The Queen Elizabeth Hospital King's Lynn NHS Foundation Trust

7. Mrs N complains about how the Trust cared for her husband, Mr N, during his admission between February and March 2022.

8. She says: • there were delays to the medical team arranging relevant tests and scans to understand the cause of his symptoms • staff delayed giving Mr N the medication he needed • on 6 March, Mr N was given a high dose of noradrenaline in error • the nurse who discovered the drug error delayed informing the team about what had happened.

9. Mrs N says the delayed tests, scans and medication meant the Trust diagnosed her husband’s lymphoma after he died and did not treat it appropriately. She feels this shortened his life.

10. Following the high dose of noradrenaline, Mr N had a heart attack and remained sedated, intubated, and unresponsive until he died. Mrs N says this meant she did not get a chance to say goodbye properly. She queries whether doctors would have taken the same course of action if the nurse had informed the team of the noradrenaline overdose straightaway.

11. Mrs N says what happened increased the distress she experienced due to her husband’s death. She says she is traumatised, and emotionally, physically, and financially drained by having to deal with what happened.

12. Mrs N wants an independent review of the care provided and service improvements. She also wants financial compensation.

13. An ambulance took Mr N to the Trust’s emergency department (ED) on 12 February. ED diagnosed several problems. The most serious were his enlarged lymph nodes and an infection. It also suspected he had blood cancer, but the Trust needed to investigate further.

14. On 4 March Mr N developed sepsis. Sepsis is when the body responds to an infection and begins to attack itself. The Trust transferred him to the critical care unit (CCU).

15. CCU staff treated Mr N’s sepsis by giving him steroids and a noradrenaline infusion to maintain good blood pressure. Noradrenaline is a hormone that regulates several functions in the body, such as heart rate and blood pressure.

16. Mr N’s condition stabilised and treatment continued with blood infusions and antibiotics. He was awake and alert and CCU staff withdrew the noradrenaline at about 11.20pm on 5 March. Approximately four hours later Mr N’s blood pressure began to rise. The nurse looking after him noticed the noradrenaline infusion was running and stopped it.

17. Mr N had a heart attack and his condition became critical. Staff sedated, intubated, and ventilated him. Intubation is when a tube is inserted into someone’s mouth and ventilation is when machine takes over breathing as the patient struggles to do it themselves. Sedation is required for comfort and safety in these circumstances.

18. Staff reduced the ventilation and stopped it on 11 March. Mr N took a long time to wake up and was awake enough for staff to remove the tube on 15 March. His diagnosis was still unclear, but he remained stable over the following days.

19. On 18 March Mr N was very unwell. He started to deteriorate and his organs started to fail. He sadly died on 25 March.

20. His cause of death was recorded as multi-organ failure and lymphoma. Lymphoma is a cancer that starts in the lymphatic system. This is a crucial part of the immune system featuring a series of nodes throughout the body.

Delayed investigations

24. Mrs N complains the Trust did not do a positron emission tomography (PET) scan to investigate her husband’s symptoms. A PET scan is an imaging technique that uses radioactive material to show how well organs and tissues are working. It is well suited to detecting cancerous tumours.

25. Mrs N says a PET scan would have helped diagnose her husband’s lymphoma. She says if he received this diagnosis whilst he was alive then his treatment would have been different. She feels different treatment could have potentially prolonged his life or made him more comfortable.

26. Good medical practice sets out that doctors should provide or arrange suitable advice, investigations, or treatment promptly. We would therefore expect staff to arrange the PET scan without unnecessary delay.

27. Staff at the Trust first tried to arrange a PET scan on 18 February. It did not have the facilities to perform the scan so referred Mr N to a different hospital. The hospital rejected the referral because the Trust did not complete the form properly.

28. Staff then arranged the PET scan for 25 February. However, this did not happen because nurses had given Mr N his breakfast that morning. Patients must not have eaten before a PET scan.

29. Staff made a third referral for a PET scan and arranged it for 2 March. Unfortunately, the machine broke. This meant the planned scan never happened as Mr N’s condition deteriorated before the hospital fixed the machine.

