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Selected Investigations Completed April - September 1998 > Part II, Case no. E.1476/97-98

Part II - Full Texts of Selected Investigations

Case No. E.1476/97-98 - Alleged failure to diagnose

Matters considered: Insufficient attention paid to medical history and physical signs; failure to perform endoscopy.

Complaint against: South Kent Hospitals NHS Trust

Complaint as put by Mrs J

1. The account of the complaint provided by Mrs J was that on 4 February 1997 her late father, Mr K, was admitted to William Harvey Hospital (the hospital), which is managed by the Trust, complaining of severe abdominal pain. Although the family understood that he required an endoscopy (an internal examination of the upper part of the digestive system) this was never carried out. Mr K underwent a number of different tests, and a range of different diagnoses was considered. His condition continued to deteriorate and, on 12 February, he underwent emergency surgery for a perforated ulcer, from which he never recovered. At post-mortem examination it was found that he had cancer which had perforated the stomach wall. On 22 February 1997 Mrs J complained to the Trust about the care that her father had received. The Trust investigated the matters which she raised, but she remained dissatisfied with their response. She asked the Trust's convener for an independent review of her complaint, but that was refused, and on 13 November 1997 Mrs J wrote to the Ombudsman.

2. The matters investigated were that the care provided to Mr K was unsatisfactory; in particular that:

1. insufficient attention was paid to his past and present medical history and to the physical signs found on examination; and
2. an upper gastro-intestinal endoscopy ought to have been done.

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Investigation

3. The statement of complaint for the investigation was issued on 27 February 1998. Two independent professional assessors—surgeons—were appointed to advise on the clinical issues in this case and their report is included within paragraphs 7-12 of this report. Information provided by Mrs J and the medical records of Mr K's treatment were examined. Technical terms used in the report are marked with an asterisk * and explained at Appendix A.

Complainant's evidence

4. In her letter of complaint to the Trust, dated 22 February 1997, Mrs J wrote:

'My father was admitted via casualty at [the hospital] on Tuesday 4 February 1997. The doctors in casualty suspected an ulcer [was] giving the pain, and we understood he would have an endoscopy to confirm what was wrong ...

'However, he remained ... in terrible constant pain for the next 8 days ... Various diagnoses were given [to] us by the medical team ... Apart from a scan and barium x-ray ... not a lot else happened until the [eighth] night ... By then he had developed septicaemia ...'

5. Key points of Mr K's medical records formed an appendix to this report which has not been reproduced in this publication.

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Trust response

6. In his formal comments to the Ombudsman the chief executive summarised the Trust's view as:

'[Mr K]'s past medical history, as given to ... [the staff grade surgeon] was only of asthma; he did not mention a long-standing history of peptic ulcer* or treatment for his dyspepsia*. His only medication on admission was for asthma. [Mr K]'s present medical history with the physical signs found on examination following his admission on 4 February 1997, indicated a possible diagnosis of "gastric* ulcer ? gastric perforation". In the light of this, an endoscopy was suggested as a method of investigation. However, following other investigations, [Mr K]'s possible diagnosis was suspected cholecystitis* for which endoscopy is not necessary as a method of investigation. At this time, there was no evidence of vomiting or melaena* which may have been more suggestive of peptic ulcer* when an endoscopy would have been indicated. The Trust feels that, given the physical findings and investigation results, it was understandable that [Mr K] received conservative treatment for acute cholecystitis*. The diagnoses considered and made, the investigations undertaken and the management and treatment instigated together with the clinical judgments made on the information available at the time were entirely reasonable.'

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7. Mr K was admitted through Casualty on 4 February 1997 and the history from both the casualty officer and the houseman clearly states that the patient had suffered from heartburn or dyspepsia* for three months. There is also a history of vomiting 'coffee grounds'* for two days and passing black stools for one week. He had suffered an acute onset of epigastric* pain over the past twelve hours and had tenderness in the epigastrium and up towards the right upper quadrant clearly marked in both histories. A rectal examination was done and it is recorded that no melaena* stool was seen on the glove.

