East Suffolk and North Essex NHS Foundation Trust

3. Miss J complains between October and December 2023 MSE, the rehabilitation hospital, and ESNEFT did not: • administer her mother, Mrs J’s regular long-term medications • effectively treat the cause of her mother’s diarrhoea.

4. Miss J complains that MSE prematurely discharged her mother from hospital at the end of October 2023.

5. Miss J also complains that the rehabilitation hospital:

• administered a glycerol suppository on 3 December 2023, despite her mother’s diarrhoea • gave her mother a blood thinner after 12 December 2023, despite the presence of blood in her stools.

6. Miss J also complains that ESNEFT did not treat her mother’s sepsis promptly from 24 December 2023.

7. Miss J says these actions caused her mother’s death.

8. Miss J is seeking an apology, service improvements and a financial remedy.

9. Miss J’s mother, Mrs J, went to MSE’s emergency department at the end of October 2023 due to a cough and shortness of breath. MSE transferred Mrs J to SDEC. It conducted an X-ray which showed she had a chest infection. MSE gave her antibiotics and discharged her home with antibiotics.

10. Three days later Miss J called 999 because Mrs J was experiencing increased shortness of breath, had an uncontrollable cough and was very weak. The ambulance service took Mrs J to MSE’s emergency department and MSE admitted her to hospital due to Covid-19 and pneumonia (a chest infection). Miss J explained that Mrs J began to experience extreme diarrhoea.

11. At the end of November MSE transferred Mrs J to a nurse-led rehabilitation ward run by the rehabilitation hospital to begin rehabilitation. The rehabilitation hospital transferred Mrs J to ESNEFT via ambulance at the beginning of December because she was experiencing chest pain.

12. ESNEFT diagnosed Mrs J with acute coronary syndrome and transferred her back to the rehabilitation hospital the following day. Acute coronary syndrome covers several disorders caused by a sudden reduction of blood flow to part of the heart muscle.

13. As Mrs J was still unwell the rehabilitation hospital transferred her back to ESNEFT via ambulance two days later.

14. Sadly, Mrs J died at the end of December due to a spontaneous gastrointestinal haemorrhage (unexpected bleeding in the digestive tract). Other conditions which contributed to Mrs J’s death but were not related to the bleed which caused her death were atrial fibrillation (a heart rhythm disorder), diabetes, frailty of old age, kidney failure and sepsis (life-threatening reaction to an infection).

15. In this report we have referred to Mrs J’s regular long-term medications. Below is an explanation of what those medications are for:

• budesonide is a corticosteroid which is a steroid hormone that helps reduce inflammation • mesalazine is an anti-inflammatory used to treat colitis, which is inflammation of the colon (bowel), which can cause symptoms like stomach ache and diarrhoea • sotalol is a beta-blocker used to treat and prevent abnormal heart rhythm conditions including atrial fibrillation • atorvastatin is a cholesterol-lowering medication which can reduce the risk of heart attacks and strokes • candesartan cilexetil is for high blood pressure and heart failure • furosemide increases urine production in the kidneys and is used for managing high blood pressure and to treat fluid retention • omeprazole is used to treat excess stomach acid • betahistine dihydrochloride is used to treat dizziness • alendronic acid is used to strengthen the bones • promethazine hydrochloride is an antihistamine that relieves the symptoms of allergies and can also be used as a sleeping pill.

Medication

19. Miss J complains between October and December MSE, the rehabilitation hospital, and ESNEFT did not administer her mother’s regular long-term medications which we have listed in the background section above.

20. Miss J is concerned that not having her regular medication may have made her mother more ill and caused her diarrhoea as some of the medication was for her colitis.

21. At the start of November MSE noted that Mrs J had acute kidney injury. This is where the kidneys suddenly stop working.

22. MSE stopped Mrs J’s promethazine hydrochloride and the rehabilitation hospital. ESNEFT also did not give it to Mrs J after she said she was not taking it at home and declined to take it. MSE stopped Mrs J’s furosemide, candesartan cilexetil and mesalazine in November and gave her budesonide instead of mesalazine.

23. The rehabilitation hospital continued to give Mrs J budesonide throughout her stay. ESNEFT reviewed this on 16 December and started giving Mrs J mesalazine again on 17 December after discussing this with her.

24. NHS England’s guidelines on acute kidney injury say doctors should consider withholding candesartan cilexetil if a person has acute kidney injury. They explain furosemide can exacerbate acute kidney injury. They also say doctors should avoid giving people mesalazine because both medicines can damage the kidneys.

