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Selected Investigations Completed April - September 1998 > Part II, Case no. E.1705/96-97

Part II - Full Texts of Selected Investigations

Case No. E.1705/96-97 - Doctor failed to carry out a diagnostic test and sanctioned discharge without adequate assessment; alleged failure in nursing care

Complaint against: Surrey & Sussex Healthcare NHS Trust (formerly East Surrey Healthcare NHS Trust), Redhill, Surrey

Complaint as put by Mr P

1. The account of the complaint provided by Mr P's uncle, the late Mr Q, was that on 12 June 1996 his wife, Mrs Q, was admitted to East Surrey Hospital (the hospital) with suspected internal bleeding. That afternoon a staff grade registrar requested an ultrasound examination of Mrs Q's abdomen. The ultrasound was cancelled by a surgical registrar after his ward round the following day. During Mrs Q's stay in hospital Mr Q was concerned that nurses did not monitor her fluid intake except to ask her if she had been drinking plenty and whether she had visited the toilet. On one occasion Mr Q noticed that his wife's intravenous (IV) fluid drip was not working properly, and he had to point that out to the nurses before it was changed. On 14 June Mrs Q was discharged by the surgical registrar with a tentative diagnosis of constipation; no follow up action was recommended. She suffered diarrhoea during the ambulance journey home, and arrived in a distressed condition. Mrs Q was re-admitted on 20 June following a home visit by a consultant geriatrician. She was diagnosed as suffering from cancer of the liver and died on 28 June.

2. On 24 June 1996 Mrs Q's GP (the GP) wrote to the East Surrey Healthcare NHS Trust (the Trust) to complain about her early discharge from hospital and aspects of her care. On 16 September a meeting was held between Mr Q, the consultant surgeon responsible for Mrs Q's care (the consultant surgeon), and the senior nurse manager for surgery. Mr Q remained dissatisfied with the explanations given at the meeting and requested an independent review of his complaint. The Trust's convener rejected that request. On 1 April 1998, the Trust joined with Crawley Horsham NHS Trust to become the Surrey and Sussex Healthcare NHS Trust (the new Trust).

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3. The complaints subject to investigation were that:

1. the surgical registrar:

   (i) cancelled a diagnostic investigation which would have revealed Mrs Q's underlying condition;

   (ii) sanctioned Mrs Q's discharge without adequate assessment of all her circumstances and medical problems; and

2. there was a failure in the nursing care in that:

   (i) there was inadequate management of Mrs Q's fluid balance;

   (ii) insufficient attention was paid to the deterioration in Mrs Q's condition on the day of her discharge.

Investigation

4. The statement of complaint for my investigation was issued on 21 August 1997. Sadly Mr Q, who made the complaint, died before I began my investigation. His nephew and next of kin, Mr P, asked me to proceed; and I considered it appropriate to do so. I obtained the comments of the Trust and relevant papers were examined, including Mrs Q's medical and nursing records for the relevant period. One of my investigators took evidence from staff of the Trust and from Mrs Q's GP and district nurse. I appointed two independent professional assessors to provide clinical advice, and their report is reproduced in paragraph 19.

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Evidence in support of the complaint

5. In his letter to me dated 18 February 1997 Mr Q wrote:

'I am dissatisfied at the level of investigation during my wife's hospital stay. I do not believe there were adequate checks of her fluid intake and output ... [A] doctor had ordered an ultrasound scan which was not carried out and I could not understand how she could be considered clinically fit for discharge without the benefit of that investigation. ... I remain dissatisfied that no [tests for blood] were made on stool samples. Instead the hospital explained the black stools as due to iron treatment and that haemoglobin levels were such that a gastrointestinal bleed could be excluded.

'On discharge, the working diagnosis was shown as "? constipation". No treatment was offered yet just prior to discharge my wife was uncharacteristically incontinent of faeces and ... suffered diarrhoea on the journey and after her return home.

'I cannot accept that my wife was clinically fit for discharge and believe that a medical opinion or the opinion of a consultant in charge of care of the elderly should have been sought before sending her home.'

