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Selected Investigations Completed April - September 1999 > Part II, Case no. E.681/97-98
Complaint against: The former Radcliffe Infirmary NHS Trust, Oxford
Complaint as put by Dr Y
1. The account of the complaint provided by Dr Y was that on 3 September 1996 his brother-in-law, Mr W, had an operation at the Radcliffe Infirmary, Oxford, (the hospital) to remove a brain tumour. He remained unconscious for a few days because of swelling of the brain. His level of consciousness varied over the following three weeks, and he suffered a degree of paralysis. The Trust's medical staff failed to recognise signs of infection and to give Mr W any antibiotics. On 26 September a mini-tracheostomy was performed to allow secretions to be cleared more efficiently, and on 27 September he was transferred to another hospital (the second hospital). On 28 September he collapsed with left-sided pneumonia. From 1 October he was given antibiotics at the other hospital, and he recovered from the pneumonia. Mr W died in August 1998. The hospital was managed by The Radcliffe Infirmary NHS Trust (the Trust) until 31 May 1999; the Trust then joined with another Trust to become the Oxford Radcliffe Hospitals NHS Trust.
2. The complaint investigated was that staff of the Trust failed to diagnose or treat Mr W's chest problems.
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Investigation
3. The statement of complaint for the investigation was issued on 16 October 1998. The comments of the Trust were obtained; and relevant papers, including Mr W's clinical records, were examined. The Ombudsman's investigator took evidence from Dr Y and from staff of the Trust. The Ombudsman appointed two independent professional assessors to provide clinical advice, and their report is reproduced in its entirety in paragraph 12 below.
Dr Y's evidence
4. Dr Y, who is a retired general practitioner, told the Ombudsman's investigator that before Mr W was transferred to the second hospital foul-smelling green secretions were being extracted from Mr W's lungs, leading Dr Y and other members of the family to believe that Mr W had a chest infection. Dr Y said that even without 100% evidence of an infection, the nature of the secretions and Mr W's varying level of consciousness were sufficient indicators for the administration of antibiotics; as was the mini-tracheostomy, performed on the night of 26 September, since the operation site was a likely source of infection. Dr Y could not understand why the mini-tracheostomy had been done late at night, as though it was an emergency yet Mr W's condition had not deteriorated; or why Mr W was transferred to the second hospital so soon afterwards. He believed that, when Mr W was transferred to the second hospital on 27 September, a letter was sent with him in the ambulance containing instructions not to give antibiotics without the consent of Mr W's wife.
5. In a letter to the General Medical Council, dated 27 January 1997, Dr Y wrote that, in the days following 14 September 1996:
'Mr W's condition improved and he was transferred [from the intensive care unit] to the ward, still needing at this stage oxygen therapy and frequent aspiration of accumulated secretions. Having asked whether he was being given antibiotic therapy we were told that he had been given a complete course of antibiotics in the immediate post-operative period but none since then ...'
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Trust evidence
6. In his formal reply to the Ombudsman's Office, of 3 November 1998, at the start of the investigation, the Trust's acting chief executive wrote:
'I have reviewed the case with [the consultant neurosurgeon who was in charge of Mr W's care (the neurosurgeon)] and read the relevant documentation. You will see from the clinical notes that staff paid particular attention to Mr W's chest problems and provided active treatment and monitoring of his condition. This included a course of antibiotics immediately post operatively and daily physiotherapy throughout his stay at [the hospital]. His temperature chart indicates that when Mr W was transferred his chest condition was under control with physiotherapy, although he required suction of his secretions, hence the mini-tracheostomy. The significance of Mr W's chest problems was also indicated in the discharge information provided to the [second hospital], to which he was transferred on 27 September 1996.
'In the light of this evidence, and the opinions of those who were responsible for his treatment, I do not accept that the complaint is justified.'
7. The neurosurgeon wrote an account of Mr W's care, which included:
'... The suggestion has been made that [Mr W] should have been given antibiotics throughout this time. He was certainly given antibiotics up to 13 September. However, a chest infection in someone in Mr W's situation is treated by clearing the secretions with suction, encouraging the patient to cough and by, of course, physiotherapy. Antibiotics are not the main way of treating a chest infection, unless the patient ... develops pneumonia. There was no evidence that I can find that Mr W had pneumonia while he was [in the ward].