25. NICE guidance on colitis also says medications like budesonide can be given instead of mesalazine to treat colitis. Therefore, MSE stopping Mrs J’s furosemide and cilexetil, candesartan and replacing her mesalazine with budesonide is in line with these guidelines.

26. At the beginning of November MSE began giving Mrs J bisoprolol instead of sotalol. The rehabilitation hospital and ESNEFT continued to give Mrs J bisoprolol. Bisoprolol is another betablocker which like sotalol is used to treat heart conditions. NICE guidance on beta blockers says bisoprolol might be preferred for people with atrial fibrillation and diabetes or for people with atrial fibrillation and heart failure.

27. Our geriatrician adviser told us because Mrs J had high blood pressure, and MSE initially thought she might have heart failure, bisoprolol was a suitable alternative. We cannot see anything wrong with the organisations not giving Mrs J sotalol.

28. We have reviewed Mrs J’s records, and we can see MSE, the rehabilitation hospital, and ESNEFT did give Mrs J omeprazole throughout her hospital stays.

29. MSE gave Mrs J her alendronic acid, atorvastatin and betahistine dihydrochloride. The rehabilitation hospital discontinued them all on 28 November and ESNEFT gave Mrs J alendronic acid and betahistine dihydrochloride but withheld atorvastatin.

30. This was after a doctor at the rehabilitation hospital conducted a review of polypharmacy (where someone is taking multiple medicines). As Mrs J was taking many different medicines at the same time, our geriatrician adviser told us is important that polypharmacy is addressed when a person is unwell because it can increase the risk of adverse drug reactions.

31. We have decided the three organisations acted in line with guidance when giving medication to Mrs J. We think there was suitable justification for not giving Mrs J some of her medication. We have not found the organisations’ administration of Mrs J’s long-term medication amounted to a failing.

Premature discharge in October 2023

32. We then looked at Miss J’s complaint that MSE prematurely discharged her mother from hospital in October.

33. MSE says there was no need for it to admit Mrs J to an inpatient ward at that time. This was because her observations were stable, and her blood results and chest X-ray indicated she had a chest infection. So, MSE gave her a course of oral antibiotics and discharged her home from SDEC into the care of her GP. This was with a request for GP to arrange a repeat chest X-ray in six to eight weeks if needed.

34. It is understandable that the short period Mrs J remained at home before MSE readmitted her to hospital three days later caused Miss J and her family concern. Especially as they did not think Mrs J seemed well enough to be discharged home.

35. NICE guidelines on pneumonia explains the CURB65 scoring system is a tool to assess someone’s risk of death due to pneumonia. A hospital should give a patient one ‘point’ for each of the following five risk factors:

• confusion • raised blood urea nitrogen (urea nitrogen is a waste product filtered out of the blood by the kidneys. High levels may indicate poor kidney function) • raised respiratory rate (30 breaths per minute or more) • low blood pressure • age of 65 years or more.

36. According to this system, someone who has a low risk (zero or one point, which corresponds to less than a 3% risk of dying) can be considered suitable for discharge home. Someone who has an intermediate risk (two points, which corresponds to a 3% to 15% risk of dying) can be considered suitable for hospital care. It also explains a hospital should refer someone who has a high risk (three to five points which corresponds to more than a 15% risk of dying) for an intensive care assessment.

37. As Mrs J was aged over 65 her score would have been at least one. We have asked MSE for its records from SDEC but what it has recorded is limited. There are no blood test results to show Mrs J’s urea levels. The records also do not include details of any of the other risk factors. MSE has confirmed it has no further records for the time period.

38. Our SDEC adviser told us without this information it is difficult to confirm if MSE’s decision to discharge Mrs J was correct due to the lack of records.

39. We have considered what Miss J and the Trust have told us, along with Mrs J’s records and advice from our SDEC adviser. We are unable to reach a conclusion on whether MSE discharged Mrs J prematurely because MSE has not kept detailed records of its assessment in SDEC.

40. The GMC is responsible for regulating and setting professional standards for doctors in the UK. GMC guidance says doctors must quickly provide or organise investigations. It says doctors should make clear and accurate records at the time or as soon as possible after an event. It also says records should include ‘relevant clinical findings, the decisions made and actions agreed’.