30. There were failings in arranging the PET scan in line with Good medical practice. This was firstly in terms of completing the form accurately, then again when staff gave Mr N food.

31. We have considered the impact this had.

32. Our oncology adviser explained in Mr N’s case, the PET scan would have shown he had widespread disease. However, it would not have diagnosed his lymphoma.

33. Instead, the result of the PET scan would likely have led to a biopsy of his lymph nodes. This procedure involves taking a small sample of tissue and examining it under a microscope. This would have taken a few days to return and been the critical test for diagnosing Mr N’s lymphoma.

34. However, it is unlikely the biopsy would have been possible given Mr N’s condition and the difficulties in performing it. This is due to the small size of the lymph nodes that need sampling and his condition at the time.

35. Our oncology adviser explained Mr N’s had enteropathy-associated T-cell lymphoma (EATL). This is an aggressive cancer often past treatment by the time it is discovered. Sadly, this was the case here. Even if staff diagnosed Mr N whilst he was alive then it would have been too late to provide curative treatment.

36. This meant if staff had diagnosed Mr N’s lymphoma they would have treated him palliatively. They could not have cured his cancer and would have made him comfortable instead. This is what happened as doctors identified early on that his condition was sadly incurable.

37. Had the scan happened, we believe the treatment the Trust gave Mr N would have remained the same. Sadly, Mr N’s life could not have been prolonged, and the Trust did not miss an opportunity to make him comfortable earlier.

38. Nonetheless, we recognise Mrs N understandably expected the PET scan to happen. The unexpected delays to this would have created some uncertainty and frustration.

39. Our Principles set out that organisations should learn from complaints to ensure the same problems do not happen again. They should also put right individual injustices by apologising. This means acknowledging what went wrong and the impact this had.

40. We have considered what the Trust has done in response to this failing and the uncertainty it caused. It apologised to Mrs N and explained it had shared her husband’s experience with staff on the ward. We cannot be certain this has put things right and have made a recommendation with this in mind.

Medication on 23 February

41. Mrs N complains the Trust delayed giving her husband the hydrocortisone it prescribed to treat his suspected sarcoidosis on 23 February. Sarcoidosis is an inflammatory disease that causes small clusters of cells (nodules) to affect the lungs and lymph nodes.

42. Hydrocortisone is a type of steroid called a corticosteroid. It is used to treat various conditions, including those featuring inflammation like sarcoidosis.

43. The Trust’s complaint response said the consultant withheld Mr N’s steroids until after the planned PET scan.

44. Mr N had a CT scan on 14 February. It showed several new nodules in his lungs, swelling in his lymph nodes and chronic liver disease. The radiologist recommended a PET scan to investigate further.

45. Blood results on 19 February showed Mr N had a raised angiotensin-converting enzyme (ACE) level at 123. A normal level is between 12 and 68. ACE is an enzyme produced primarily in the lungs and is often associated with active sarcoidosis.

46. At 9.30am on 23 February the consultant planned to give Mr N steroids ‘for likely sarcoidosis’. The first steroid would be hydrocortisone, then followed by another type of corticosteroid (prednisolone). Later that day the consultant withheld the steroids until after the planned PET scan.

47. BTS guidance recommends initially treating sarcoidosis with corticosteroids.

48. Our respiratory adviser told us raised ACE is an indicator for sarcoidosis, but it is not definitive. They also explained the CT scan results from 14 February did not show enlarged lymph nodes within Mr N’s lungs or in the centre of his chest. These are typical features when someone has sarcoidosis.

49. Therefore, sarcoidosis was a possible diagnosis based on some of Mr N’s symptoms. However, the wider clinical picture was not typical of sarcoidosis, and it was later established he did not have the disease.

50. Whilst steroids are appropriate first-line therapy for proven sarcoidosis, doctors had not made this diagnosis on 23 February. Furthermore, steroids can suppress lymph node swelling and reduce the body’s uptake of the radioactive material used in the PET scan.

51. Due to the unconfirmed sarcoidosis diagnosis and planned PET scan, we are satisfied doctors acted in line with guidance when they withheld steroids on 23 February.

