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Selected Investigations Completed April - September 1999 > Part II, Case no. E.1019/97-98

Chapter 1: Hospital, Community Health and Ambulance Trusts

Case No. E.1019/97-98 - Hospital treatment of a woman with abdominal pain

Complaint against: St Helens and Knowsley Hospitals NHS Trust

Complaint as put by Mr W

1. The account of the complaint provided by Mr W was that his wife was admitted to Whiston Hospital, which is managed by the Trust, on 15 November 1996 with abdominal pain and vomiting blood. She was discharged on 22 November, still suffering from abdominal pain. She was readmitted on 25 November with severe abdominal pain and the following day surgeons operated to remove a section of her bowel. Although initially her health appeared to improve, she deteriorated and on 20 December a doctor told Mr W that his wife urgently required surgery but that there was a high risk that she would not survive. Mrs W had surgery later that day. She died on 22 December.

2. The complaints investigated were that:

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Investigation

3. The summaries of complaint for the investigation were issued on 8 January and 11 June 1998. The comments of the Trust were obtained and relevant papers were examined. Evidence was taken from Mr W and the Trust staff involved. The Commissioner appointed independent clinical and nursing assessors to advise him on the clinical issues in this case: a consultant surgeon; a consultant physician/gastroenterologist; and a senior nurse. They attended interviews with key relevant members of staff. Their report is included at paragraphs 19-28 and 53-65 of this report. In reaching my findings I have taken into account the assessors' report, as well as the oral and written evidence obtained during the investigation.

Complaint (a) Unsatisfactory arrangements for Mrs W's discharge

Mr W's evidence

4. Mr W said that he did not think his wife should have been discharged on 22 November as no firm diagnosis had been made and she was still in pain. He did not know what further investigation or treatment was planned. Although his wife had a follow-up outpatient appointment for 3 December, that had been made two months earlier.

5. He said that when he collected his wife at about 1.00pm on 22 November an auxiliary nurse told him that his wife needed to take some medication with her but it was not ready. He returned to collect it at about 2.30pm, but a nurse told him that the afternoon staff were now on duty and any medication waiting to be collected when they arrived would have been returned to the pharmacy and destroyed; it would probably be available again on the following morning. He returned the next day and collected a bottle of lactulose liquid (a medication to help emptying of the bowels); nothing else was provided. His wife had a stock of her regular medication at home.

6. Neither Mr nor Mrs W was given a discharge summary for her general practitioner (GP) or other written information; and although Mrs W was still in pain, she was given no advice about what to do if it worsened.

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Trust Comments

7. In comments at the start of this investigation, the chief executive wrote:

' .... The cause of the abdominal pain was not firmly established and investigations were to continue into this. Mrs W did have gallstones and the possibility of the pain being related to this was considered, as were other possible diagnoses .... as Mrs W's symptoms eventually settled she was discharged with the intention of continued follow up .... a patient is often discharged without a firm diagnosis .... being made and [the] investigation continues, whilst it is unnecessary for the patient to remain in hospital .... On balance, despite the outcome, I .... feel Mrs W's discharge was timely [and] appropriate .... there seems little further the medical staff could have done .... that could not be continued as an outpatient. In fact Mrs W herself was very keen to go home .....'

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Documentary Evidence

8. The Trust's discharge policy at the time of Mrs W's discharge included:

'Information about discharge will be given both verbally and written to all patients/carers. This will include information on medication and will .... also include details of follow-up appointments ....

'In order that good practice occurs the overall responsibility for co-ordinating the mechanisms of discharge rests with the primary/named nurse/ward manager responsible for the patient's nursing care'.

9. Entries in the nursing notes include:

'21.11.96 9.00pm: Patient mentioned pain [on] 2 occasions .... nursing staff unalerted [Mrs W did not] mention doesn't wish it [to] stop her going home—painfree at time of writing—however encouraged her to tell us—described as nibbling pain across underarm—[Mrs W] thinks wind—bowels not opened for 3 days, is taking opening medication.

'22.11.96 6.00am: Comfortable night. Slept quite well.

Complained of pain at 9am across [left] side of chest. Lasted a few seconds. No other complaints ....

12.45pm: Mobile and self caring. Discharged for home as per hospital policy.'

