Chelsea and Westminster Hospital NHS Foundation Trust

3. Mr X complains about the care and treatment provided to his mother, Mrs X, during in April 2023. In particular he complains the Trust,

• carried out his mother’s knee operation even though she had a swollen foot • gave his mother a general anaesthetic • were responsible for his mother getting pneumonia • did not give his mother her medication on 16 April.

4. Mr X believes these failings in care had a negative impact on his mother’s outcome.

5. Mrs X was admitted to her local hospital for a right total knee replacement on in April 2024. She developed post-operative abdominal distension (a visible or measurable increase in the girth or size of the abdomen, often due to a buildup of substances like gas, fluid, or tissue) and this led to a major aspiration (food content going into the lungs) which caused a cardiac arrest. While the medical team were able to resuscitate her at that stage, she was in a critically unwell state from which she never recovered. She sadly died in the intensive care unit in late April.

11. Before we decide if we should conduct a detailed investigation of a complaint, we look at whether there are signs the Trust has got something wrong. We do this by comparing what should have happened with what did happen. We have done this and have not found any indications that something has gone wrong. The reasons for our decision is set out below.

Pre-operative assessment

12. Mr X said on the morning of the operation he pointed out to the anaesthetist that his mother’s right ankle was swollen. He said that his view was that the operation should not have gone ahead. He added that he felt that felt this contributed to his mother’s death.

13. The records show the anaesthetist assessed Mrs X and noted that she had a swollen ankle. Our anaesthetist adviser said this a common finding in elderly patients with limited mobility. Our adviser explained this finding is not in itself suggestive of a deep venous thrombosis and did not mean that the surgery should have been postponed. Our anaesthetist adviser said there are no relevant standards/guidance which apply here.

14. We have taken into account the advice from our anaesthetist adviser which is based on their extensive experience as an anaesthetist. We consider it is reasonable to rely on their advice in the absence of a relevant standard. In the circumstances, taking into account the available evidence there are no indications of failings regarding this aspect of Mr X’s complaint.

Anaesthetic

15. Mr X said it was agreed with the anaesthetist prior to surgery his mother was for spinal anaesthesia as she had mild cognitive impairment. However, he said his mother was asked to consent to a general anaesthetic on the day of the operation despite concerns she had been diagnosed with memory problems and therefore could not decide for herself. He said the Trust should have called him and he would have asked for surgery to be postponed. Mr X said he considered the general anaesthetic resulted in the small bowel blockage and stomach adhesions.

16. We can find no indication of failings on the part of the anaesthetists. Our anaesthetist adviser said regional anaesthesia, in the form of a spinal anaesthetic, is the first choice for knee replacement (see GIRFT guidance) and is recommended in the elderly and others at risk from postoperative cognitive dysfunction (confusion/delirium). This technique was attempted by the anaesthetist but they were unable to insert the needle into the correct place. They sought help from another senior anaesthetist, who also was unable to place the spinal anaesthesia.

17. After these attempts to place a spinal anaesthesia, they proceeded to administer a general anaesthesia, which was appropriate. Our anaesthetist adviser said they used a technique known as Total Intravenous Anaesthesia (TIVA), which is associated with a lower incidence of postoperative cognitive dysfunction than other techniques (see BJA Education article). This was an appropriate course of action. The anaesthetic chart suggests that the anaesthetic was competently managed.

18. We recognise Mr X’s concerns about the use of a general anaesthetic. The available evidence we have considered including our anaesthetist adviser’s advice suggests there is no indication of failings regarding this issue.

Pneumonia

19. Mr X complains his mother was considered to be a high risk of pneumonia, but she was not kept in a private room or nursed away from others to reduce the risk of her developing this. He also has concerns of how she was monitored post-operatively. He said this contributed to her death.

20. Our surgeon adviser said Mrs X developed an aspiration pneumonia which is different than a pneumonia which is acquired from another person. Therefore a side room or nursing her away from others would not have had any influence on this complication.

21. Our surgeon adviser confirmed Mrs X was reviewed on a regular basis by the teams (surgical, physiotherapy, nursing). She was initially making good progress and there were even provisionally plans being made for her discharge.

22. The primary team sought advice from other specialities for ongoing concerns: the plastic surgical team regarding a swollen hand, the general surgical team re vomiting and abdominal distension. This would be in line with the GMC’s Good Medical Practice which says,

“You must provide a good standard of practice and care. If you assess, diagnose or treat patients, you must: a adequately assess the patient’s conditions, taking account of their history (including the symptoms and psychological, spiritual, social and cultural factors), their views and values; where necessary, examine the patient b promptly provide or arrange suitable advice, investigations or treatment where necessary c refer a patient to another practitioner when this serves the patient’s needs.”

23. Our surgeon adviser explained a naso-gastric tube was inserted to decompress the stomach and reduce the risk of aspiration. Unfortunately the night prior to the aspiration, Mrs X removed this tube. Our surgeon adviser it was likely that if an attempt was made to reinsert the naso-gastric tube at that stage there was a risk she may have removed it again. The team sought advice from the general surgical team who advised to organise a CT scan of the abdomen/pelvis to check for abdominal problems such as obstruction. Unfortunately, Mrs X had the major aspiration at that stage and this started events which led to her passing.

24. Taking into account the above and our surgeon adviser’s advice there is no indication of failings from the orthopaedic team in managing Mrs X’s care and seeking appropriate advice from other teams in line with guidance.

Missed medication

25. Mr X complains his mother did not receive medication on 16 April. He said he feels this missed medication contributed to his mother’s deterioration.

26. There is no indication of failings regarding the medication. Our surgeon adviser explained when a patient has abdominal distension and vomiting, they are not going to absorb medication effectively. The medication will either be vomited up or not absorbed. At this point, the team need to decide which medication are essential to be given and if these medications can be given via an alternative route (intra-venous; intra-muscular, sub-cutaneous). Often some of a patients regular pressure tablet may not be necessary because a patient in bowel obstruction maybe relatively dehydrated and have a low or normal blood pressure reading. There are nursing protocols in place to ensure the safe administration of medication in these circumstances. (Professional-Guidance-on-the-Administration-of-Medicines-in-Healthcare-Settings.pdf).

27. On this occasion, Mrs X continued to have intravenous antibiotics which was important. Our surgeon said there was no issue with temporarily holding the other medications. Therefore, there are no indication of failings regarding this aspect of Mrs X’s care.

Conclusion

28. We have carefully considered Mr X’s complaint about the Trust. We have not identified any indication of failings regarding the care and treatment provided to his mother. We recognise that the death of Mr X’s mother has greatly impacted on him and we are sorry about that. We hope we have clearly explained the reasons for our decision not to carry out a detailed investigation.

1. We have considered Mr X’s complaint about Chelsea and Westminster Hospital NHS Foundation Trust (the Trust). We have seen no indication that anything went seriously wrong

2. We recognise that Mr X is devasted by the loss of his mother. We have carefully considered the above issues in reaching our decision not to carry out a detailed investigation. The reasons for our decision are set out below.