41. In line with this guidance, we would have expected MSE to have assessed Mrs J’s risk factors to decide if it was appropriate for it to discharge her home. We would also expect MSE to have documented its assessment.

42. We cannot be sure if the decision to discharge Mrs J was the right one. It is possible it was and MSE did not record its assessment as it should have done.

43. As MSE admitted Mrs J to hospital just three days later and she remained in hospital for two months until she died at the end of December, we have decided it is not possible for us to link the discharge in October to Mrs J’s death. The events are too far apart, and her continuous medical care during her long hospital stay makes it highly unlikely the October discharge caused her death.

44. There also remains the possibility that MSE did properly assess Mrs J but did not document the assessment. We do not know either way.

45. We have also not seen any evidence that the bleed which caused Mrs J’s death was present when MSE discharged her in October, which makes it even harder to link the two.

Diarrhoea

46. Miss J complains between October and December 2023 MSE, the rehabilitation hospital, and ESNEFT did not effectively treat the cause of her mother’s diarrhoea. She said at its worst her mother was having ten episodes of diarrhoea a day and it was like she had a ‘sickness bug’.

47. At the start of November MSE sent a stool sample which was negative for infective diarrhoea. The rehabilitation hospital explains Mrs J started to experience significant diarrhoea from the 5 December onwards. It completed a diarrhoea risk assessment form, and a stool specimen was negative for infection.

48. It monitored the frequency at which she was passing stools, and the consistency of her stools using the Bristol stool chart. This is a chart for classifying stools into different categories. Types one (hard lumps) to two (sausage shaped but lumpy) are classed as constipation and types six (mushy) to seven (watery) are classed as diarrhoea.

49. ESNEFT investigated Mrs J’s diarrhoea on admission to hospital by an oesophagogastro duodenoscopy (OGD) and the result was normal. An OGD is a procedure where a doctor uses a flexible tube with a camera at the end to look inside the digestive system. ESNEFT also explains it found no abnormalities in the stool specimens it took on 15 and 22 December.

50. We have reviewed Mrs J’s records which show she was experiencing diarrhoea during her hospital stay. The first record we can see of Mrs J having diarrhoea was on 31 December when MSE recorded she had a type seven stool. There is no further reference of her stools until 2 November when MSE recorded a type four stool.

51. There are records of type six and seven stools on 3, 7, 9 and 11 Nov and then no further reference to diarrhoea. Miss J says it continued throughout Mrs J’s hospital stay.

52. The records show MSE took a stool sample on 7 November to try to find whether there was an underlying infection causing her diarrhoea. The stool sample showed there was not.

53. The rehabilitation hospital’s records indicate Mrs J had no diarrhoea on 25 or 26 November, but two type five stools in the morning of 27 November. A type four stool in the morning but then type seven in afternoon of 28 November. Then multiple type four, five, six and seven on 8 December. The rehabilitation hospital took a stool sample on 8 December which showed no evidence of an infection.

54. The rehabilitation hospital noted multiple type six and seven stools for the rest of Mrs J’s hospital stay (until 13 December).

55. ESNEFT also took a stool sample on 15 December but this was negative for an infection.

56. To help us understand if it appears anything went seriously wrong we sought independent clinical advice from our geriatrician adviser. They told us the main treatment for diarrhoea is to address its underlying cause, so antibiotics to treat a bacterial infection or medication for colitis.

57. They told us in Mrs J’s case there would be no need for the organisations to investigate chronic diarrhoea. This is because these investigations were done to reach a diagnosis of colitis when she was originally diagnosed.

58. GMC guidance says doctors ‘must promptly provide or arrange suitable advice, investigations or treatment where necessary’.

59. NICE guidance on diarrhoea says diarrhoea lasting less than 14 days is usually caused by a bacterial or viral infection. It says healthcare professionals should exclude the possibility of infectious diarrhoea. It says caused of diarrhoea lasting more than four weeks include things like diet, bowel cancer and inflammatory bowel disease.

60. We know diarrhoea is a common symptom of colitis. So, it is reasonable to conclude that Mrs J’s diarrhoea was caused by her colitis as her stool samples had excluded an infection. The duration of her diarrhoea also indicates it was less likely caused by an infection.

61. As discussed above, the organisations had been giving Mrs J medication to treat her colitis. There is also evidence of clinicians increasing her colitis medication in response to her flare up of colitis, conducting blood tests to exclude other reasons for diarrhoea and providing intravenous (IV) fluids when needed. This is line with BNF guidance on diarrhoea. IV is where something is given directly into someone’s vein.