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10. Entries on the preparation for discharge plan (the discharge plan) included:

'20/11 [Ward round] .... if OK home Friday TTO [medication to take out] .... Reinject 3/12/96. Already has this appointment.

'21/11 Discharge tomorrow 22/11/96 at 12.00 - 1.00pm.

'22.11.96 [Seen by consultant physician] - home after bowels open - 2 enemas given with good result

For reinjection 3/12/96 Patient got own information

- TTOs .... '

There was a tick by the entry 'TTOs'.

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11. The medical records contain notes about Mrs W's treatment made following ward rounds on 20, 21 and 22 November. They do not refer explicitly to a decision to discharge her.

12. The records contain three discharge summary forms for Mrs W's GP. They are dated 20, 21 and 22 November. The first lists five medications she was to take home and states she has been given 'full' information. The second and third do not contain full details but note simply 'extra TTOs'. The second increases the recommended dose of one of the medications mentioned before, and the third adds a laxative medication.

13. The Trust's Checklist/Guidelines for Routine Discharge (the discharge checklist) consisted of a list of 16 items. The entry on Mrs W's form for 'GP summary forwarded to GP' has not been ticked but a date of 22 November has been entered against the date the summary was sent to the GP via the patient/relative. 'Medication supplied' and 'written advice for discharge given to patient' were both ticked.

14. The GP's records contained two copies of each of the discharge summary forms completed on 20 and 21 November, but not that from 22 November. It is not possible to tell how and when they reached the GP but usually one copy would be posted and the other sent with the patient.

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Evidence of Trust staff

15. The consultant physician, who had since retired from the Trust, wrote to this office that they had found that Mrs W had varices (varicose veins in the gullet of which chronic liver disease is a possible cause) and assumed that they had caused the bleeding and that the abdominal pain had been caused either by gallstones or by a urinary infection. She was given intravenous antibiotics. The pains had settled and her condition had improved enough for discharge. The plan had been to re-inject her varices in a further two weeks; no other investigations had been arranged.

16. None of the nurses, interviewed separately, who were involved in Mrs W's first admission, could remember Mr or Mrs W.

17. The senior nurse manager, the ward sister and three nurses, interviewed separately, said that the tick on the discharge plan against TTOs indicated that the medication had been arranged. If it was not ready when a patient was ready to leave a relative could return to collect it later. It was not routinely returned to pharmacy if uncollected.

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18. They said that the ticks by the GP summary, medication and written advice sections on the discharge checklist indicated that Mrs W had been given the GP summary, her medication and a hospital discharge leaflet. The senior nurse manager added that a GP summary would have to have been completed for the medication to be provided by pharmacy.

19. Mrs W suffered from primary biliary cirrhosis; a gradually progressive disease of the liver eventually resulting in liver failure and death. She had been on steroids for three years and on admission on 15 November 1996 (under the care of the consultant physician) was on Ursodeoxycholic Acid (a drug used to treat her liver problem) and Spironolactone (a drug to prevent accumulation of fluid). She was admitted having vomited bright red blood on three occasions and had probably passed a melaena stool (faeces containing blood altered by stomach acid). She had experienced a niggling pain across the lower abdomen and a feeling of tightness. The lower part of her abdomen was very tender when touched.

20. On admission she was pyrexial (feverish) and jaundiced (a yellow discolouration of the skin associated with liver problems). She had spots on the skin called spider naevi which are typically seen in patients with liver disease. On examination, her abdomen was soft and there was some tenderness and guarding in the lower part of the abdomen. She was assessed and found to be anaemic (lacking in haemoglobin—the carrier of oxygen in the blood) and had a temperature of 37.7C. She was given intravenous fluids, started on antibiotics and an examination of the lining of the stomach, oesophagus and duodenum was carried out to try and ascertain the source of the blood loss. That revealed varices in the lower part of her oesophagus which would fit in with a diagnosis of primary biliary cirrhosis. No active bleeding was noted and there was no sign of any blood in the upper gastrointestinal tract. One slightly abnormal vein was injected to prevent bleeding.

