saturation levels. The nurses had difficulty in keeping Mrs Z in a sitting position. They did have pillow shortages at times, but patients usually had a minimum of three pillows; she did not believe that Mrs Z only had one pillow on 22 August. It was usual to allow relatives to bring pillows if they asked. On 23 August, Mrs Z was ‘specialled’, because of her deteriorating condition, and subsequently transferred to the CCU. The second sister understood Mrs X’s frustration with the delays to her mother’s amputation. She also acknowledged that better written records should have been kept. However, she believed that the nurses provided appropriate nursing care.
29. The complaints manager told the investigator that on 18 August Mrs X complained because Mrs Z’s operation had been cancelled three times and was not scheduled until 23 August. Mrs X believed that the delay would allow time for gangrene to spread and result in the need for more extensive surgery. The complaints manager telephoned the first sister, who told her that the registrar had already decided that the operation could be brought forward to the next day. The registrar had tried to inform Mrs X about that but her telephone was continually engaged. The complaints manager subsequently managed to telephone Mrs X and told her that her mother’s operation was to be carried out on 19 August. The complaints manager believed that the operation was not carried out on 16 August as originally planned because Mrs Z had refused.
30. I reproduce next, in its entirety, the report of the professional assessor to the Ombudsman.
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Report by the Professional Assessor to the Health Service Ombudsman for England of the clinical judgments of staff involved in the complaint made by Mrs X:
Professional assessor: A Consultant Physician
1. Matters considered
- Whether or not the Trust managed Mrs Z’s condition with sufficient urgency, or provided appropriate care and treatment when she developed a chest infection.
2. Basis of report
Documents, including Mrs Z’s clinical records and statements from staff were made available to me by the Ombudsman’s office. Also, I participated in the investigator’s interviews with Trust staff.
3. Background
3.1 At the time of these events Mrs Z was 86 years old with a past medical history of high blood pressure and hardening of the arteries, particularly affecting the blood supply to her legs. Her GP wrote to the first consultant on 9 April 1999 seeking advice on the management of her foot. The foot was described as suffering the effects of poor blood supply (ischaemia) and an infected bunion that was resistant to antibiotic treatment. An X-ray had shown no evidence of infection in the bone underneath the bunion. The patient had had a left leg amputation under the care of the second consultant some years previously.
3.2 The GP’s referral letter said that the patient was ‘finding the pain in the foot becoming quite intolerable’ and mentioned that the patient was already attending the pain clinic. A ‘stimulator device’, implanted in Mrs Z’s spine after her first amputation to help manage her pain, had helped ease her back pain but had not helped ease the pain from her foot. The GP asked for an out-patient appointment, saying that he felt the patient may well ‘end up with another amputation’.
3.3 The referral letter was returned to the GP on 19 April with a letter from the first consultant explaining that it would be difficult for him to see Mrs Z without the ‘express permission’ of the second consultant, as she had been the second consultant’s patient previously and the second consultant had arranged for Mrs Z to see the pain consultant.
3.4 On 29 April, the GP wrote to the first consultant again and asked him to see the patient, explaining that the patient did not wish to see the second consultant. No additional clinical information was offered. The first consultant agreed to see Mrs Z and a handwritten note on the letter (in the first consultant’s handwriting) indicated that an appointment should be made for the next vascular clinic on 28 May, four weeks after the second GP letter and seven weeks after the first letter.
3.5 On 28 May the first consultant’s assessment at the out-patient visit indicated that Mrs Z’s foot was not threatened by the ulcer over the bunionit was noted that the foot pain was due to poor blood supply and suggested that an X-ray showing the flow of blood through the leg arteries (angiogram) be done. Surgery to improve the blood supply to the leg was contemplated, depending on the results of the angiogram.
3.6 On 30 June the radiologist performed the angiogram and reported this formally on 1 July. The first consultant saw Mrs Z in clinic on 16 July and in a letter to the GP, dated 20 July, he ruled out the possibility of a major operation on the blood vessels in the leg, but suggested that a more limited procedure to widen the arteries from within (angioplasty) might be of some help. The letter said that the patient would be admitted ‘as soon as possible’. In the handwritten out-patient consultation notes of 16 July the first consultant wrote that, if the angioplasty failed, an above knee amputation would probably be necessary. There was no note or information in the letter to the GP as to whether this had been specifically discussed with the patient.