'... the temperature chart and nursing observation notes ... [show] that his temperature was swinging between 16 September and 20 September, but thereafter was reasonably flat and the last temperature recording on 27 September, prior to discharge was recorded as 37.5.
'In summary therefore, I can find no evidence to suggest that either the medical or nursing staff failed to diagnose Mr W's chest problems and no evidence to suggest that these were not treated expertly.'
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8. Mr W's clinical records include the following information:
323.1() he was given antibiotics from 5 September to 12 September;
323.2() he had chest physiotherapy once or twice a day on every day from 4 September to 27 September;
323.3() he had chest x-rays on 3, 5, 9, 10, 14 and 27 September;
323.4() sputum samples were taken on 5, 9, 14, 17 and 27 September; and
323.5() suction of secretions from his respiratory tract was performed frequently.
9. The discharge letter, a copy of which accompanied Mr W in the ambulance to the second hospital, was completed by a senior house officer in neurosurgery (the SHO), and included the following:
'... Productive chest with difficulty clearing secretions ... Minitrach[eostomy] inserted 25 9 96 to aid clearance of secretions.
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'INFORMATION GIVEN TO PATIENT
'... Not able to comprehend [diagnosis] in view of clinical condition. Wife fully informed at all times.
'... Poor prognosis in view of large area of infarct and site of infarct. Wife aware of this.
'... Other family members other than wife reluctant to accept poor prognosis.'
The discharge letter makes no reference to the withholding of antibiotic treatment, or to the consent of Mr W's wife being required for such treatment.
Further details from the clinical records are referred to in the clinical assessors' report at paragraph 12 below.
10. The neurosurgeon told the Ombudsman's investigator that he would never send a letter to another hospital telling them that antibiotics should not be given without a patient's wife's consent. He had no knowledge of any agreement with Mrs W about administering or withholding antibiotics. He did not use just antibiotics to treat chest infections—Mr W had been given a mini-tracheostomy and physiotherapy. His top priority had been to clear the secretions. He found that Mrs W had realistic expectations about her husband's prognosis; when he spoke to Dr Y he found him to have unrealistic expectations about the future quality of Mr W's life.
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11. The SHO told the investigator that she prepared the discharge letter prior to Mr W's transfer to the second hospital. She did it on the neurosurgical department's computer system, and it was the only letter which went with Mr W. (Note: the Ombudsman's investigator made enquiries at the second hospital—they have no trace of having received another letter.) Decisions about whether to give antibiotics to patients were made largely on the advice of the Trust's microbiologists. Following the mini-tracheostomy, Mr W's chest improved and antibiotics were felt to be unnecessary; she had considered him fit for transfer. The SHO spoke to Mrs W on several occasions—she had a realistic understanding of her husband's prognosis. They never discussed the question of withholding or withdrawing treatment; Mr W was given full, supportive active treatment at all times.
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12. I reproduce next, in its entirety, the report prepared by the Ombudsman's professional medical advisers:
Professional Assessors Report
Matters considered
Whether the staff of the Trust failed to diagnose or treat Mr W's chest problems, in particular at the time of transfer to the second hospital. Secondary considerations were whether feeding, or care in general, were withdrawn or withheld.
Basis of report
The report was based on documents made available at the Ombudsman's Office, listed below, and interviews undertaken by the Ombudsman's investigator and one of the assessors with the neurosurgeon and the SHO.
The following documents were considered:
(a) copies of Mr W's medical and nursing records for the period 2 September 1996 to 27 September 1996;
(b) the interview notes with Dr Y on 12 January 1999;
(c) copies of the response from the chief executive of the Trust to the Ombudsman's Office, and, enclosed with that, medical report dated 26 October 1998 prepared by the neurosurgeon; and
(d) a letter from Dr Y to the BMA Ethics Department, dated 10 October 1997.
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Review of the treatment of Mr W
Post-operative condition
On 3 September 1996, the day after admission, Mr W underwent a scheduled operation on his large residual pituitary tumour by craniotomy (opening the head to expose the tumour). Major technical difficulties were encountered with severe bleeding necessitating the clipping off of important brain arteries. As a consequence, post-operatively Mr W was suffering generalised seizures which necessitated intensive care and mechanical ventilation. His level of consciousness varied over the next few days with evidence of some degree of right sided paralysis. On 16 September he was transferred to the ward from the intensive care unit at which time he was not opening his eyes, was obeying verbal instructions, was unable to speak, but was making incomprehensible sounds. A brain scan showed damage to the frontal parts of the brain on both sides. On 17 September the neurosurgeon wrote in the notes that he felt Mr W's long term prognosis was poor in terms of functional recovery.