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21. She was seen by the surgical team on 16 November and there was no sign of peritonitis (infection of the membranes covering the bowel). Her haemoglobin was still low. An ultrasound scan (a diagnostic procedure to examine deep tissues) of the abdomen was carried out. That showed an enlarged liver and spleen and that she had stones in the gall bladder. She was reviewed by the surgical team on 18 November and was noted to be much better. Her condition seemed to remain satisfactory although on 20 November she had quite considerable swelling of both legs (oedema) which occurs in liver disease. The oedema was probably associated with the replacement fluids she was given, as they contained quite a lot of salt.

22. On 21 November Mrs W was mobile, self-caring and had taken a bath. An entry in the nursing records at 9.00pm states that Mrs W mentioned that she had had pain on two occasions during the afternoon but had not mentioned it as she did not want it to stop her going home. At that time she was pain-free but was told to report any recurrence. The night of 21 November was satisfactory; she had some pain on the left side of the chest which lasted for only a few seconds, but no other complaints. Nursing staff said that, in such circumstances they would normally discuss with the patients the need to tell them about pain so that it could be treated and investigated if necessary. They would pass the information on to medical staff when the patient was next reviewed, but would not necessarily document that. The nursing record for Mrs W does not indicate that the information about her pain had been passed to medical staff. Although ideally that should have been done and documented, failure to do that would not mean that the care had fallen below a reasonable standard. There was no entry in the medical notes that Mrs W was in pain on 22 November and we therefore conclude that the medical staff did not know that she had suffered intermittent pain over the 48 hours before her discharge. Had they known, they would have needed to examine Mrs W and come to a conclusion about whether she needed to stay in hospital or be discharged. The action required would have depended on their assessment of the importance of the pain from the point of view of site and severity. Mrs W might still reasonably have been discharged, because of the fleeting nature of the discomfort and the fact that she had been up and about in the ward.

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23. During this admission the precise cause of Mrs W's bleeding was not detected although it was likely that she had bled from one of the varices in her oesophagus. However, the bleeding stopped and by the time of her discharge her haemoglobin levels had risen without the need for a blood transfusion.

24. Similarly, no definitive reason for her abdominal pain was ever diagnosed. While there are no entries in Mrs W's notes, that she received any advice as to what to do if her pain recurred, it would have been normal practice for somebody to have told her to return to hospital if it did. That is the kind of information that would not necessarily have been documented although it should have been.

25. On the day of her discharge she was seen by the consultant physician and was due to see him again for further injection of her varices, at an outpatient appointment on 3 December.

26. Although no definitive diagnosis had been reached, we believe it was appropriate for Mrs W to have been discharged. The nurses recorded that Mrs W had experienced some pains which were of short duration and which we do not consider were of clinical significance. They should have reported this information to the medical staff. There were no entries in the medical notes to indicate that she was in pain and she was seen on the day of discharge by her consultant physician. The length of time between her discharge and outpatient appointment, nine days later, was appropriate and that appointment would have offered sufficient opportunity for Mrs W to discuss any symptoms.

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27. The Trust has a robust and comprehensive discharge policy. Mrs W's discharge was planned using the routine discharge checklist which nursing staff confirmed was not completed until an action had been carried out. The discharge checklist was complete and indicated that Mrs W had received a GP summary, a hospital discharge leaflet and her medication.

28. Although it is not best practice for patients to be discharged from hospital until medication is available, there is no doubt that the pressure for beds for medical emergencies frequently means that patients who are fit for discharge are requested to vacate their beds and wait in day rooms until their medications are dispensed from pharmacy. It must also be recognised that should a patient wish to leave hospital without their medication, and suggest that someone will return to collect it, or indeed that they do not require it as they have stocks at home, there is little nursing staff are able to do to prevent that. The hospital records would support that medication was prescribed and dispensed. As Mr W was only given one of the items and it is not clear that he was actually given a GP summary or a hospital discharge leaflet, it must be assumed that for whatever reason the system broke down on this particular occasion.