3.7 On 23 April and 25 June the patient was seen in the pain clinic by the pain consultant and the stimulator device was adjusted on both occasions to provide better pain control. No mention was made in these two out-patient consultation notes about the state of the foot, but on 30 July the pain consultant noted ‘Area of gangrene [in the] l[eft] great toe. Angioplasty arranged (11/8). Still stim[ulation] in foot. ? See as inpatient’.
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4. Referral to the on-call surgical team
4.1 The GP notes of 26 July indicate that the GP discussed Mrs Z’s case with a ‘surgical registrar’ who agreed to see the patient that day. No name is given, so it remains unclear whether the GP spoke to a registrar or to the second SHO. However, the GP’s referral letter was addressed to the second SHO. The GP asked ‘if more definitive treatment is required’ since the foot was deteriorating.
4.2 Mrs Z attended A&E, and at some point she was transferred to the A&E observation ward. She was seen by the first SHO initially, then was assessed by the second SHO. It does not appear that a registrar or consultant saw the patient on this occasion.
4.3 The patient’s foot was described as swollen and cold with redness (erythema) of all the toes. The patient was then discharged home with antibiotics and anti-inflammatory drugs prescribed. The notes state: ‘to await angioplasty’ (Mrs Z’s admission for that had been arranged for 11 August). There is no indication of communication with the GP that evening or the following day, other than the brief discharge summary from the A&E observation ward.
5. The in-patient admission
5.1 On 11 August Mrs Z was admitted for her angioplasty. The foot was swollen and cool to touch, but Mrs Z was described as comfortable. An angioplasty was performed the next day, with a technically reasonable result, in that blood flow initially appeared improved. (This finding does not necessarily imply that improvement in the condition of the foot is to be expected.)
5.2 The first HO’s notes of a ward round by an SHO and registrar on 13 August indicate that discharge was planned for Monday 16 August. It is also noted that the patient’s pain was worse at night and that the toe was looking ‘wet’. A discharge summary was also prepared that day.
5.3 The first HO’s notes of a registrar’s ward round on 16 August implied that there was a discussion of ‘the possibility of removing the toe before discharge’, but no record of whether the patient was involved in the discussion or of the outcome. A subsequent note indicated that the registrar felt that amputation was necessary, and that this should take place ‘this week ? tomorrow’.
5.4 The operation was arranged for the emergency list on the evening of 17 August and blood tests were taken. The blood tests showed anaemia, with a blood count (haemoglobin) of 8g/dl which is low and also significantly different to the blood count of 11.8g/dl on 12 August, five days previously. The patient received one unit of blood by transfusion. The prescription of the oral anti-inflammatory drug Diclofenac continued from admission until 20 August although it was not taken on a number of occasions. No comment is made as to the possible cause of the anaemia.
5.5 On 18 August the registrar recorded that he had spoken to the patient’s daughter, who had expressed anger that the operation had been postponed. It was explained that an emergency operation took precedence over her mother’s urgent procedure. It was also explained that this might happen again if the patient was placed on an emergency list, therefore an elective list would be preferable. It was explained that the patient had refused removal of her toe when this had been discussed with her a week earlier. At 10.30am that morning Mrs Z was seen by the third consultant. He referred her to the second consultant for below knee amputation the next day. At this point the blood count had improved slightly to 10.8g/dl following the transfusion of one unit of blood on 17 August. The transfusion was not recorded in the medical notes, nor was any discussion regarding investigation of the possible cause of the anaemia or plans for future management in this regard. Notes made on 18 and 19 August indicate that attempts were made by the registrar and the third SHO to contact the patient’s daughter.
5.6 On 19 August the first HO noted that the patient was sleeping better and that pain control appeared adequate. Amputation of the right leg below the knee was performed that day.