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Diagnosis and treatment of chest infection
(a) Intensive Care
In intensive care, antibiotics were administered for Haemophilus influenzae chest infection (Cefuroxime from 5 September to 12 September inclusive and Metronidazole from 6 September to 12 September). The tube for mechanical ventilation inserted into the throat was removed on 4 September and an airway was required in his nose to assist breathing and suction of secretions. Regular physiotherapy and chest suction were undertaken.
Nevertheless Mr W continued to have respiratory problems, which was to be expected given his poor level of consciousness. Proper care and monitoring were given to an excellent standard.
(b) Nuffield 1 Ward
Regular chest physiotherapy and suctioning were required. The first mention in the nursing notes of secretions being a creamy/pale green colour is to be found on 25 September and from this date more difficulty with breathing was documented. On 26 September Mr W developed rapid breathing (rate 30-40 per minute) and his chest sounded awful. Blood gases were measured and sputum was cultured. A neurosurgical registrar discussed the problem with the neurosurgeon who recommended a mini-tracheostomy, which was performed. A chest x-ray taken on 27 September showed fluid outside the lung but "no signs of pneumonic consolidation" (infection in lung tissue).
Mr W's temperature was satisfactory prior to the date of transfer, having been intermittently elevated before. Only one measurement reached 37.5C from 21 September to 26 September. On the morning of 27 September his temperature was over 38C on two occasions, but reduced to 37.5C at 10.00am, the last recording before the transfer. Infection was found in the sputum sample of 27 September (reported on 30 September as mucopurulent with a profuse growth of Haemophilus influenzae). Green sputum was recorded on 27 September, and the white cell count had risen. Shortly before transfer, oxygen saturations deteriorated to the low 90s and respiration was measured at 36 breaths per minute, which settled on 28% oxygen by mask.
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Plans for transfer
On 23 September the notes record that Mrs W (who was registered as the next of kin) wanted Mr W transferred back to the second hospital (which was nearer their home). At this time he was continuing to improve slowly and a further note records that he could be transferred there for rehabilitation after discussion with the clinician concerned. On 26 September the notes record that the neurosurgeon had been consulted and was happy for transfer to be arranged to the second hospital. The SHO spoke to a registrar at the second hospital on 26 and 27 September. She discussed the mini-tracheostomy and the registrar was "happy to resume care". One must presume the conversation on 27 September mentioned his current condition.
A computer generated discharge letter gave a brief summary of the treatment, mentioning the mini-tracheostomy and difficulty clearing secretions, but not specifically the evolving chest infection. There is no evidence of any other letter. There is no mention of withholding or withdrawing treatment. There is mention of the reluctance of members of Mr W's family, other than his wife, to accept his poor prognosis.
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Feeding
Dr Y was concerned that "the consultant in charge decided to withhold all feeding (including water and i.v. [intra-venous] therapy) thus sentencing the patient to die within a few days".
Prior to transfer, there were difficulties with feeding due to problems replacing the nasogastric tube which was removed by Mr W. Feeding was re-established prior to transfer. The dietician recorded the feeding regimen in the notes, and handed the plan over to the nutrition support service at the second hospital.
Assessors' comments on the actions of medical staff
1. There is ample evidence that infection was not only expeditiously diagnosed, but also enthusiastically treated whilst Mr W was on the neurosurgical intensive care unit. Although antibiotics were stopped prior to transfer out of the intensive care unit, this would seem entirely consistent with standard clinical practice as the diagnosed chest infection had subsided.
2. Ongoing efforts to contain further chest infections continued on Nuffield 1 ward with regular chest physiotherapy and suction of chest secretions. There is evidence that a new chest infection was developing at the time of transfer because of the increasing respiratory rate, green sputum and increasing fever in the light of evidence of infection on blood tests. In the absence of evidence of lung infection on x-ray, antibiotics cannot be considered imperative. Current best microbiological practice advises withholding antibiotics until culture results are available, unless the clinical condition is too bad to do so, to limit emergence of resistant organisms in hospitals. Clearly, close observation of the progress of this chest infection was going to be important in the ensuing days.