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Findings: (a)

29. There are two aspects to this head of the complaint: first, whether Mrs W should have been discharged when no firm diagnosis had been reached and second, about the practical arrangements. In respect of the first aspect, the nursing records show that Mrs W was in pain on the day before her discharge but had been reluctant to mention it in case it might affect her planned discharge. The nurses properly recorded that and encouraged her to report pain to them, which she did the following morning: but there is nothing to show whether they passed that information on to the doctors and it appears that they did not. While it would have been better if they had, the advice of the assessors is that that did not mean the care was below a reasonable standard. I cannot know what the doctors would have done, had they known. I am advised by the clinical assessors that, not knowing that Mrs W was in pain, it was appropriate for to have been discharged although no firm diagnosis had been reached: she had been seen on the day of discharge and had a further outpatient appointment. I accept that advice. They also advise that it might have been reasonable to discharge her even if the doctors had known she was still having some pain. They believe that she would have been advised to return to hospital if the pain recurred: they comment that that should have been documented although it was not. Since it was reasonable (though not ideal) that the nurses apparently did not tell the doctors about the further episodes of pain, and reasonable in those circumstances for the doctors to discharge Mrs W, I do not uphold this aspect of the complaint.

30. In respect of the second aspect, Mr W said that he had been unable to collect all the prescribed medication, and that he and Mrs W had been given neither a discharge summary for the GP nor any other information. The discharge documentation described by the nurses, none of whom remembered the events, suggests that all those items had been prepared and supplied but there is no evidence that Mr and Mrs W received them, though the GP did receive a copy of two of the three summaries prepared. Nor does the evidence enable me to determine why the confusion over the medication arose. However, as the assessors said, it appears that the discharge system broke down. I uphold this aspect of the complaint.

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Complaints (b) and (c) Failure to take appropriate action after surgery and family not adequately informed of Mrs W's condition

Mr W's evidence

31. Mr W said that on 25 November he went with his wife to the hospital's accident and emergency department. She was suffering from severe abdominal pain. She was examined and had a series of x-rays but nobody explained anything to him. When he visited Mrs W the next day, a doctor told him that he suspected that there was a blockage in her bowel which would require surgery. An operation was performed later that day. When he rang that night he was told that although part of his wife's bowel was gangrenous and had been removed, she was stable.

32. About three days later, a nurse told him that she thought his wife would be going home soon. Although the staff grade surgeon (the surgeon) who performed the operation did not speak to him personally, his wife told him that the surgeon was pleased with her progress. The next time the surgeon visited it was decided to start Mrs W on solid food. She tried to eat but solid food seemed to cause her discomfort. Mr W thought she probably did not tell anybody about that.

33. Some time later the nurses called a doctor to see Mrs W who was shaking and shivering. The doctor told him that it might be a liver problem and he would ask the consultant physician to examine her as soon as possible. Two days later the consultant physician had still not visited and Mr W told the nurses he would like to speak to him but that did not happen. When the consultant physician visited he suggested that Mrs W be taken off solid food and given high protein drinks.

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34. A few days after the operation Mrs W's condition deteriorated: the abdominal pain had returned ; her legs and abdomen began to swell; and she had problems walking. She was also losing a lot of weight but when Mr W asked a doctor about that he was told it was because she was not eating. The surgeon suggested that a tube be inserted so that she could be fed but that never happened; another doctor told him that, because of problems with her blood, inserting a tube might cause further complications and it would be better if she could manage the high protein drinks.

35. The surgeon had thought there might be a build up of fluid and after two scans, a drain was inserted. The drain discharged a yellow coloured substance but one night Mr W noticed a change in the colour; a nurse told him that that was a sign of improvement. Later the substance turned a dirty brown colour and he asked a doctor why that had happened. The doctor sent a sample for tests and told him that it was possible that the substance was coming from Mrs W's bowel.

36. Over the next few days she seemed to get weaker but nobody told him anything. When he visited her on 20 December, there were doctors and nurses in her room. He asked a doctor what was happening and she told him that his wife needed another operation; it was suspected that she had a small hole in her bowel. They would like to operate as soon as possible. Later, an anaesthetist came and asked him if he knew his wife was dying and explained that, because of her liver problems, her blood was not clotting properly. It was possible that she would not survive the operation. That was the first time Mr W had been told that his wife was seriously ill. He did not understand why he had been told that by a doctor whom he had never seen before. He did not think that his wife had known any more about her condition than he had.