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5.7 On 20 August, the first post-operative day, Mrs Z appeared stable. On the morning of 21 August the medical and nursing notes also suggest that Mrs Z’s condition was stable. However, in the afternoon or early evening the nursing notes recorded that Mrs Z vomited some dark fluid described as ‘coffee ground vomit’. This term is used to describe the appearance of blood altered by acid digestion in the stomach, and implies that there had been some bleeding, possibly minor, from the inner lining of the stomach or upper intestine. The second HO noted this finding, and that review by a SHO was required. However, there is no indication in the notes that that review took place, whether a registrar reviewed the patient, or whether the blood count was checked. In the afternoon of 21 August, the nursing notes record a slightly low level of oxygen (92%) in the patient’s blood as measured by an infrared device attached to the finger. Oxygen was given at a rate of 2 litres a minute through plastic tubing fitted under the patient’s nostrils, so-called ‘nasal specs’. No reference was made to this in the medical notes and the oxygen is not written up on the prescription chart. At 10pm the vital sign assessment (TPR) chart shows a satisfactory level of oxygen in the patient’s blood.
5.8 On 22 August, the third post-operative day, Mrs Z was reviewed by the second HO again and found to have diarrhoea and nausea but stable pulse and blood pressure. There was no reference in the medical notes to the low oxygen levels or the oxygen therapy. The TPR chart at 6am showed that the oxygen level in the blood was too low at 77% and this was recorded in the nursing notes. The next note recorded a satisfactory level of ‘95% on 7 litres’ indicating that a mask had been substituted for the ‘nasal specs’.
5.9 On 23 August, the fourth post-operative day, the second HO reviewed the patient at 6.15am and found her to have a raised temperature and low oxygen concentration in the blood. The second HO sat the patient upright and administered oxygen, with some improvement in the patient’s condition. The second HO’s impression was that the patient had a chest infection and an appropriate antibiotic was given intravenously. On the same day (but at an indeterminate interval after the second HO saw the patient) Mrs Z was reviewed by the registrar. An additional diagnosis of heart failure due to fluid overload was made and a drug given to increase urine flow. An on-call medical SHO (the fourth SHO) reviewed the patient and on examination found signs of heart failure. On rectal examination ‘profuse melaena’ (black, tarry, offensive stools, indicating bleeding in the alimentary tract) was seen. That implied bleeding from the upper part of the gut. The note did not state whether this was fresh or old, however, the wording of the note would suggest a recent event.
5.10 Blood tests revealed anaemia, which had recurred since the pre-operative blood transfusion (haemoglobin at 8.1g/dl) and very high white blood count. The ECG showed a pattern called ‘left bundle branch block’ (a delay in conduction of impulses to the left ventricle of the heart). This pattern is associated with heart disease, and was said in the nursing notes to have been present on Mrs Z’s ECG since 1992. It is not possible to diagnose a heart attack in the presence of this finding on an ECG (except in rare circumstances which do not apply here). However, the blood tests also showed a raised level of an enzyme released by damaged heart muscle during a heart attack. The fourth SHO diagnosed a gastro-intestinal bleed and a heart attack with heart failure. The intravenous fluid prescription charts reveal that, contrary to the fourth SHO’s note, the patient had received 12-hourly, not eight-hourly, litres of intravenous fluid.
5.11 Mrs Z was managed actively and appropriately, with additional intravenous antibiotics. Blood transfusion was planned; the medical notes at 11am indicated that the transfusion should be given as soon as possible. I can find no record of a blood transfusion at this point, and a subsequent medical review indicated that transfusion should be withheld until further blood tests were available later in the day. Mrs Z’s condition was reviewed frequently during the morning and early afternoon and she responded to treatment and stabilised. Her anaemia persisted with a low level of haemoglobin at 7.5 g/dl.
5.12 At 8pm on 23 August the nursing records stated that Mrs Z was lying on her left side with no complaints of pain and that she did not appear short of breath. Her oxygen saturation level was good at 100%. At 10.30pm Mrs Z’s clinical condition rapidly deteriorated, and she became breathless. An on-call medical HO (the third HO) was called and a central intravenous line was inserted. The notes indicate that Mrs Z’s family agreed that further resuscitation was not appropriate. Mrs Z continued to deteriorate and died at 1.20am on 24 August.
5.13 The notification of death sent to the GP indicated that the cause of death was pulmonary oedema (fluid build up in the lungs), caused by left ventricular failure (failure of the main pumping chamber of the heart), and a myocardial infarction (heart attack). It is noted that a bleed into the gut also contributed, and that this probably occurred two days before death.