3. Whilst transfer with an evolving chest infection is far from ideal, it is sometimes necessary in busy neurosurgical units because of the pressure on facilities. However in these circumstances, and in particular with hindsight, it might have been wiser to have commenced antibiotics or to have delayed transfer.
4. Verbal communication on 26 and 27 September will have alerted receiving medical staff to the chest problems, but the written communication does not mention an evolving chest infection.
5. There is no evidence of withdrawal, or withholding, of care.
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Conclusion
Whilst the circumstances of the transfer do not appear to have been optimal, there is no evidence of failure to diagnose or treat Mr W's chest infection, nor of withholding, or intention to withhold, treatment. With the exception of the transfer arrangements, treatment was conducted to an extremely high standard.
Findings
13. Dr Y believes that Trust staff failed to diagnose or treat Mr W's chest infection. There is no doubt, or dispute, that Mr W was suffering from a chest infection post-operatively. The information recorded in his clinical records clearly shows that staff were aware of his chest problems, in that x-rays were taken, sputum samples were sent for analysis, chest physiotherapy was performed and he was given frequent suction of secretions from his respiratory tract (aided from 26 September by a mini-tracheostomy). An x-ray taken on 27 September showed fluid outside the lung but 'no signs of pneumonic consolidation' (that is he did not have pneumonia at that time). I agree with the assessors' view that there is no evidence that Trust staff failed to diagnose Mr W's chest infection. I do not uphold this aspect of the complaint.
14. Having diagnosed Mr W's chest problems as an infection, medical, nursing and physiotherapy staff took a range of steps to help him. The neurosurgeon wrote, in his account of the case, that antibiotics are not the main way of treating a chest infection, and he told the investigator that his top priority had been to clear the secretions from Mr W's respiratory tract. That was done with the aid of physiotherapy, encouraging Mr W to cough, and suction. The assessors have explained in their report that the decision to stop antibiotic treatment on 12 September was entirely consistent with standard clinical practice. They have explained also that it is best microbiological practice to withhold antibiotics until culture results are available, if possible, to limit the emergence of antibiotic-resistant organisms in hospitals. I do not accept that Trust staff failed to treat Mr W's chest problems; Dr Y has focussed on the fact that Mr W did not receive antibiotic therapy, but he did receive a range of other treatments, all of which are regarded as appropriate. I do not uphold this aspect of the complaint.
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15. In addition to the questions of whether Mr W's condition was diagnosed and treated appropriately (which it was), some other issues have emerged during this investigation. First, it is clear that Dr Y and other family members had a much more optimistic view of Mr W's prognosis than did the medical staff and Mr W's wife. I believe that that difference of view may have contributed to the disagreement between Dr Y and the Trust. Secondly, although it did not form part of this investigation, Dr Y has asserted that Mr W was deprived of food and fluids; there is no evidence to support that assertion. Finally, the assessors have expressed some concern about the decision to transfer Mr W to the second hospital while he was so ill, and about the information which was included in his discharge letter. They have said that, with the benefit of hindsight, it might have been wiser to have delayed the transfer or recommenced antibiotic treatment. I agree with that; but that is not to say that the decisions taken at the time, with the information which was then available to the clinicians, were in any way defective. I recommend that the Oxford Radcliffe Hospitals NHS Trust take steps to ensure that the clinical condition of patients who are being discharged from their care is assessed fully, and that comprehensive details of their conditions and treatment regimes are included in their discharge letters.
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Conclusion
16. I have set out my findings in paragraphs 13 to 15. The Oxford Radcliffe Hospitals NHS Trust have accepted my recommendation in paragraph 15. I do appreciate the distress which Dr Y and his relatives have experienced throughout Mr W's illness, and I hope that they will be re-assured by this report that the actions of Trust staff were entirely reasonable in the circumstances.
Addendum
Since this report was issued, Dr Y has informed the Ombudsman's Office that his assertion that foods and fluids were withheld from Mr W did not relate to the period when Mr W was in the Radcliffe Infirmary. That was not clear from the evidence which he submitted.
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