62. We recognise how upsetting it must have been for Miss J and her family to see Mrs J when she was unwell. We have concluded there were no failings in how the organisations responded to Mrs J’s diarrhoea.

Glycerol suppository

63. We next considered Miss J’s complaint the rehabilitation hospital administered a glycerol suppository on 3 December, despite her mother’s diarrhoea. A glycerol suppository is a medication used to relieve constipation.

64. The rehabilitation hospital gave Mrs J two glycerol suppositories on 3 December after she had reported being constipated.

65. Our geriatrician adviser told us when someone has not opened their bowels for several days this is usually considered to be faecal loading or impaction. They told us suppositories are often used to treat this, and they were appropriately used in Mrs J’s case.

66. We understand Miss J is concerned as she was worried about her mother’s diarrhoea. We have reviewed Mrs J’s nursing notes which show she had complained to hospital staff about being constipated. Constipation is when someone has hard stools which are difficult to pass or when they pass stools less often than usual.

67. Mrs J’s stool chart supports this as it also shows she did not open her bowels between 29 November and 4 December.

68. NICE guidance on constipation says if someone is experiencing a build-up of stool in the bowel which cannot be passed without help they may need a suppository. Our decision is the rehabilitation hospital’s decision to give Mrs J glycerol suppositories on 3 December was in line with NICE guidance. As this was an appropriate response at the time our decision is there was not a failing in this part of the complaint.

Blood thinner

69. Miss J also complains the rehabilitation hospital gave her mother a blood thinner after 12 December, despite the presence of blood in her stools.

70. The rehabilitation hospital says Mrs J had been taking a blood thinner called rivaroxaban since 2020 for atrial fibrillation. The rehabilitation hospital said it did not give Mrs J any additional blood thinners.

71. Our geriatrician adviser told us atrial fibrillation makes people more likely to have a stroke. Rivaroxaban thins the blood to reduce the risk of blood clots causing a stroke.

72. NICE guidance on rivaroxaban recommends using it to prevent strokes in people who have atrial fibrillation and at least one risk factors such as high blood pressure. As Mrs J had these conditions giving her rivaroxaban was in line with NICE guidance on rivaroxaban.

73. While Mrs J’s records on 12 December show she opened her bowels they do not mention she had blood in her stools or black stools. Black stools could indicate a bleed in the digestive system. This is because blood turns dark when it is digested.

74. Mrs J’s records show the only blood thinner the rehabilitation hospital gave her was rivaroxaban. It gave her the last dose of rivaroxaban at 8am on 13 December and transferred her to ESNEFT via ambulance at this time due to a fast heart rate and chest pain.

75. This is also documented by ESNEFT’s emergency department records which list Mrs J’s presenting complaint s ‘fast AF [atrial fibrillation], chest pain’. ESNEFT’s emergency department records say when it assessed Mrs J at 9.05am on 13 December she ‘passed large black stool’.

76. ESNEFT then reversed the action of the rivaroxaban with a drug called andexanet alfa. It gave her a blood transfusion to replace the blood she had lost and did not give her any further doses of rivaroxaban.

77. Mrs J’s records show she opened her bowels on 12 and 13 December. There is no indication there was any blood in her stool. For this reason, our geriatrician adviser told us there was no reason for the rehabilitation hospital to stop giving Mrs J rivaroxaban.

78. Based on the evidence, we have decided it is more likely that not that signs of blood in Mrs J’s stools only appeared after she arrived at ESNEFT’s emergency department on 13 December and were not seen while she was under the care of the rehabilitation hospital.

79. Rivaroxaban was one of Mrs J’s long-term medications used to reduce the risk of blood clots. The rehabilitation hospital giving it to her to help prevent a stroke due to Mrs J’s atrial fibrillation and high blood pressure follows NICE guidance on rivaroxaban. Our decision is there was not a failing in the rehabilitation hospital continuing to give Mrs J a blood thinner after 12 December.

Sepsis treatment from 24 December 2023

80. Miss J is concerned ESNEFT did not treat her mother’s sepsis promptly from 24 December. She says when she visited Mrs J on 25 December she had a lot of fluid retention. She does not think oral antibiotics were enough and says ESNEFT should have given her mother IV antibiotics sooner than 26 December.