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6. The GP told my investigator that on 12 June he visited Mrs Q, who had been complaining of pain in her abdomen. He rang the hospital; and while he was on the telephone Mr Q informed him that Mrs Q had vomited what looked like 'coffee grounds' and had passed black stools. The GP therefore informed the hospital doctor, possibly a senior house officer, that he was referring Mrs Q to the hospital with suspected gastro-intestinal bleeding. Mrs Q was very ill, and he was 'aghast' to discover that she had been discharged from hospital only two days later. He believed that the only reason Mrs Q was discharged on Friday 14 June was because of pressure on beds at the hospital. The district nurse said that Mr Q telephoned on 14 June and asked her to visit his wife, who had been discharged from hospital that day - she said it was unusual to have to visit a patient on the day of discharge. When she arrived, Mrs Q was very poorly and had vomited and suffered diarrhoea during the ambulance journey home. Mr Q was very distressed and did not want his wife to have to go back into hospital; he wanted to try to cope at home over the weekend.

The Trust's response to the complaint

7. In the Trust's formal reply to my Office sent in September 1997 at the start of my investigation, the chief executive wrote:

'... I am satisfied that [Mrs Q's] discharge was a reasonable decision ...

'During the meeting held on Monday 16 September ... [Mr Q] was advised that the nursing [records] showed amounts of fluid intake on a regularly recorded basis together with the recorded output. ... there was no mention on the nursing records of a drip having to be changed on [the afternoon Mr Q had specified].

'... the Trust accepts that, with hindsight, there could have been better discharge planning for Mrs Q, but ... her discharge was a clinical decision and was not based on a need to make beds available for other patients. The Trust also accepts that communication between medical staff and [Mr Q] was not of the standard that we aim to achieve and we regret any distress caused by this.'

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Mrs Q's medical and nursing records

8. Mrs Q's medical records include an entry by a staff grade registrar dated 12 June 1996:

'Soft [abdomen] Tender on the Right irregular solid mass involving the [right] side of the abdomen. ? [very] large liver or Ca[ncer]. For [abdominal ultrasound].'

'Patient well, apyrexial, not tachycardic, for free fluids ... [white blood count] 21.9'

10. The entry, by the same senior house officer, for the surgical registrar's ward round on 14 June reads:

'Patient well, apyrexial [no jaundice] ... pain resolved, for home today no follow up.'

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11. Mrs Q's nursing records include: 13 June untimed

' ... Remains [nil by mouth] mouthwashes given IV due [at 8.00 am] now due at [2.10 pm] [has not passed urine] overnight. Refused analgesia [this morning] painfree.' Entry by the night sister.7.00 am 'Has now passed 200mls urine. ...' Entry by the night sister.8.30 pm 'No complaints ... told to [use] bedpans, but tipped it down the toilet.' Entry by the senior staff nurse.untimed 'pulled out IV ... [doctor] informed - not for re-siting.' Entry by the night sister.14 June 11.15 am 'No [complaints of] pain. ... self caring morning. All [observations] stable. ... GP letter ... Transport booked for [afternoon] Husband aware.' Entry by junior staff nurse.~8.45 am 'Patient went into bathroom ... was incontinent of faeces slightly, helped wash her back [and] bottom [patient] was slightly confused why in the bathroom, escorted [back] to bed.' Entry by auxiliary nurse (see paragraph 18).3.30 pm '[District nurse] is not happy that [Mrs Q] has been sent home without any social input but I stressed that [Mrs Q] refused social intervention on admission, she was happy with this and apologised.' Entry by the ward sister.

Evidence of Trust staff

12. The surgical registrar told my investigator that he saw Mrs Q during his ward round on 13 June. He could not remember if he had given Mrs Q a physical examination, but said that, if he had examined her and had noticed an enlarged liver, there would have been nothing he could do about it; a frail, 90 year old woman was not a candidate for surgery. He could not remember if he had read the staff grade registrar's note recommending an abdominal ultrasound before he saw Mrs Q; but after he saw her he decided there was no need to order one. She had been admitted with a suspected bleed, and it seemed better to leave her alone and see how she coped. He believed it was pointless to put frail elderly patients through unnecessary tests when there was nothing that could be done for them. Even if the ultrasound had been carried out, he did not believe the outcome of that would have altered Mrs Q's treatment. She would still have been discharged, although the palliative care team might have taken over her care sooner. He said that, with hindsight, it would have been nice to have given Mrs Q a diagnosis of her illness, but if a similar patient were admitted to him again tomorrow under the same circumstances, he would not proceed any differently. He accepted that Mrs Q had effectively been denied the opportunity to know the cause of her illness.

13. The surgical registrar said that it was up to him to decide if a patient was clinically fit to be discharged; but he relied upon the nurses to tell him if there were other reasons why a patient could not go home. He said that nurses were very protective of their patients, and were unlikely to send a patient home if they thought it was not in the patient's best interests.