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6. Comments on the actions of clinical staff
6.1 Mrs Z’s GP referred her to the first consultant on 9 April. It is courteous, seeing that a colleague has already treated a patient for the same condition, to bring this to the attention of the referring doctor. The first consultant wrote in these terms to the GP.
6.2 It is important to note that during this period the pain consultant continued to see Mrs Z regularly in a separate out-patient clinic following an earlier referral by the second consultant. Indeed she was seen on 23 April, some two weeks after the initial GP referral letter to the first consultantfour weeks before her first out-patient appointment with the first consultant.
6.3 The GP anticipated in the initial referral letter that another amputation might eventually prove necessary, but there is no indication of whether this was discussed with the patient. Mrs Z had already had one leg amputated as a result of her peripheral vascular disease and might well have been anxious about the prospect of a second amputation. It is clear, however, that Mrs Z and her daughter did not understand the sequence of events leading to the angiogram and how, and when, the results would be communicated to them. Discussion of the likely outcome of Mrs Z’s illness in the early stages of planning, investigation and management, including the possibility of amputation, could have led to more realistic expectations about the outcome.
6.4 The GP records of 26 July indicate that the GP had discussed Mrs Z’s case with a surgical registrar to review Mrs Z that day, despite the fact that she was to be admitted within two weeks for an angioplasty. In fact, the second SHO, rather than a registrar, reviewed the patient. The medical records do not indicate whether the second SHO was able to access Mrs Z’s full medical records, including details of the out-patient consultation, although full information was provided by the GP.
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6.5 Information provided by the Trust on bed occupancy of 26 July did not appear to indicate serious pressure on beds. Further data on surgical admissions, referral and theatre cases did not give a clear indication of the pressure on staff at the time.
6.6 The second SHO was only made aware of the complaint and the Trust’s subsequent responses to the complainant during the Ombudsman’s investigation. It has therefore been difficult, two years after the events, for him to give a detailed recollection of events. This has made investigation of the circumstances surrounding Mrs Z’s discharge from the hospital on the night of 26 July very difficult. However, I consider that the second SHO probably should have sought senior advice on 26 July, given that Mrs Z’s foot was described as being red, cold and swollen, and given that her GP had personally requested same-day review of an elderly patient who was under consultant care, in continuing pain and due to be admitted in two weeks’ time. Available information would suggest that a duty registrar or consultant would have been available to discuss or review Mrs Z’s case that evening. Mrs Z’s GP should have been given better information regarding the assessment in A&E. In the event it seems that the inadequate discharge note was the only response.
7. The in-patient admission
7.1 Cover arrangements following the first consultant’s sudden absence on sick leave on 11 August were ad-hoc and resulted in further pressure on hard-pressed consultant colleagues and junior doctors. It appears that no guidance was available to junior medical staff or patients as to which consultant was in charge of which of the first consultant’s patients. A consultant did not see Mrs Z until six days after admission. The team seemed ready to discharge Mrs Z on 16 August having treated her as a routine angioplasty admission, again emphasising the lack of appropriate senior support in the hard-pressed situation created by the sudden absence of the first consultant. There was no evidence of planned and structured management of such workforce crises at a directorate or Trust level. The additional constraints of shift patterns, compliance with junior doctors hours of work and more structured training programmes may have further confused lines of responsibility, accountability and continuity of care.
7.2 The situation was further compounded by the ‘weekend factor’. Apparently it was usual for consultant surgeons to visit the hospital over the weekend but there are no notes to indicate that anyone more senior than a SHO reviewed Mrs Z over the weekend of 21 and 22 August. Specialist medical advice from the on-call doctors would have been available but was not requested. There appears to have been no linkage between medical and surgical firms to allow early and continuing medical advice for complex surgical cases at a junior level out-of-hours. Senior support and supervision for the second HO over the weekend of 21 and 22 August was not apparent. Clearly this is not in line with reasonable practice and I would recommend that more formal arrangements for review of current in-patients should be made to cover weekend and statutory holiday periods, particularly as it is possible that HOs may be very inexperienced or new to weekend on-call duty.