Medication on 5 March

52. Mrs N complains when the Trust gave her husband his initial dose of steroids on 5 March it was too high. She wonders whether it caused her husband to have unusually low blood pressure (hypotension).

53. The Trust explained CCU staff gave Mr N three doses of 100mg of steroids on 5 March. They gave four doses of 100mg from 6 to 9 March, and two doses of 100mg on 10 March. It said the first hydrocortisone dose was not too high and reduced it as Mr N’s condition allowed. It added the hydrocortisone was unlikely to have caused his hypotension.

54. Sepsis guidelines recommend giving corticosteroids to adults with sepsis experiencing septic shock. Septic shock is the most severe stage of sepsis when blood pressure drops and organs fail. It is often fatal.

55. The typical corticosteroid dosage limit is 200mg per day when needed for acute problems. However, CCUs widely use doses of up to 400mg per day in the early phases of septic shock. This is within accepted practice.

56. At this point Mr N’s condition had deteriorated significantly. He had developed sepsis, his blood pressure was dropping and his organs were failing. Doctors gave steroids to treat this acute problem – not the previously suspected sarcoidosis.

57. Our respiratory adviser explained the steroids given in critical care were correct for the clinical situation. Whilst doses were relatively high for a few days, they were consistent with national practice, including the taper to withdrawal. They said doctors gave Mr N the steroids to successfully increase his blood pressure.

58. We are satisfied doctors gave Mr N steroids in line with guidance and have found no failings here.

Noradrenaline

59. Sepsis guidelines set out how doctors should manage patients with septic shock when on drugs like noradrenaline. The guidelines say doctors should maintain the patient’s mean arterial blood pressure at above 65mm Hg. Mean arterial blood pressure is a way to assess blood flow through the body. Between 70 and 100mm Hg is generally considered normal.

60. The Trust transferred Mr N to the CCU on 4 March as his blood pressure had dropped and doctors suspected he had sepsis. Part of the doctors’ treatment for Mr N’s sepsis was giving him noradrenaline.

61. On 5 March Mr N had a mean arterial blood pressure of 78mm Hg and it remained stable. Doctors gradually reduced the noradrenaline throughout the day and stopped it entirely at 11.20pm. He was awake and alert at this time, but doctors kept the line in place so they could restart the noradrenaline if needed.

62. At 2.57am on 6 March the noradrenaline was restarted. A nurse later reported they noticed it was being given at between 20mls/hr and 40mls/hr. This was significantly higher than the 0.5 to 4mls/hr he had been receiving previously.

63. Mr N’s blood pressure began to increase, and records show it reached a peak of 143mm Hg at 2.59am. His blood pressure then started to fall and was back to normal 15 minutes later.

64. Doctors also tested Mr N’s troponin-I at 5.15pm. This is a protein released into the blood when someone’s heart is damaged. The most common cause is a heart attack.

65. The result was 1083 ng/L. This is exceptionally high, and the Trust requires referral to a doctor if the level is over 70 ng/L.

66. Our critical care adviser explained Mr N’s mean blood pressure on 5 March meant he no longer needed the noradrenaline. There were no indications staff should have restarted it.

67. The Trust’s investigation found the noradrenaline was likely unknowingly restarted. We would not expect notes to document this, but it means we cannot say how it happened. However, we know the noradrenaline should not have been given at this point.

68. We recognise how upsetting it is for Mrs N that we cannot provide a further explanation for this. We also understand the incredible worry she experienced at the time and still feels to this day.

69. We have found giving this additional noradrenaline was a failing. We have therefore considered the impact of this.

70. Mrs N says the noradrenaline caused her husband to have a heart attack which resulted in staff intubating and sedating him. She says he remained unresponsive until he died. Mrs N says this meant she did not get a chance to say goodbye properly and it has made the distress caused by her husband’s death even worse.

71. Mr N did wake up after his period of sedation. However, he could not speak or follow commands.

72. Our critical care adviser explained the noradrenaline increased Mr N’s blood pressure. The elevated blood pressure injured his heart and resulted in him developing fluid on his lungs and chest pain.

