Lancashire Teaching Hospitals NHS Foundation Trust

5. Mr K complains about the care provided to his wife, Mrs K, by the emergency department (ED) of Lancashire Teaching Hospitals NHS Foundation Trust (the Trust) on 11 to 12 December 2023.

6. He complains:

• about the delay in Mrs K being seen by a doctor • about the timings between Mrs K’s observations • Mrs K was not given appropriate pain relief.

7. Mr K says Mrs K could have survived her surgery if she was seen earlier. He says she missed an opportunity for cancer treatment, and he has missed out on more time with his wife. He says had her observations been taken appropriately, her deterioration may have been noticed.

8. Mr K also says Mrs K suffered in pain more than she should have done.

9. Mr K would like the Trust to acknowledge its wrongdoing and apologise. He wants the Trust to make service improvements, and he would like a financial remedy.

10. On 11 December 2023, Mr K and Mrs K attended the ED at the Trust. She was complaining of abdominal pain for a few days, vomiting, being unable to keep water down, and looked pale and clammy.

11. Mr K says they arrived at 8.48pm. The Trust’s records say they arrived at 9.30pm. We have been unable to say what time she arrived due to the conflicting evidence. To proceed with our investigation, we have focused on what happened after she was recorded to be triaged at 9.58pm.

12. Mrs K was triaged by a nurse at 9.58pm. She had bloods and observations returned at 10.42pm. She was triaged as ‘yellow’. Mrs K remained in the waiting room.

13. She had a further set of observations taken at 2.42am the next morning. The Trust took a further set of her observations at approximately 5.22am.

14. Shortly after, Mrs K’s condition deteriorated, and she became unresponsive in the waiting room.

15. She was then admitted to the resuscitation area (for patients needing immediate emergency care) of the ED and was reviewed by a doctor.

16. She was taken for a CT scan at approximately 7.38am which showed her bowel was ischaemic (when blood flow to the bowel is blocked). The doctor recommended an emergency laparotomy (abdominal surgery).

17. She was taken for emergency surgery at approximately 10.40am. She had a distended (swollen/enlarged) bowel, bowel ischaemia, a tumour and a hard liver lesion. At this point, the Trust said it was not survivable.

18. The Trust were unable to keep Mrs K’s heart going with medication and withdrew the medication. After a discussion with Mr K and giving him an opportunity to see Mrs K, the Trust withdrew the life supporting medication. Sadly, Mrs K died shortly after this.

Delay in Mrs K being seen by a doctor and timings between observations

23. Mr K complains about the amount of time Mrs K waited to be assessed by a doctor after arriving in the ED on 11 December 2023. He says the Trust missed an opportunity to treat her earlier and Mrs K may have survived the operation had she been seen earlier.

24. He also complains about the timings of Mrs Ks’ observations, he thinks there was a delay in taking her observations. He says the Trust missed an opportunity to notice her deterioration and provide earlier treatment.

25. In response to the complaint, the Trust said at the time she was admitted to the ED, the ED was experiencing extremely high numbers of admissions and there was no vacant area to assess her. It said the early tests offered reassurance that she was not immediately time critical.

26. The Trust acknowledged there was a delay in Mrs K’s observations being completed. It said she should have had a set of observations between 2.42am and 5.22am, which may have been an opportunity to identify her worsening condition and aim to prioritise her assessment.

27. Mrs K was triaged in the ED at 9.58pm. Her symptoms included central abdominal pain for a few days, vomiting at triage, being unable to keep water down and looking pale and clammy. Her pain was recorded as ‘5 moderate’, she had her observations taken and the Trust requested blood tests. She was triaged as ‘yellow’.

28. The MTS says to triage patients with symptoms including persistent vomiting, being hot and in moderate pain as category yellow. Our ED adviser said the Trust triaged Mrs K appropriately based on her symptoms.

29. The MTS says someone triaged as ‘yellow’ is considered urgent and should be seen by a clinician within 60 minutes. In line with the MTS, Mrs K should have been assessed by 10.58pm.