7.3 The delay and cancellation of the planned amputation was unsatisfactory but unavoidable given the pressure of emergency work, which took precedence on the emergency theatre lists. It therefore was appropriate to plan to operate on Mrs Z on an elective list.
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7.4 Oxygen therapy was given at an appropriate concentration but not appropriately prescribed. Oxygen should be treated as a drug and prescribed as such. There is no written policy for oxygen therapy in the Trust and the ‘unwritten policy’ was not adhered to. The cause of the low blood oxygen level was not investigated and arterial blood gas levels were not taken for two days. In Mrs Z’s case there were many potential causes of a low blood oxygen level post-operatively. Mrs Z was cared for on a general surgical ward and the absence of adequate HDU facilities for the care of post-operative patients in the Trust is relevant to the standard of care that clinical staff were able to provide.
7.5 The clinical investigation and management of the anaemia, likely to have been caused by a gastro-intestinal bleed, was unsatisfactory and could have been considered at an earlier stage. The planned review by an SHO on 21 August, after the nurses reported that Mrs Z had vomited ‘coffee ground’ blood, did not take place. This was unreasonable for the second and third day after a major surgical procedure in a patient with known cardiovascular disease and unexplained anaemia developing new medical complications. The significance of the falling blood count in the first few days of the admission was not appreciated and the non-steroidal anti-inflammatory drug, which was a possible cause of the bleeding, was continued inappropriately. The blood count was not checked after the coffee ground vomit on 21 August and the profuse melaena noted on 23 August might well have indicated further acute bleeding.
8. Conclusions
8.1 Mrs Z’s out-patient care was managed with sufficient urgency, although more discussion with the patient and her daughter of the management plan and likely outcome would have been appropriate.
8.2 When Mrs Z attended A&E on 26 July the second SHO should have sought senior advice. It was probably inappropriate to discharge Mrs Z that day. However, I cannot say with certainty that an earlier operation would have been carried out, had the patient been admitted. It is surprising that the Trust felt able to comment on the actions of the second SHO when he was not made aware of this complaint until the Ombudsman’s investigation took place.
8.3 I was concerned to note that Mrs Z did not have a designated consultant following the first consultant’s unexpected absence from 11 August. The Trust should ensure appropriate support in the management of cover arrangements for the absence of consultants, including clarification of lines of accountability and responsibility for clinical care. The impression given after detailed examination of the evidence in this case is of a committed surgical team struggling to cope with the unexpected and unpredictable absence of a senior member of the team in an already constrained situation without additional resource or co-ordinated management support.
8.4 The lack of availability of senior medical advice during the weekend of 21 and 22 August was unreasonable. Formal arrangements should be made to ensure review of in-patients in the surgical wards over the weekend period to ensure adequate support and supervision of junior staff and the timely recognition of change in the clinical condition of patients, particularly those who are unstable or immediately post-operative.
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8.5 While it is clear that Mrs Z’s surgery was postponed, it is unlikely that an earlier operation would have resulted in a less extensive amputation, given that the possibility of amputation was mentioned by the GP on 9 April, and given that the first consultant felt on 16 July that an above knee amputation might prove to be necessary.
8.6 When Mrs Z developed a chest infection reasonable care and treatment was provided within the resources available to clinical staff at the time. However, I consider that the investigation and management of the anaemia and the gastro-intestinal bleed were unsatisfactory. Better care would have been available for the whole post-operative period had Mrs Z been managed in a HDU; the adequacy of HDU support within the Trust should be assessed.
Findings (a)
31. Mrs X was concerned that her mother’s condition was not managed with sufficient urgency, and that Mrs Z’s amputation might not have been as extensive if it had been carried out sooner. In reaching my findings I have taken account of the assessor’s report at paragraph 30. The assessor has advised me that she has no concerns about Mrs Z’s care prior to the attendance at A&E on 26 July. However, she believes that the second SHO should have sought a senior view and that Mrs Z should have been admitted that day, although she was unable to say whether that would have led to an earlier operation.