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Trust comments

37. In comments at the start of the Commissioner's investigation the chief executive wrote:

'Subsequent to the [operation] undertaken on the 26 November 1996, at which it was found that [Mrs W] had an infarcted distal loop of ileum [the lower part of the small intestine starved of blood because of an arterial blockage] with the terminal ileum also looking ischaemic [lacking in blood], [Mrs W] seemed to make a good recovery. She was on the verge of being discharged home when she became pyrexial and her white cell count rose [an indication of infection]. Investigation was undertaken which included ascitic tap [the collection of fluid from the abdominal cavity], CT scan [which could give more information about the state of the abdominal organs] and drainage of sub-phrenic collection [an abnormal accumulation of fluid or pus against the diaphragm] of thick foul smelling fluid.

'[Mrs W's] general condition remained poor but neither improved [nor] worsened. She retained an appetite and her bowels continued to work reasonably normally. However as fluid continued to drain a gastrograffin enema [insertion of a special dye visible on x-ray] was undertaken which suggested a small leak, possibly at the site of the previous anastomosis [joining together by operation]. [Mrs W] was taken back to theatre for repair however, sadly, she died [two days later].

'.... when dealing with any patient and particularly one as seriously ill as [Mrs W], communication can always be improved .... Whilst I feel the documentation .... supports the fact that Mrs W herself was kept fully informed, I accept that this was not made as clear as it could have been to [Mr W]. Having said that, he was aware of [Mrs W's] long standing multiple problems and as soon as the outlook looked poor was informed of this, of course by this time he felt it was too late .... Apologies were sincerely offered to [Mr W] regarding this aspect of his complaint .... although it was felt that communication was not significantly at fault ....'

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Documentary evidence about communications

38. Entries made on Mrs W's 'patient interview' form on 25 November included entries of 'fully aware' in the sections for recording the family's and the patient's understanding of the patient's condition.

39. Entries made in the nursing notes included:

'27.11.96 Comfortable on return to ward. Husband informed of [wife's] return and basicalities of operation

'10.12.96 [1.00pm]: 'Husband present on ward as concerned about wife's condition reassured by [house officer]

'10.12.96 pm: Husband wishes to speak with [surgeon] ....

'20.12.96 'Returned from theatre, [senior house officer] interviewed family as to poor prognosis....'

40. An entry made in the medical records on 20 December, by the senior anaesthetic registrar included:

'I have explained to her husband in view of her medical problems compounded by surgical problems she remains at high risk of dying .... but she will certainly die if she has no [operation].'

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Evidence of Trust staff

41. The surgeon said that it was not until 6 December 1996 that Mrs W's condition appeared to deteriorate. The house officer decided that there might be an infection of the ascites [a fluid collection, often developed by patients with chronic liver disease, within the abdominal cavity]. A request was made for her to be reviewed by a medical registrar. (Note: the clinical record shows that the medical registrar visited and examined Mrs W on 6 December.)

42. When he saw Mrs W on 9 December her abdomen was swollen and tender and her haemoglobin level was low. He arranged an x-ray and that revealed a sub-phrenic collection. From the records he knew that the surgical house officer also saw Mrs W that day and drew off some 'thick faeculant smelling bloodstained fluid' from inside Mrs W's abdomen. It was sent for testing. He could not remember if he had been told anything about that at the time. On 11 December he arranged for a CT scan and a drain was inserted to draw off the sub-phrenic collection. He thought he would have told the consultant about that but did not record such a discussion. At his ward round on 13 December the consultant surgeon thought Mrs W's symptoms were due to infected ascites.

43. On 17 December there was a rise in her white blood cell count and a change in the colour of the drainage fluid to a dark cloudy liquid; until then it had just looked like infected ascitic fluid. At that time he thought the change in the symptoms might be due to a small bowel fistula (a hole in the small bowel) and sent the drainage fluid for tests. The results were received on 18 December and he arranged for a gastrograffin enema which was carried out on 20 December; the findings suggested a leakage out of the bowel and a slight irregularity in parts of the colon suggestive of ischaemia.

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44. He could not remember whether he spoke to Mr or Mrs W but it was his usual practice to talk to patients and their relatives. He would explain about the patient's condition and the options for treatment. In Mrs W's case, he would have explained that he would not know what he would find until he performed the first operation and that she would be very poorly afterwards. After the operation, he would also explain what had happened. However, he had not documented any such conversations.