30. Mrs K remained in the waiting room until she went into respiratory arrest at around 6am on 12 December 2023. She was admitted to the resus area of the ED and was seen by a clinician at approximately 6.15am. This is over seven hours later than when she should have been seen, and it is not in line with the MTS.

31. We recognise the Trust was overcapacity that night and it has provided evidence of this. This evidence shows that at 12.20am on 12 December 2023, there were 120 patients in the department, and 75 patients needed to be admitted. There were 17 trained nurses and 5 health care assistants (HCA), when there should have been 21 nurses and 10 HCA. This was a staffing deficit.

32. The average wait time to be seen was six to seven hours, and the nurse in charge escalated this to the site manager who was looking for space in the wards. By 7am, there was an eight to nine hour wait time to be seen.

33. The Trust had initiated its escalation plan on 11 December 2023 and the ED was categorised as ‘OPEL high’ at the time of Mrs K’s visit, which means actions to deliver capacity had failed. The escalation plan includes initiating the ED surge and opening the trolley bay, trying to obtain more staff, and enacting the bed escalation plan to different wards, which the Trust did throughout the night.

34. It also tried to obtain further staff from a different hospital. The site manager and executive on call were informed. Unfortunately, the Trust could not deescalate the problems with capacity. We recognise the Trust followed its escalation plan and tried to reduce the risk that night.

35. Our ED adviser said this is an incident of ED crowding which has led to a poor experience and is reflective of emergency departments across the country which has been raised by the Royal College of Emergency Medicine as a serious public health challenge facing the NHS.

36. We know Mrs K was not seen by a clinician in an appropriate timeframe on 11 to 12 December 2023. We have seen evidence from the Trust which shows it was over capacity that night and had followed its escalation plan. We do not think it was possible for a clinician to see Mrs K in the 60 minute timeframe set out by the MTS. As it was not possible for a clinician to see her in this timeframe, we are not considering this a failing by the Trust.

37. Whilst Mrs K was in the waiting room, a nurse took her observations and assessed her using the NEWS2 system (a tool used to assess the degree of illness of a patient) on three separate occasions.

38. The NEWS2 guidance sets out what the clinical response should be in response to a NEWS2 score.

39. At 21.58pm, Mrs K’s observations were completed, and she was given a NEWS2 score of two. The NEWS2 guidance says a score between one to four requires monitoring every four to six hours. The Trust took Mrs K’s next set of observations within this timeframe at 2.42am.

40. At 2.42am, Mrs K’s NEWS2 score had increased to six. The NEWS2 guidance says a score between five and seven requires monitoring hourly. Mrs K’s observations were not taken again until 5.22am. Mrs K should have had observations repeated one hourly. Mrs K missed two sets of observations during this timeframe.

41. We consider the Trust failed to take Mrs K’s observations in line with the NEWS2 guidance.

42. The NEWS2 guidance says when a patient has a NEWS2 score of five to seven, they need an urgent assessment by a clinician or team with competencies in the care of acutely ill patients, and to provide care in an environment with monitoring facilities.

43. The records show after her NEWS2 score increased to six at 2.42am, she was prescribed pain medication and nausea medication with the approval of a senior nurse.

44. Our ED adviser said Mrs Ks’ NEWS2 score of six should have triggered an urgent response, and she should have been admitted to an area where clinical care could have been provided.

45. We have found the Trust failed to escalate Mrs K’s care as it should have at 2.42am as set out in the NEWS2 guidance.

46. Although, we accept that the Trust were over capacity, which is why we have not found a failing in the Trust not seeing Mrs K in the initial 60 minute timeframe, we consider that by 2:42am when the NEWS score showed that Mrs K’s condition had significantly worsened, the Trust should have taken urgent action, in line with the NEWS2 guidance, at this stage. The Trust did not do this, and we consider this a failing.

47. Also, as Mrs K was not monitored hourly after 2:42am, as she should have been in line with the NEWS2 guidance, we consider the Trust missed a further opportunity to respond to Mrs K’s deterioration and escalate her care to a clinician. We consider this a failing. We have considered the impact of these failings later in our report.