32. Mrs Z was admitted on 11 August and the first consultant was taken ill suddenly that day. It is clear that his absence placed the surgical team under a great deal of pressure. While I appreciate that the first consultant’s illness could not have been anticipated, I am concerned that the Trust did not have an adequate contingency plan for such a situation. I am particularly concerned that it was unclear who was in charge of Mrs Z’s care, and that she was not seen by a consultant until six days after admission. I criticise the Trust for not providing an adequate level of service in this respect. I recommend that the Trust ensure that a clear policy is in place for the provision of consultant cover in the event of such circumstances.
33. There is some confusion about when Mrs Z’s surgery was to take place; the nursing records indicate that she was fasted on 16 August, and again on 17 August. However, the medical records indicate that surgery was planned for 17 August. Mrs X was under the impression that the surgery would be performed on 16 or 18 August. In the event, the operation took place on 19 August. It is also unclear from the records precisely when Mrs Z refused surgery; the registrar’s note of 18 August simply states that she had refused surgery ‘a week earlier’. I criticise the Trust for such poor standards of record-keeping and communication.
34. The assessor was concerned that, following surgery, Mrs Z was not seen by anyone more senior than a SHO over the weekend of 21 and 22 August, and that a planned review by a SHO, after Mrs Z had vomited coffee ground blood, did not take place. I share the assessor’s concerns; I recommend that the Trust ensure that patients are reviewed by sufficiently experienced medical staff at the weekends and that such reviews are noted in the clinical records.
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35. Mrs X’s concerns arose from her firm belief that her mother’s leg would be saved with early intervention. I agree with the assessor that it would have been better to prepare Mrs Z and Mrs X for the possibility of amputation; Mrs X might then have had more realistic expectations of her mother’s prognosis. It is clear from all clinical accounts that it was anticipated from the outset that an amputation might prove to be necessary, given Mrs Z’s history of vascular disease. The assessor has said that it is unlikely that an earlier operation would have resulted in a less extensive amputation. She was of the opinion that the delay and cancellation of the planned amputation was unsatisfactory but unavoidable, as emergency cases took precedence. She has advised me that it was reasonable to place Mrs Z on an elective list, rather than on the emergency list, to give the best possible chance of the surgery going ahead. I note that the surgery planned for 23 August was actually brought forward to 19 August. However, it is clear that Mrs Z’s case could have been handled more expeditiously prior to that. I uphold the complaint to that extent.
Findings (b)
36. The second matter to address is that of the management of Mrs Z’s chest condition. Mrs X has said that when she visited on 22 August, Mrs Z had one pillow only and was nursed lying flat. Mrs X believed that that, and the use of an incorrect type of oxygen mask, had contributed to her mother’s chest infection. The first sister and second sister have said that while there was a shortage of pillows occasionally, relatives could bring in pillows if they wished; the second sister did not think that Mrs Z had only had one pillow. Neither the first sister nor the second sister could recall a shortage of oxygen masks. I have therefore been unable to shed further light on these matters. The first sister and the second sister have both explained that it was difficult to keep Mrs Z in an upright position after the amputation, as she kept slipping down the bed.
37. The assessor has advised me that the care and treatment of Mrs Z’s chest infection was generally reasonable. Oxygen therapy was given at an appropriate concentration. However, the assessor was concerned that the oxygen therapy was not written up on the prescription chart; the Trust did not have a formal written policy for oxygen therapy and the ‘unwritten policy’ was not adhered to. I recommend that the Trust ensure that oxygen therapy is appropriately prescribed and documented. However, in the light of the assessor’s comments I consider that Mrs Z received appropriate care and treatment when she developed a chest infection; I do not uphold the complaint.
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Additional comments
38. In her report the assessor expressed concern about the investigation and management of Mrs Z’s anaemia and gastro-intestinal bleed. While Mrs X did not complain about that matter to the Ombudsman formally, I consider it important to bring to the Trust’s attention the assessor’s concerns. The assessor concluded that better care would have been available for the whole post-operative period had Mrs Z been managed in a HDU, and she recommended that adequacy of HDU support within the Trust should be assessed. I endorse that recommendation.
Conclusions
39. I have set out my findings in paragraphs 31 to 38. The Trust have agreed to implement my recommendations in paragraphs 32, 34 and 37 and have asked me to convey through my reportas I dotheir apologies to Mrs X for the shortcomings I have identified.
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