73. The doctors looking after Mr N intubated and ventilated him in response to his acute problems. Our critical care adviser explained this intubation, sedation and unresponsiveness would probably have been avoided if the noradrenaline had not been restarted.

74. We consider Mr N’s unresponsiveness meant Mrs N could not properly say goodbye to him before he died. This has left her traumatised, and emotionally, physically, and financially drained by having to deal with what happened.

75. The Trust conducted a serious incident investigation of what happened. It does this to take a detailed look at an event with serious consequences. The Trust did this to find out what happened and identify lessons to stop it happening again.

76. The serious investigation report found the device used to deliver the medication to Mr N had several ports so staff could connect more than one infusion at the same time. In this instance, Mr N was receiving two other infusions at the time of the incident.

77. The report said although Mr N did not start any new infusions it was possible someone could have restarted the noradrenaline when they meant to adjust a different medication.

78. The investigation recommended the CCU puts a system in place to identify high-risk medications easier. It should also change its working practices, so staff discontinue high-risk medications within a set period and audited the outcome. CCU also shared what happened with its staff to raise awareness and promote future learning.

79. We have independently reviewed what happened and got our own clinical advice on events. We cannot provide any additional factual detail to that set out in the Trust’s investigation report. However, we hope this independent investigation provides reassurance to Mrs N and can bring some comfort in time.

80. Having considered the Trust’s investigation, we are satisfied it has done enough to avoid similar problems happening again in the future. However, it should take further action to put right the individual impacts Mrs N has experienced. We have set this out in the recommendations section below.

Time taken to inform the team

81. Mrs N complains the nurse took too long to inform the team when they spotted Mr N’s noradrenaline was being administered. She says the doctors would not have intubated her husband if they had raised their concerns earlier.

82. The Code says nurses should raise their concerns immediately whenever they find situations that put patients at risk.

83. At 2.57am on 6 March a nurse noticed Mr N’s noradrenaline infusion had restarted. He emailed the ward manager on 7 March and said he had noticed Mr N’s noradrenaline had restarted but did not know how it had happened.

84. The Trust’s investigation report explained the nurse who reported the noradrenaline had recently joined the Trust from abroad. The nurse said they were concerned about how the incident would be managed, as their previous experience overseas was that it would be punished.

85. Its investigation found the nurse had delayed sharing relevant information under its own Duty of Candour policy and The Code. It was a failing that the nurse did not report their concerns about the noradrenaline as they should have done. We have therefore considered the impact this had.

86. Our critical care adviser explained Mr N’s sudden deterioration and later intubation would not have happened if the noradrenaline was not restarted. However, there is no indication intubation was the wrong response to his declining condition. Therefore, the delay to reporting had no impact on Mr N’s treatment.

87. The Trust’s investigation identified what happened and acted to avoid the same thing happening again. Its report set out that the nurse responsible must have a detailed discussion with the ward manager and reflect on their actions. The ward manager should also work with the nursing team to create a culture of transparency.

88. Having compared the Trust’s response to what happened to our Principles, we are satisfied it has done enough to stop the same problem happening again. This is because it has addressed the systemic and individual causes of what happened appropriately.

1. We have found a failing in that The Queen Elizabeth Hospital King’s Lynn NHS Foundation Trust (the Trust) gave Mr N an unnecessary dose of noradrenaline. This meant Mrs N was unable to properly say goodbye to her husband before he died.

2. We also found the Trust failed to arrange a scan to investigate Mr N’s symptoms. Although this meant the scan did not happen, it made no difference to how the Trust cared for Mr N.

3. The nurse who discovered the unnecessary noradrenaline dose failed to inform colleagues as promptly as they should have done. The Trust has done enough to put this right.

4. There were no failings when the Trust delayed giving Mr N steroids, or the amounts it gave him.

5. We have therefore partly upheld this complaint.

6. We have made two recommendations to the Trust for it to put right the unresolved impacts we have identified. The Trust should audit complaints to see if service improvements have stopped the problem with scans happening again. It should also pay Mrs N a financial remedy.