45. The consultant surgeon (under whose care Mrs W was re-admitted on 25 November) said he first saw Mrs W on 29 November and was surprised to find her relatively well, given her underlying problems. He saw her again on 2 December. On 6 December her condition had started to deteriorate and on 9 December, the ascitic fluid was found to be thick and faeculant smelling. He thought staff may have continued to think simply that the ascites were infected rather than of the possibility of a leakage from the bowel. They were still thinking that on 15 December, when Mrs W became quite poorly.

46. He considered that an opportunity had been lost because it took so long to recognise the leak. If it had been diagnosed, although that would have been difficult at that time, on 6 December the outcome might have been different. However, even at the time of her first admission Mrs W was very poorly and was a poor candidate for surgery. She had a severe systemic disease which was a constant threat to her life, and it was difficult to say just how much difference an earlier diagnosis would have made. A second operation would have been extremely risky at any time but, despite that, he thought that should have been performed on 9 or 10 December. The fact that Mrs W was relatively well immediately after her first operation might have lulled them into a false sense of security; if the anastomosis was going to break down he would have expected that to have happened in the first week.

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47. The consultant surgeon believed he spoke to Mr and Mrs W about her condition but he could not be sure as that was not documented. However, he remembered that Mr W was a frequent visitor.

48. The consultant physician, who had been treating her liver condition and who was responsible for Mrs W's care during her first admission, wrote:

' .... During the second admission she knew the cause of her acute abdominal [pain] was .... an infarcted [dead as a result of lack of blood supply] small bowel but we did not know why this had happened.

'My role during [Mrs W's] second admission was to give advice when requested by the surgeons .... I would certainly have visited her as a matter of routine as an old patient of mine who had recently been discharged from my care but would not have interfered with the surgical management unless requested.

'If [Mr or Mrs W] had wanted to speak to me .... there would have been no problem. Obviously [Mrs W] could speak to me when I was on my ward rounds and [Mr W] could have arranged a time via the nursing staff.

'I recall speaking to [Mrs W] about her condition on both admissions .... I seem to remember speaking to [Mr W] at [his wife's] bedside on the second admission but not in great detail. [Mr W] would presumably have spoken to [the consultant surgeon] and/or [the surgeon] as they were in charge of [Mrs W's] clinical care. It can lead to serious confusion or misunderstanding if someone not in direct control of the patient also provides information without knowing what has already been said.'

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49. The house officer said that she remembered speaking to Mr W and telling him his wife was poorly. She visited the ward each day and always told patients and their relatives what was happening. At that time she did not always document such conversations but she did so now. If a patient or relative wanted to see the consultant then an appointment was made for them to do so.

50. The nurse who recorded on 10 December that Mr W wanted to speak to the surgeon said that if the surgeon had not visited the ward by the time she went off duty, she would pass that information on to other nurses. The surgeon always spoke to relatives or patients if he were asked and she thought he had spoken to Mr W.

51. Mrs W's named nurse said that another nurse (who has since left the Trust) had completed the patient interview form (paragraph 38). She recollected that Mrs W had been very poorly after the first surgery but then seemed to improve to the point where they thought she might go home soon. Mrs W then took a turn for the worse. Mr W visited regularly, for long periods of time; he was very anxious and always asked questions. She thought he had been told about his wife's condition, but had not realised quite how poorly his wife was. His questions had been about day-to-day issues rather than about Mrs W's long term prognosis. If she had been involved in giving 'bad news' to a patient she would have documented that.

52. The senior nurse manager said the entries on the patient interview form meant that Mrs W's condition would have been explained to her and her family. Requests to nurses by patients or relatives to see a doctor should be documented but, with the nursing documentation at that time, that might not have happened. New documentation would shortly be implemented. That included a larger section for recording the summary of the patient's and relatives' understanding of condition on admission. There was also a section for documenting oral communication between nurses, doctors and patients, as well as a sheet for use by nurses and patients and relatives to communicate in writing with each other.

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Assessors' report

53. Mrs W was readmitted as an emergency late in the evening of 25 November 1996 when she complained of sudden upper abdominal pain and vomiting in the few hours prior to admission. On examination, she had signs of liver failure with evidence of jaundice and spider naevi. There was fullness of the abdomen and examination suggested there was free fluid present in the abdominal cavity. She was tender on the right side of the abdomen.