14. The consultant surgeon said that Mrs Q's GP had asked for her to be admitted because of suspected gastro-intestinal bleeding; but she displayed no symptoms during her stay in hospital which supported that. He said there was a conflict between the observations made during Mrs Q's first stay in hospital and the information that came to light after she was re-admitted on 20 June; and he believed that an ultrasound examination of Mrs Q's abdomen should have been carried out during her first stay. That would have 'clinched' Mrs Q's diagnosis and would have allowed the palliative care team to be called in earlier and the possibility of hospice care to be raised with Mr and Mrs Q. After his meeting with Mr Q on 16 September, the consultant surgeon had checked to see whether the staff grade registrar had actually ordered the ultrasound examination - he had not. The consultant surgeon felt that, as the staff grade registrar had suggested that Mrs Q required an ultrasound, he should have made sure that it was carried out. He would not have expected the surgical registrar to read Mrs Q's notes before seeing her on 13 June.

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15. The consultant surgeon said that when the surgical registrar decided to discharge Mrs Q on 14 June, he had 48 hours' worth of medical and nursing observations to help him make that decision. If Mrs Q had shown signs of jaundice the surgical registrar would have been more concerned; but, as the symptoms she came in with were no longer causing her a problem, then he could see why the surgical registrar decided to send her home. He said that, presented with the same medical and nursing observations, he would probably have made the same decision to discharge her.

16. The ward sister who was on duty on 13 June (the sister) told my investigator that she could not remember Mrs Q or her husband. She said that when monitoring a patient's fluid she would fill in a fluid balance chart, and record on the drug chart when an IV drip had been changed. As Mrs Q's medical records showed that she was awake and aware, nurses would have explained to her that if she needed to use the toilet, she should take a bedpan into the bathroom and inform a nurse when she had finished so that the nurse could measure the quantity of urine. The sister did not know why Mrs Q had been given a saline infusion at 4.00pm when a solution of 5% dextrose had been prescribed (paragraph 6 of my professional assessors' report), although she admitted she had signed the entry on the drug chart. She said it would not have made much difference to Mrs Q's treatment. The sister explained that a discharge planning form had been completed for Mrs Q by a staff nurse (the junior staff nurse), who would have contacted Mr Q to find out whether he was prepared to take Mrs Q back home and whether the home environment was suitable for her. The junior staff nurse could not recall Mrs Q, but said that if she had seen anything to indicate that Mrs Q was not fit for discharge then she would not have filled out the discharge form and would have alerted the nurse in charge of the ward.

17. The senior staff nurse said that, when patients were mobile, it could be difficult to check their fluid balance. For example, Mrs Q had been asked to use a bedpan so that nurses could monitor her fluid output; but on 13 June Mrs Q had used a bedpan and then emptied the contents down the toilet (paragraph 11). She was on duty for only four hours that day and so could not comment on Mrs Q's fitness for discharge. She was sure that the surgical registrar would have taken the opinion of nurses into account before he made the decision to discharge her.

18. The auxiliary nurse made the entry in the nursing records about Mrs Q being confused and incontinent of faeces on the morning of 14 June (paragraph 11). She said that she had not been looking after the patients in Mrs Q's bed bay, but had happened to see Mrs Q in the toilet and had offered to help. She could not recall exactly why her note, timed at 8.45am appeared after the previous entry timed at 11.15am, but thought she might have completed it after she had been back to see her own patients.

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Professional assessors' report

19. I reproduce next, in its entirety, the report prepared by the professional assessors whom I appointed to advise me about this complaint.

Report by the Professional Assessors to the Health Service Ombudsman for England of the clinical judgments of staff involved in the complaint made by Mr P

Professional Assessors:

The first assessor, FRCS MRCPConsultant General Surgeon

The second assessor, RGN RMN Ward Sister

Introduction

1. The report is based on the documentation provided, including Mrs Q's medical and nursing notes and the notes of the formal interviews conducted by the Ombudsman's investigating staff. 2. Mrs Q was a 90 year old lady who was admitted to East Surrey Hospital on 12 June 1996 with right sided abdominal pain of 10 days duration. She had been referred to the hospital by her GP with suspected gastro-intestinal bleeding. Mrs Q was treated conservatively and was discharged on 14 June with no follow up.

3. The matters we considered were:

1. The surgical registrar cancelled a diagnostic investigation which would have revealed Mrs Q's underlying condition, and sanctioned her discharge without adequate assessment of all her circumstances and medical problems.
2. There was inadequate management of Mrs Q's fluid balance, and nurses paid insufficient attention to the deterioration in Mrs Q's condition on the day of her discharge.

