Sandwell and West Birmingham Hospitals NHS Trust

4. Miss A complains about the care and treatment Mr B received from the Trust between late March and early April 2024, when he sadly died.

5. She complains that the Trust did not:

• treat Mr B with intravenous (IV) fluids and antibiotics

• recognise pins and needles and calf pain as symptoms of clotting before he was transferred to the Intensive Care Unit (ICU)

• appropriately consider if the blue discolouration of Mr B’s feet was a sign of sepsis

• carry out an emergency scan quickly enough in ICU after he lost sensation in one side of his body.

6. Miss A believes better care and treatment could have prevented her fiancé’s death. She also questions whether different treatment would have meant his care could have been transferred to a different hospital, increasing his chances of survival.

7. Miss A describes the great distress she, her family and her fiancé’s children have experienced. They are struggling to understand the loss of Mr B.

8. Miss A wants the Trust to recognise the impact of its mistakes on her and her family, and to provide a financial remedy which reflects this.

9. Mr B attended A&E in late March 2024 presenting with symptoms the Trust considered to be consistent with gastroenteritis. This is an infection that causes diarrhoea and vomiting. He was admitted as an inpatient because he appeared to be experiencing severe gastrointestinal upset.

10. After several days, Mr B experienced an elevated heart rate and loss of sensation in one side of his body. He was admitted to ICU. The Trust conducted investigations and found multiple blood clots in his lower limbs and left ventricle, which is a lower heart chamber.

11. The Trust considered transferring Mr B to a different hospital for specialist care. Unfortunately, he deteriorated to such an extent that it did not deem it beneficial to do so.

12. Mr B’s condition continued to worsen. He sadly died the following day from multiple organ failure secondary to sepsis, which is the body’s extreme response to an infection.

13. Miss A and other members of Mr B’s family met with the Trust in May 2024. It explained to them that unfortunately what happened was very rare, and it could not see any way that it could have foreseen this outcome.

The Ward

IV treatment

18. Miss A remains concerned the Trust did not give Mr A IV antibiotics and fluids throughout his time on the ward. She thinks this would have been a more effective means of treating him given he was being so sick.

19. As outlined above, Mr A was admitted with suspected gastroenteritis. Mr B’s medical records show the Trust recognised Mr B was dehydrated. It quickly started treating him with IV fluids.

20. The relevant guidance for Mr B’s presentation at this time is NICE’s ‘Scenario: Adult gastroenteritis’. This says hospital admission should be considered when ‘there is an inadequate response to oral rehydration salt (ORS) solution, the person is unable to take ORS solution orally, or they are clinically deteriorating’. The guidance also says admission should be considered ‘[…] as the person may need intravenous fluids […]’. We can see the Trust began administering fluids by IV promptly and in line with this guidance.

21. After two days as an inpatient, the Trust noted he had not vomited since admission and there were no signs of dehydration. This means there was not a clinical need for IV fluids at this stage. The Trust encouraged oral intake and explained it would place Mr B on IV fluids if he vomited.

22. The Trust also gave Mr B co-amoxiclav, an anti-biotic. It gave this to him orally. The medical records show Mr B reported an episode of vomiting after taking this, and the Trust subsequently discontinued it.

23. We understand Miss A believes the Trust should have given Mr B the antibiotic via IV and done so throughout his time on the ward.

24. The Academy of Medical Royal Colleges’ ‘Statement on the initial antimicrobial treatment of sepsis’ explains ‘the healthcare professional must recognise that the person has a potentially serious illness and that it could be sepsis.’ It also says:

‘if an infection is thought to be the cause of the illness, or tests show that that this is the case, antibiotics must be given promptly and then changed or stopped later on when more test results are available.’

25. The Trust gave Mr B a dose of antibiotics on the ward. However, our physician adviser was unclear why the Trust had prescribed this. They explained Mr B was not showing any sign of infection at the time.

26. The records show the Trust carried out a screening for sepsis after he was prescribed the oral antibiotics. It found there was a low risk of sepsis.

27. There is no evidence Mr B was presenting with signs of an infection at this point. This means it would not have been necessary or of any clinical benefit to give Mr B the antibiotics via IV. Our physician adviser did explain that the dose of oral antibiotics would not have caused Mr B any damage.

28. Taking all the above into account, we have seen no evidence of failings in the Trust’s provision of IV fluids. We have not seen any evidence that the Trust should have provided IV antibiotics whilst he was on the ward. We know Miss A remains very concerned about this and thinks this would have been more effective treatment. We hope our explanation offers some reassurance and is helpful to her.

Pins and needles and calf pain

29. We understand Miss A remains very concerned the Trust might have missed an earlier opportunity to identify the blood clots. In particular, she tells us Mr B’s mother reported he was experiencing pins and needles. She recalls the member of staff explained it was likely because of his lack of movement.

30. The Trust did not document this discussion, but the Trust has accepted it happened. The Trust explained that whilst, with hindsight, pins and needles are associated with the development of the multiple clots it later found, they are common. In the absence of other serious signs of new illness, it did not escalate them.

31. Our physician adviser agreed pins and needles are a non-specific symptom, and would not necessarily be an indicator of anything more serious on their own.