8. A differential diagnosis* of peptic ulcer* +/- perforation and pancreatitis* were recorded at that time and appropriate investigations were performed to exclude pancreatitis* and perforation of a peptic ulcer*. A full blood count also performed showed no evidence of anaemia [due to loss of blood] but the white cell count was raised suggesting some inflammatory process. When patients have epigastric* pain of this nature and present as an emergency then acute cholecystitis*, peptic ulceration* and its complications and acute pancreatitis* form the basis of common disorders which cause this type of clinical picture. The patient was started on intravenous Ranitidine*. This was entirely appropriate before establishing a definite diagnosis, thus treating a peptic ulcer*, demonstrating that the differential diagnosis was still being considered and acted upon. Further blood tests showed a raised bilirubin* which increased the possibility of acute cholecystitis* as the primary diagnosis and an ultrasound scan was appropriately requested which showed a large gallbladder containing stones supporting that diagnosis. The ultrasound scan also showed a focal lesion in the liver with a differential diagnosis* of inflammatory mass or neoplasm*. Although the scan did raise the possibility of neoplasm, the clinical picture was of an acute inflammatory process and it is therefore not unreasonable to accept the scan as being consistent with that clinical picture and not investigate further.

9. The patient was appropriately treated conservatively at this stage as both the remaining differential diagnoses of gastric ulcer* and acute cholecystitis* were treated with Ranitidine* and antibiotics respectively, and the patient's general condition appeared to be improving.

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10. The fact that when Mr K became constipated on 9 February a Barium enema was performed shows that the clinicians were still actively responding to the changing symptoms and clinical status of the patient. This is also reflected in the medical opinion which was sought in response to the changes seen on the chest x-ray. A further medical opinion was then sought when his condition deteriorated on 11 February and when he developed signs of acute peritonitis* suggesting that the inflammatory process was now generalised and the likelihood of the perforation or rupture of an abscess. The patient was promptly reassessed and laparotomy* performed. The relatives were informed pre-operatively of the high risk of this procedure and the operative procedure performed was entirely appropriate given the condition of the patient at the time.

11. In summary the assessors do not believe that insufficient attention was paid to the past and present medical history or the physical signs found on examination. They believe the treatment given to Mr K was entirely appropriate.

An upper intestinal endoscopy ought to have been done

12. With the history of possible coffee ground* vomit and passing black stools together with a three months history of dyspepsia* in someone of this age, a peptic lesion was considered on admission and the fact that this was appropriately treated with Ranitidine* to lower the gastric acidity throughout the admission suggests that this was still part of the differential diagnosis*. The possibility of an upper intestinal endoscopy is not mentioned in the notes but, with a differential diagnosis* of a possible perforated gastric ulcer or with an acute peptic ulcer causing marked tenderness or guarding* in the upper abdomen, perforation or imminent perforation are always considered and would contraindicate an endoscopy during the acute stage of the illness as this could, in itself, have precipitated a perforation and peritonitis. This is standard surgical practice and therefore the fact that an endoscopy was not mentioned in the notes is not particularly surprising. It is impossible for us to second guess whether the surgical team were considering an endoscopy at a later stage, but we do not think that we can criticise the team for not writing in the notes that they are not going to perform an endoscopy at this stage because it is contraindicated. We would support the clinical team in not performing a gastroscopy at that time.

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Findings

Complaint (a)
Insufficient attention to medical history and physical signs

13. I can understand why the family questioned whether more should have been done when Mr K ultimately developed peritonitis; a perforated peptic ulcer was found at surgery after he had been in hospital for over a week; and after his death he was found to have had cancer. However although only the nursing records rather than the medical records indicate a history of peptic ulcer, it is clear that that was seen as a possible cause of Mr K's illness from the start. Three main diagnoses were considered: a peptic ulcer, inflammation of the pancreas and inflammation of the gall bladder. Various tests were performed which, at one point, made inflammation of the gall bladder seem most likely, though suitable treatment for ulceration was continued throughout. At one point Mr K's condition had appeared to be improving, and the assessors explained that in the circumstances the conservative treatment was appropriate. In summary the assessors concluded that sufficient attention was paid to Mr K's past and present medical history and that the treatment given was entirely appropriate. I agree. I do not uphold the complaint.

Complaint (b)
An endoscopy ought to have been done

14. A peptic ulcer was always seen as one possible, but not the only possible, diagnosis, and treatment for that was given. Although the possibility of an endoscopy is not mentioned in the notes, I recognise that that may well have been mentioned to the family at some point. However the assessors explain that an endoscopy could have been dangerous to Mr K: given the possible diagnoses, it might have caused perforation of an ulcer or peritonitis if that had not already occurred. The treatment which was given aimed to treat an ulcer and thus prevent perforation. The assessors have advised that the surgeons acted reasonably in not performing an endoscopy. I do not uphold this complaint, though I hope that the advice of the assessors will have provided reassurance to Mr K's family about his treatment.

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Conclusion

15. I have set out my findings in paragraphs 13-14.

Appendix A to E.1476/97-98

Glossary of technical terms

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Short text of this investigation

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Last updated: 12 January 2006