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Medical Care

4. Mrs Q's initial assessment at the hospital showed that she had traces of glucose, protein and blood in her urine. She was admitted to Tandridge ward by a house officer (the house officer) who took a complete patient history from her. He noted that she had marked epigastric tenderness (Note: that is, tenderness in the upper central region of the abdomen) but no masses, that her stools were dark but there was no fresh blood, and that she was taking iron supplements and erythromycin (an antibiotic). Her pulse rate was 120. Subsequent tests showed that her haemoglobin level was 14.2 and her white blood cell count was raised at 23.3. The house officer recommended that Mrs Q should be 'nil by mouth' and should receive intravenous (IV) fluids. He prescribed 50mg of Pethidine (an analgesic) and 10mg of Metoclopramide (a drug used to treat nausea).

5. Later the same day, Mrs Q's medical notes show that she was examined by a staff grade registrar who noted that she had an irregular solid mass involving the right side of her abdomen; he queried either a very large liver or cancer, and suggested that an abdominal ultrasound be carried out. The next entry in Mrs Q's notes is dated 13 June and is a note of the ward round made by a surgical registrar. It states that Mrs Q was well and apyrexial (without fever), she had no tachycardia (rapid pulse), her haemoglobin level was 14.5 but her white blood cell count remained high at 21.9. It was recommended that she be given free fluids. The entry for 14 June, again recording the surgical registrar's ward round, shows that Mrs Q's pain was resolved and that she was to be discharged that day with no follow up. Her pulse was between 80 and 90 and her blood pressure had been maintained at around 150/80.

Nursing Care

6. Mrs Q was assessed on admission and it was noted that she had refused any social intervention. We noted that her nursing records did not include a care plan. The nursing records show that she was given her medication at 6.30 pm on 12 June and that she settled and slept for varying periods. She refused analgesia on the morning of 13 June and did not complain of pain for the remainder of her stay in the hospital. She was given four litres of fluid intravenously during a 36 hour period, from 12 June until the afternoon of 13 June when it was noted that she had pulled out her IV drip when she went to the toilet. A doctor was informed who decided that the IV drip should not be re-sited (that is restarted in a different vein). It seems an infusion of normal saline was administered when 5% dextrose was prescribed, but this was unlikely to have an adverse effect. She was given mouthcare when she had no oral fluids. Her urine output was monitored infrequently; the nursing records showed that she had been asked to use bed pans but that she had emptied them into the toilet.

7. The nursing record for 14 June notes that Mrs Q passed a melaena stool (one which contained blood) overnight. In the morning she was self caring and all her observations were stable. A discharge planning form was completed, transport booked, her husband consulted and a letter was written to her GP. However, a note which appeared later in the nursing record, but which was timed earlier than the previous entry, said that she had suffered some faecal incontinence in the bathroom and that she was slightly confused. She was attended to by nursing staff.

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Findings

8. There were some aspects of her medical management which concerned us. The staff grade registrar had suggested that Mrs Q might have cancer, and we feel her raised white cell count was indicative of something serious. Junior medical staff should have taken more notice of that. We believe liver function tests, including a Gamma GT level should have been ordered. (Note: a raised level of the enzyme Gamma GT - gamma glutamyl transpeptidase - may indicate liver disease.) We doubt whether the surgical registrar read the staff grade registrar's notes on his ward round of 13 June and we criticise him for that. We were also concerned to note that Mrs Q was not seen by a consultant during her admission. However, since Mrs Q was a 90 year old woman in poor health and not a fit candidate for any intervention, we find, on balance, that her medical management was adequate.

9. It appears that the ultrasound scan recommended by the staff grade registrar was never actually booked. We feel that, had it been performed, her cancer would have been identified earlier and medical staff would have had a working diagnosis for her. Mrs Q, her relatives and GP would have been told about the diagnosis. This might have led to an earlier introduction of Macmillan nurses to provide palliative care. To that extent we criticise the Trust.

10. Mrs Q's medical problems appear to have stabilised during the 48 hours that she was in hospital. She had been sent in with suspected gastro-intestinal bleeding, but her haemoglobin levels of 14.2 on the day of admission and 14.5 the following day, had established that, if there had been any bleeding, it could not have been very much. Although her stools were dark, and the nursing records state that Mrs Q passed a melaena stool on 13 June, it is more likely that the dark colour was caused by the iron supplements she was taking. As well as making stools black, iron, possibly in conjunction with antibiotics, may also cause gastro-intestinal irritation. Mrs Q was apyrexial, her pulse had come down from 120 on admission to between 80 and 90 on discharge, and her blood pressure had been maintained at around 150/80. The surgical registrar sanctioned Mrs Q's discharge after assessing her in the morning, reviewing the clinical evidence and consulting the nursing team. Therefore, we feel that Mrs Q was discharged home after an acceptable assessment of her circumstances and needs.