Pain relief

48. Mr K complains Mrs K was not provided with appropriate pain relief whilst in the waiting room. He said Mrs K was in absolute agony for over seven hours.

49. The Trust said whilst Mrs K was in the waiting room, staff were unable to give her morphine.

50. The RCEM pain management guidance says patients in moderate pain should be offered oral analgesia within 15 minutes of arrival and should be re-evaluated within 30 minutes of the first dose.

51. The RCEM pain management guidance says it is important to reassess the pain control within 15 to 30 minutes in patients with moderate and severe pain. Where analgesia is still found to be inadequate, stronger or increased dose of analgesics should be used.

52. When Mrs K was triaged at 9.58pm, her pain was scored ‘5 moderate’. As she had moderate pain, she should have been given analgesia by 10.15pm and reassessed by 10.45pm. She was given paracetamol, an antiemetic and intravenous fluids at 12.03am. This is outside the timeframe set out by RCEM.

53. In line with the RCEM pain management guidance, the Trust should have reassessed her pain after administering the paracetamol and considered whether increased analgesics should be administered within 30 minutes of the first dose. This should have been done by 12.33am.

54. Mrs K condition deteriorated and her NEWS2 score increased to 6 at 2.42am. Her pain was not reassessed, but she was prescribed dihydrocodeine (an opioid painkiller used to treat moderate to severe pain) at 3am. Mrs K’s pain should have been reassessed and provided further pain relief, if needed, by 3.30am.

55. Her pain was not reassessed, but at 5.07am she was prescribed a further dose of dihydrocodeine.

56. The Trust prescribed Mrs K morphine at 5.41am, but she had become unresponsive and admitted to the Resus area before it was administered.

57. Our ED adviser said Mrs K’s pain was worsening, and severe pain should be managed with a strong opioid in an area where a patient can be observed. They said Mrs K did not receive timely pain relief.

58. As Mrs K had moderate pain upon admission, which the evidence suggests was worsening through the night, the Trust should have reassessed her pain control within 15 to 30 minutes of providing analgesia, in line with the RCEM pain management guidance. The Trust did not do this at any stage during this period in the ED. We have found this is a failing by the Trust. We have considered the impact of this below.

Impact

59. We have found failings by the Trust to assess Mrs K in an appropriate timeframe, to take regular observations, and to assess her pain and administer timely and appropriate pain relief.

60. Mr K says the Trust missed an opportunity to treat Mrs K before it was too late, and she may have survived surgery if she had been seen sooner. He also thinks the Trust missed her deterioration due to the delay in taking her observations.

61. The Trust concluded in its response that although there were some gaps in Mrs K’s care, it would not have changed her outcome.

62. In the Trust’s incident review, a surgeon who operated on Mrs K advised if she had had surgery earlier, it is possible her outcome may have been different in the short term.

63. When Mrs K was admitted on 11 December 2023, she had been suffering with abdominal pain for two days which had worsened that day and she was now vomiting and unable to keep water down. She had continued to vomit over the next few hours.

64. She was reviewed again at 5.22am. Her diastolic blood pressure had increased from 46 to 106 (the normal range is 49 to 89), and a pulse of 124 (the normal range is 51 to 89). According to the NICE blood pressure guidelines, stage two hypertension is considered when there is a clinic blood pressure of 160/100mmHg or higher but less than 180/120mmHg. As Mrs K’s diastolic blood pressure had increased to 106, she would be considered hypertensive.

65. She then became short of breath and unresponsive. At 6am, she went into respiratory arrest in the waiting room.

66. Trust staff put her onto a trolley and provided emergency care to stabilise her. She was admitted to the Resus area at approximately 6.15am.

67. She was provided with further medication, intubation (a tube in the windpipe) and mechanical ventilation (a machine to help her breathe). She had to have a suction catheter (a tube to remove secretions from the airway) in place due to her vomiting.

68. At this time, her abdomen had become very distended and hard. Trust staff took further blood gases and the results showed her lactate levels had increased, and she had metabolic acidosis.