54. She was initially seen by the on-call medical team, who felt that she was ill and needed to be seen by a surgeon. She was subsequently seen by the surgeon, who diagnosed peritonitis and a possible hole in the bowel. The surgeon felt he should operate to find out exactly what was going on.

55. Investigations had revealed that Mrs W's blood clotting was abnormal due to her poor liver function and this was corrected preoperatively. She was seen by the on-call anaesthetist team who passed her as ASAIV (American Society Anaesthetist Class 4); that means that Mrs W had a severe systemic disease which would seriously reduce her chances of surviving anaesthetia and surgery.

56. A laparotomy (exploratory operation) was performed by the surgeon on 26 November. He found a 15 inch loop of small bowel with no evidence of an effective blood supply. He felt that this was probably due to a blockage in the arteries of the bowel. He also noticed that some of the coverings of the organs in the stomach showed evidence of very poor blood supply and that veins were present in this tissue which was thrombosed (blocked). The far end of the small bowel, with part of the beginning of the large bowel, was removed and an anastomosis was performed.

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57. Mrs W's initial postoperative recovery was satisfactory. There were some problems relating to her abnormal blood clotting and a deficiency of platelets (blood cells which assist in the clotting process). However, she made good progress until 6 December when she had a sudden onset of pain and fever. She was noted to be tender low down on the right side of the abdomen and her white blood cell count was raised indicating infection; blood cultures were taken to try and see what this infection was. It was initially thought that she had developed an infection of the ascitic fluid present in the abdomen and so a medical doctor (the on-call medical registrar) was called to her.

58. On 9 December she was noted to have persistent fever with a distended and tender abdomen. An ascitic tap was performed which produced foul-smelling blood-stained fluid that looked as though it could have come from within the bowel.

59. A chest x-ray was performed on 10 December and that suggested there was a collection of pus below the diaphragm and a CT scan was carried out the following day. That confirmed the presence of the collection of pus suspected from the chest x-ray and a drain was inserted to clear the pus. To assist with the insertion of the drain a second scan was carried out. That is standard practice.

60. The following day her temperature had fallen and her condition improved. However, this did not last long and, on 15 December, there was a further rise in temperature and she had rigors (hot and cold shivery bouts). On 17 December it was considered that she might have a leak of bowel motion into the abdomen and subsequently into the drain. She was seen by the consultant physician the next day. He suggested she must have a fistula in the small bowel and on 19 December a gastrograffin enema confirmed the leak at the junction between the small and large bowel, the site of the first operation. An anaesthetist came and re-assessed Mrs W to see if she was well enough to have an anaesthetic. He felt that the surgery would be a high risk as the patient was still categorised as ASAIV but it was decided that a further operation was necessary.

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61. On 20 December a surgical registrar carried out the operation. He found a litre of faecal fluid within the abdomen and a small hole was present at the junction of the small and large bowel. That was stitched and an ileostomy (bringing the end of the small bowel to the surface of the abdomen) was performed. Unfortunately the patient's condition deteriorated over the following 24 hours and she died on 22 December.

Conclusions

62. We deal first with the delay in diagnosis of the anastomotic leak. Mrs W was admitted to Whiston Hospital on 25 November with acute abdominal symptoms due to mesenteric venous thrombosis (blood clots in the veins leading from the intestine). That is a serious, though not well known, complication of primary biliary cirrhosis which leads to gangrene of the intestines followed by peritonitis and death, if surgery is not carried out; although the surgery itself carries a high risk of mortality and morbidity. The type of operation may be either a resection (removal) with joining up of the intestine at the time of operation, or removal with bringing up of the ends of the remaining intestine to the surface of the abdomen. The worry about joining the bowel up after removal of the diseased portion at the time of the initial operation is that it may leak due to poor blood supply and lead to peritonitis. If joining up is carried out at the first operation many surgeons would suggest having another look 24 hours later to see if all is well and to check the blood supply to the remaining bowel. The exact procedure carried out in an individual patient is a matter for mature clinical judgement.