11. We believe that Mrs Q's IV drip had been set up so that blood could have been given if the need had arisen; there was a possibility of haemorrhage if her initial diagnosis of gastro-intestinal bleeding had been confirmed. Although Mr Q stated that the IV drip had stopped, there is no documentation regarding this and the IV infusions were administered more or less to time. The amount of fluid administered was adequate for a frail elderly lady, and she was given mouth care when she had no oral fluids. We did note some errors in the fluid administered, but they were not significant. Her urine output was not monitored, although we know that she did go to the toilet to pass urine. We feel that Mrs Q's fluid balance was monitored to an acceptable standard.

12. On the day of her discharge, Mrs Q had some faecal incontinence in the bathroom and appeared to be confused. There is no reason for this episode to have prevented her discharge home as there was no indication that her overall condition had deteriorated. It is very stressful for an elderly person to be in hospital and ambulance journeys can be extremely uncomfortable and distressing. We feel that her deterioration occurred after her discharge rather than before.

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Conclusion

13. We have given our comments regarding the management and care of Mrs Q while in hospital and her subsequent discharge home. Although we criticised the omission of the ultrasound examination, we had no criticism of the level of assessment during Mrs Q's admission or of the decision to discharge her from hospital. We were satisfied with the management of Mrs Q's fluids by the nursing staff, and with their actions on the day of her discharge.

Findings

(a) (i) The surgical registrar cancelled a diagnostic investigation

20. On 12 June 1996, Mrs Q was admitted to hospital with suspected gastro-intestinal bleeding. That afternoon, she was examined by a staff grade registrar, who queried whether she had either a very large liver or cancer, and suggested an abdominal ultrasound. However, the ultrasound was not booked; and the following day the surgical registrar decided not to pursue it. He believed it was not worth putting elderly patients through tests when there was nothing that could be done for them. The consultant surgeon said that the ultrasound should have been carried out; and that view is supported by my professional assessors, who also believe that liver function tests should have been ordered. They have said that junior medical staff should have taken more notice of Mrs Q's raised white blood cell count, which was indicative of something serious and that, had the abdominal ultrasound been performed, Mrs Q's cancer would have been identified earlier and medical staff would have had a working diagnosis for her.

21. I accept that an earlier diagnosis of cancer would not have altered Mrs Q's treatment, but I can see that it might have made a great deal of difference to her care. Both the consultant surgeon and my professional assessors have suggested that Mrs Q could have benefited from an earlier introduction to palliative care; and Mr and Mrs Q could then have considered the option of hospice care. As it was, Mrs Q was discharged home without any firm diagnosis only to be re-admitted to hospital less than a week later, where she remained until she died. I consider that this caused Mr and Mrs Q unnecessary distress. As the ultrasound scan was only suggested, and not ordered, I cannot uphold the complaint as put. However, I consider that, in not carrying out the scan and liver function tests the Trust effectively denied Mrs Q the opportunity to know the cause of her illness and so failed in their duty of care; to that extent, I uphold this aspect of the complaint.

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(a) (ii) The surgical registrar sanctioned Mrs Q's discharge without adequate assessment

b) (i) Failure in nursing care - inadequate management of Mrs Q's fluid balance

23. As my assessors have noted, Mrs Q's nursing records show that, from her admission on 12 June until the afternoon of 13 June, when she pulled out her IV drip, she was given four litres of fluid. After that, she was given oral fluids. My professional assessors have stated that the amount of fluid administered to Mrs Q was adequate for a frail elderly lady. They did note some errors in the fluid administered, but did not consider them significant. The senior staff nurse said that it was difficult to check the fluid output in patients who, like Mrs Q, were mobile. Mrs Q had been asked to use a bedpan so that her output levels could be checked; but the nursing records show that, at least on one occasion, she emptied the contents into the toilet. My professional assessors have concluded that Mrs Q's fluid balance was monitored to an acceptable standard. I agree. I do not uphold this aspect of the complaint.

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b) (ii) Failure in nursing care - insufficient attention paid to the deterioration in Mrs Q's condition on the day of her discharge

Conclusion

25. I have set out my findings in paragraphs 20 to 24. The new Trust have asked me to convey to Mr P - as I do through this report - their apologies for the shortcomings I have identified.

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Last updated: 12 January 2006