69. She was reviewed by a doctor who decided to place her under general anaesthetic to take her for a CT scan.

70. At approximately 7.54am, once she had stabilised, she was taken for a CT scan. The images were available to review at around 8am.

71. A consultant surgeon reviewed these shortly after. The scan showed a bowel obstruction, the bowel was distended, and an enlarged colon. There was a short segment stricture (narrowing of the colon) which was possibly malignant (cancerous).

72. The scan also showed possible metastatic deposits in the liver (a spread of cancer cells to secondary sites in the body).

73. A bowel obstruction is a complication common with colorectal cancer, as the cancer can narrow the bowel an obstructs the bowel. The consultant suspected Mrs K had rectosigmoid cancer with liver metastases, which is an advanced stage of colorectal cancer which has spread to the liver.

74. The consultant suspected Mrs K’s bowel had become ischaemic. Bowel Research UK say says acute ischaemia happens when the blood supply is suddenly obstructed entirely. When this happens, it is often too late for treatment. Symptoms of this include sudden abdominal pain, vomiting, and a distended abdomen.

75. Mrs K was taken to theatre at approximately 10.40am for an exploratory laparotomy. During the surgery, it is noted she was extremely unstable and required adrenaline bolus (emergency resuscitation).

76. The consultant found the bowel was ischaemic, and the whole bowel was non-viable (it was incapable of surviving). The consultant found a tumour between the colon and the rectum.

77. The doctors considered Mrs K’s condition was not survivable. The Trust withdrew life support and Mrs K died at approximately 11am on 12 December 2023.

78. The Trust has told us an abdominal CT scan would be the first line of investigation for a patient in the ED with acute abdominal pain where a serious disease is suspected.

79. Our ED adviser said Mrs K’s blood tests at 10.42pm showed a raised white blood cell count and neutrophil count, and in the context of severe abdominal pain and vomiting it should have raised concerns of an abdominal issue.

80. If Mrs K had been seen by a clinician at 2.42am, she would have likely had another set of blood gases taken. Due to her acute abdominal pain, she would likely have been taken for a CT scan after. This was a missed opportunity for an earlier scan and diagnosis, which would have led to earlier surgery.

81. The POSSUM tool preoperatively uses blood tests and observations to calculate the risk of mortality within 30 days of surgery. It is a rough indication of possible surgical outcomes.

82. Using this tool, our colorectal adviser said based on Mrs K’s observations at approximately 10pm and her blood tests at 10.42pm, the risk of mortality during surgery was 21.8%.

83. Based on her observations at 2.42am, our colorectal adviser said the risk of mortality increased to 26.5%.

84. Based on her blood tests and observations at approximately 7.45am and the clinical findings in her surgery, the risk of mortality was approximately 62.5%.

85. For completeness, our colorectal adviser used a similar calculator of risk related to emergency abdominal surgery, the NELA tool. This suggested her risk of mortality increased from 10.94% at 10.42pm to 12.34% at 2.42am to 41.7% at 7.45am. Our adviser said based on these scores it is reasonable to say her risk of mortality significantly worsened over the time she waited.

86. Our colorectal adviser said the bowel ischaemia occurred due to the bowel blockage not being treated. Bowel Research UK explains that treating a bowel blockage promptly (before it becomes ischemic) is crucial for survival. Our colorectal adviser said the biggest factor as to whether earlier surgery would have made a difference to the outcome here was at what stage Mrs K’s bowel became ischaemic. Unfortunately, our adviser is unable to establish this definitively based on the information we have.

87. Mrs K deteriorated between 10.42pm and 6am evidenced by her increasing NEWS2 score, and her blood gases showing her increased lactate levels which was a sign of her condition worsening. Mrs K’s distended abdomen, a sign of bowel ischaemia, was not noted as a symptom until she deteriorated at around 6am.

88. At the time of her surgery, none of the bowel was viable and her condition was not survivable. Our colorectal adviser said some of her bowel could have been viable had she been operated on earlier which would have allowed the Trust to treat the obstruction, but unfortunately, we cannot establish this definitively without the clinical findings of a laparotomy.