63. Mrs W initially made a satisfactory recovery from the first operation but became unwell with signs of infection and subsequently this proved to be due to an intestinal anastomotic leak. We would agree that there was unreasonable delay in making the diagnosis of the cause of the infection; the patient was clearly at risk from this complication and the surgical staff should have been more suspicious about the cause of Mrs W's deterioration. Nevertheless, the deterioration began some ten days following surgery and it is unusual for anastomotic leaks to present at this stage. Usually one would expect problems within the first five days after surgery but Mrs W was described as being well, mobile around the ward and self-caring and we think that this window of improvement probably prevented staff from pointing out that although she had made this improvement, Mrs W was still extremely ill.

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64. Second, regarding communication about Mrs W's illness, part of the nursing admission documentation included a patient interview form, a section of which refers to the family and patient's understanding of condition. There would appear to be no common understanding of these entries among the nursing staff. After 10 December the nursing records contain no other reference to Mr or Mrs W being made aware of Mrs W's condition until Mrs W returned from theatre on 20 December when an entry states that Mrs W's family were made aware of the possible poor outcome.

65. We can find no positive evidence in the medical/nursing notes that Mr W was told about the seriousness of his wife's condition. We do, however, note that Mr W was a regular visitor to the ward and all three members of the surgical staff who were interviewed visited the ward regularly and expressed their willingness to talk to patients and relatives. We think it likely, therefore, that some information was imparted to Mr W though, clearly, it was inadequate. It is a pity that at the time when surgery was contemplated it seems to be the anaesthetist who spelt out the appalling prognosis. His very candid comments must have come as a shock to the family.

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Findings (b)

66. The consultant surgeon considered that it would have been difficult to have diagnosed the cause of Mrs W's deterioration earlier, but if that had been done, the outcome might have been different although he could not say to what extent. He further believed that the doctors had been lulled into a false sense of security by her recovery in the first few days after the first operation. Both he and the clinical assessors make the point that it is unusual for a leak to occur, where the cut ends of the bowel have been joined, as long after surgery as this one did. The clinical assessors have advised me, however, that despite that, the delay in diagnosing the leak was unreasonable. They say that the surgical staff should have been more suspicious about the cause of Mrs W's deterioration as she was clearly at risk from this complication. I accept that advice. I conclude that doctors failed to take appropriate action when there were signs of complications. I uphold the complaint.

Findings (c)

67. Mr W believed that throughout his wife's second admission, he and his family were inadequately informed about the seriousness of her condition. It clearly came as a shock to him when, immediately before her second operation, he was told by an anaesthetist about the high risk that she would die. Communication with patients and relatives about their condition is very important: but many factors have to be taken into account. The staff's first duty is to the patient, who may not always wish relatives to be given information about their condition. There is nothing to suggest that Mrs W did not wish to information to be shared with her husband. Patients and relatives may want different amounts of information at different times and may not always take it in when first told. Patients' conditions change and reassurance given one day may not hold true the next: I note that Mrs W initially improved after her first surgery but then deteriorated. Staff cannot predict with certainty what the outcome of treatment will be. There is a difficult balance for staff to strike between emphasising the worst possible outcome but potentially causing unnecessary distress and alarm to some patients, or trying to make patients feel better by providing reassurance and an optimistic note, but leaving them shocked if the outcome is poor. Efforts to meet patients' and relatives' needs for information will be jeopardised if there is no record of exactly what they have been told and understood so far: it is all too easy for each member of staff to assume that another has already explained the situation.

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68. The records of communications with Mrs W and her family are poor. Mrs W had a serious long standing liver condition. The initial entry of 'fully aware' against the patient's and relatives' understanding of Mrs W's condition, gives little real indication of what they understood about that or her particular problems at that time. I have quoted from nursing and medical records where they do refer to information being given to Mr W. The nurses and doctors from whom evidence was taken all said that a doctor would have spoken to Mr W if asked. Both the consultant surgeon and the consultant physician recollected speaking to Mr W, but if they did, neither discussion was documented. I note the new documentation that the Trust propose to introduce to record communication and I recommend that they monitor the effective use of that. Lacking any evidence of clear communications with Mrs W and her family about the seriousness of her illness until very late in the day, I uphold the complaint.

Conclusion

69. I have set out my findings in paragraphs 29-30 and 66-68. The Trust have agreed to implement my recommendation in paragraph 68 and they have asked me to convey through my report—as I do—their apologies to Mr W for the shortcomings which I have identified.

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Last updated: 9 January 2006