32. Our physician adviser explained that if Mr B’s pins and needles had been accompanied with calf pain, the Trust should have took action to exclude deep-vein thrombosis, which is when clotting develops in a vein. This is because the NHS’s publicly available ‘DVT (deep vein thrombosis)’ guidance, lists the following symptoms:

• ‘throbbing pain in 1 leg (rarely both legs), usually in the calf or thigh, when walking or standing up • swelling in 1 leg (rarely both legs) • warm skin around the painful area • red or darkened skin around the painful area – this may be harder to see on brown or black skin • swollen veins that are hard or sore when you touch them’

33. Miss A tells us Mr B was also experiencing calf pain at this time.

34. As set out above, both parties have accepted Mr B said to staff he had pins and needles. We have therefore considered if there is any other evidence to show he made staff aware of any leg pain. There is nothing in Mr B’s records to show he complained of this.

35. However, we also accept there was no record of the conversation about pins and needles. Records of conversations with the family after Mr B had sadly died document the family asking why the Trust did not listen when they reported pins and needles. The initial complaint to the Trust and follow-up questions by Mr B’s mother solely refer to pins and needles. From what we can see, the first mention of leg pain was during the meeting the family attended in May 2024.

36. The General Medical Council’s (GMC’s) ‘Good medical practice’ says practitioners must ‘propose, provide or prescribe effective treatment based on the best available evidence’. From the evidence available to us, we cannot say the Trust was aware Mr B was also experiencing leg pain along with the pins and needles. As above, our physician adviser explained about pins and needles being a non-specific symptom. Therefore, we cannot say the Trust needed to take different action at this time, in line with this guidance.

37. We want to be clear this is not a criticism of Miss A or anybody else in Mr B’s family. We understand from the meeting recording that they were left wondering if they could have done more. We know Miss A and the rest of Mr B’s family were heavily invested in his treatment, and they could not have done more to support him.

ICU

Skin discolouration

38. Miss A is concerned the Trust failed to identify Mr B’s skin discolouration was a sign of sepsis. The Trust attributed Mr B’s skin discolouration to ‘lower limb ischemia’, which is a restriction in blood supply.

39. The Academy of Medical Royal Colleges’ guidance on sepsis referred to above says ‘the healthcare team must provide basic support for the person when their body is not working properly, for example giving extra fluid to increase blood pressure or oxygen to assist breathing. The team must also perform tests to see why the person is ill.’

40. The Trust had carried out a screening check for sepsis when Mr B was on the ward. His ICU records note he was ‘asepsis’, meaning there were no indications of sepsis. This tells us the Trust was considering sepsis, in line with the above guidance. Staff also noted mottling of the skin, which is a discolouration of the skin with a marble effect. We understand this is the blue discolouration of Mr B’s feet Miss A refers to.

41. Our critical care adviser explained Mr B’s records do not show any signs of sepsis when Mr B was on ICU. We understand Miss A is very concerned about the discolouration of Mr B’s skin. Our adviser told us in the absence of any other indicators it would be reasonable to attribute this to the ischemia.

42. This is in line with NICE’s CKS on ‘Peripheral arterial disease’ which lists ‘Pallor (or cyanosis or mottling)’ as a symptom of acute limb ischemia. We therefore do not think the Trust got anything wrong in attributing the discolouration to the ischemia.

43. We know it will have been very concerning that sepsis might have been missed when ICU staff were treating Mr B. We hope we can offer some assurance that there is no evidence that there was evidence of sepsis that the Trust missed at the time.

Timeliness of scan in ICU

44. Miss A is very concerned about the timeframe in which the Trust carried out the scan in ICU. The Trust was carrying out the scan when she and Mr B’s mother arrived that day at around 10am. She thinks the Trust should have done this as soon as he started deteriorating in the early hours.

45. When it met with Mr B’s family, the Trust explained the steps it took after he started to deteriorate. It explained that when he initially reported loss of sensation and a raised heartrate in the early hours, it was not overly concerned about his presentation.

46. The Trust explained it started to become seriously concerned at 6.26am when Mr B’s heartrate raised further and his blood pressure became unreadable.

47. At this point the Trust ordered an MRI scan, and it planned to follow-up with a CT scan if this did not identify the problem.

48. Our critical care adviser explained there is a lot to consider when a patient becomes critically unwell. Arranging a scan possibly means taking the patient away from an environment where staff can respond quickly to further deterioration. They advised there is no specific guidance of relevance, and in their clinical view a scan was carried out within an appropriate timeframe.

49. Taking all the above into account, we will be taking no further action on Miss A’s concerns. We understand it has been difficult to understand how her fiancé could have deteriorated and died so rapidly. Our critical care adviser agreed what happened to Mr B was unusual and sadly catastrophic. We do not underestimate just how difficult this has been for her and her family. We hope our explanations offer some assurance to Miss A.

1. We have carefully considered Miss A’s complaint about the care and treatment her fiancé, Mr B, received from the Trust. We understand this was an extremely distressing time for Miss A and her family, and they continue to grieve the tragic loss of Mr B.

2. We have considered Miss A’s concerns carefully, with reference to the relevant guidelines that tell us what should have happened in this case. We have not seen indications of failings in the elements of Mr B’s care we have been asked to consider. Unfortunately, Mr B’s deterioration and death was sudden and unexpected. We do not underestimate just how difficult this has been for Miss A.

3. We explain our decision below.