81. ESNEFT says concerns were raised on the 25 December when Mrs J had worsening fluid retention, a headache, nausea and reduced appetite. It says it gave Mrs J IV antibiotics on 26 December to treat the underlying source of infection when Mrs J’s condition had not improved.

82. Sepsis is when the body is infected and is showing abnormal signs such as changes in vital signs because it is reacting strongly to fight the infection.

83. The National Early Warning Score (NEWS) is a system for monitoring a patient’s six vital signs. These are respiration rate, oxygen saturation (a measure of how much oxygen the blood is carrying), temperature, blood pressure, pulse rate and level of consciousness.

84. Each of these areas is given a score depending on how close the measurement is to the normal range. Health professionals add these scores up to show how closely a patient needs to be watched. With a score of seven or more being more abnormal and requiring more intervention than a score of zero.

85. NICE guidelines on sepsis say the first line of treatment for people who healthcare professionals suspect have sepsis is IV antibiotics within one hour, wherever possible.

86. Mrs J’s NEWS was between one and two on 24 and 25 December. When a doctor reviewed her on 24 December she did not appear to be overly unwell and she was taking oral antibiotics. When a doctor reviewed her again on 25 December she was still unwell.

87. The doctor reviewed Mrs J’s blood test results and diagnosed her with kidney failure. The doctor put a plan in place to give Mrs J anti-sickness medication, encourage her to consume fluids, to monitor her fluid intake and output and take a further blood test the following day.

88. ESNEFT gave Mrs J her antibiotics at 8am on 26 December with her next dose due at 2pm that day.

89. Mrs J’s health suddenly deteriorated on 26 December and her NEWS increased to eight at 9.12am. Her oxygen saturation and temperature were low and her blood pressure was unmeasurable. Nursing staff escalated her case to a doctor to review. The doctor reviewed Mrs J at 9.30am and tried to insert a canula with ultrasound guidance at 9.45am but this was unsuccessful. A second doctor also tried but this was also unsuccessful.

90. Mrs J had a chest X-ray at 1.22pm after which an anaesthetist made a third attempt at 2.49pm to insert a canula which was successful. This meant they were able to give her IV antibiotics at 3.10pm and IV fluids 3.35pm. Mrs J’s health deteriorated further overnight and sadly Mrs J died the next morning due to a spontaneous gastrointestinal haemorrhage.

91. We can see once Mrs J’s health deteriorated on 26 December ESNEFT escalated her care to a senior doctor. When the doctor reviewed Mrs J at 9.30am and her NEWS score was eight, we think ESNEFT should have suspected sepsis and followed NICE guidelines by giving Mrs J IV antibiotics within one hour.

92. We can see ESNEFT did suspect sepsis at this point as staff were trying to insert a canula so they could give Mrs J IV antibiotics. Unfortunately, their attempts were unsuccessful which led to a delay from 10.30am. ESNEFT did not give her IV antibiotics until 3.10pm and IV fluids at 3.35pm to support blood circulation. We have concluded this was a failing.

93. We consider the rest of ESNEFT’s management from 24 December was appropriate.

94. Our geriatrician adviser told us there is no medical guideline or research that clearly shows what difference a delay in IV antibiotics makes when someone is already receiving oral antibiotics and has not been improving. They told us given Mrs J was already receiving oral antibiotics and had not responded to treatment, it is difficult to conclude giving her IV antibiotics sooner on 26 December would have made a meaningful difference.

95. Even if ESNEFT had started IV antibiotics sooner this would not have stopped the haemorrhage from happening. We cannot confidently says starting IV antibiotics earlier would have prevented Mrs J’s death.

96. We know this does not take away the sadness for Miss J and her family. We are sorry to hear how concerned they have been thinking more could have been done for Mrs J. We can clearly see how distressing Mrs J’s death is for Miss J and her family. We have not identified any failings which caused Mrs J’s death.

1. Miss J complains about the care three organisations provided to her mother, Mrs J, before she sadly died. We have been unable to reach an impartial view on whether MSE prematurely discharged Mrs J from hospital at the end of October 2023. This is due to the lack of same day emergency care (SDEC) records. We have decided is it is not possible for us to link the discharge in October to Mrs J’s death.

2. We have not identified any other failings in Mrs J’s care. Our decision is to partly uphold Miss J’s complaint. It is clear to us how much Miss J and her family cared for Mrs J and wanted to support her and be present for her. We are sorry to hear about Mrs J’s death and the experiences Miss J and her family had while visiting her in hospital.