89. As Mrs K was 50 years old and had been relatively fit before these issues began, our colorectal adviser said due to this, it is possible that her body may have been compensating for the obstruction and/or ischaemia when she presented at the ED, and whilst her observations appeared stable, there is a possibility she could have had an ischaemic bowel when she presented to the ED.

90. The bowel ischaemia study found that bowel ischaemia has an overall mortality of 60% to 80%. Mrs K’s chance of mortality was high at the point her bowel became ischaemic. Unfortunately, we are unable to establish definitively when this happened.

91. Due to the uncertainty about when Mrs K’s bowel became ischaemic, our colorectal adviser could not conclude that Mrs K would have survived surgery had she been operated on earlier. However, it is clear from the POSSUM tool scores that her risk of mortality worsened significantly over the time she waited to be seen.

92. Mrs K’s chances of mortality, based on the evidence we have, increased by nearly 40% following her observations at 2:42am, which should have triggered the urgent assessment. This shows she deteriorated significantly after 2:42am. By the time she had surgery, her chance of surviving surgery was significantly reduced.

93. As we cannot establish at what point Mrs K’s bowel became ischaemic that night, which made her condition not survivable, we are unable to conclude she would have survived an earlier surgery. However, based on her earlier observations, and symptoms, we can say she had a better chance of surviving an earlier surgery.

94. We conclude Mrs K missed a small chance of surviving surgery due to the delay she faced. She may have potentially survived an earlier surgery as her chances of mortality were significantly lower earlier that night, and her bowel may not have been ischaemic, which would have allowed the Trust to treat the blockage in the bowel.

95. We found this is a significant injustice to Mr K as he has been left not knowing whether earlier treatment could have made a difference to the eventual sad outcome.

96. Mr K says Mrs K was in absolute agony that night, she could not settle and was kicking her legs in pain. He says he was begging for someone to help her.

97. We found this extended period of pain could have been avoided or reduced had the Trust assessed Mrs K’s pain appropriately and provided appropriate and timely pain relief in response. This was worsened by them being in a waiting room.

98. This experience undoubtedly caused Mr K significant distress and concern for his wife. He says he begged for someone to help her due to how much pain she was in. We also recognise his last hours with his wife were spent in a waiting room, which Mr K says was actually a crowded corridor, watching her suffering, which has had a lasting impact on him.

99. We have found this experience caused significant distress to Mr K. Mr K not only had to witness Mrs K in significant pain before she died suddenly, but he will continue to experience significant distress by not knowing whether the poor care caused or contributed to her death.

1. We are very sorry to hear about Mr K’s wife, Mrs K’s, death in December 2023. Mr K told us he thinks the Trust failed to assess Mrs K in an appropriate timeframe and missed an opportunity to treat her and prevent her death. He also complains the Trust did not provide Mrs K with appropriate pain relief causing unnecessary suffering before she died.

2. We are sorry to hear Mr K’s concerns, we understand it would have been very distressing for Mr K to witness Mrs K’s sudden decline and to see her in such pain. We also recognise the lasting impact this has had on Mr K, and we thank him for taking the time to bring this complaint.

3. We have carefully investigated Mr K’s complaint. We found the Trust failed to assess and treat Mrs K in an appropriate timeframe and it failed to take regular observations. We have not found Mrs K’s death was avoidable, as there is a possibility even if she had earlier surgery, her bowel may have been ischaemic, at which point, it is unlikely she would have survived surgery. We have found this failing led to a missed opportunity for Mrs K to have a better chance at surviving surgery. We have also found the Trust failed to provide appropriate pain relief, which caused Mrs K unnecessary suffering before she died, which also caused Mr K significant distress. Therefore, we will partly uphold Mr K’s complaint.

4. We consider the Trust needs to take further steps to put this complaint right. We recommend the Trust writes to Mr K to acknowledge and apologise for the failings we have found and the impact it has had. We also recommend the Trust make service improvements and pay Mr K a financial remedy of £3,750.