Bedfordshire Hospitals NHS Foundation Trust

3. Miss A complains about the care and treatment Bedfordshire Hospitals NHS Foundation Trust (the Trust) provided to her fiancé, Mr G, during his hospital admission from 7 to 12 March 2024. She says the Trust failed to appropriately monitor and treat her fiancé, and there was a delay in seeking input from a liver specialist. Miss A also says the Trust did not communicate with the family about the seriousness of her fiancé’s condition.

4. Miss A says the Trust’s lack of care and treatment contributed to her fiancé’s death. She says the Trust’s poor communication meant she was not prepared for his death and missed the chance to say goodbye. She says this has caused significant upset and distress to her and to her fiancé’s family.

5. Miss A is seeking an apology, service improvements and a financial remedy.

6. Mr G had liver cirrhosis. Cirrhosis is a form of progressive liver disease that develops because of chronic inflammation.

7. On 7 March 2024, Mr G attended A&E. Clinicians decided to admit him to the emergency assessment unit for further review. On 10 March 2024, clinicians transferred Mr G to the gastroenterology ward.

8. On 11 March 2024, Mr G’s condition deteriorated and he became unresponsive. He was transferred to the intensive care unit (ICU) for further management. That evening, clinicians decided to withdraw active treatment. Mr G very sadly died early the next morning. His cause of death was decompensated alcoholic liver disease.

Care and Treatment:

12. Miss A says the Trust did not properly assess, treat or monitor or treat her fiancé during his admission between 7- 12 March and there was a delay in liver specialist reviewing him.

13. The Trust provided a detailed explanation of the care it provided to Mr G. It says Mr G’s multi-organ failure was due to his liver disease and nothing further could be done to change the very sad outcome.

14. Cirrhosis causes permanent scarring of the liver which can damage and interfere with its functioning. Decompensated liver cirrhosis is an advanced stage, when the body is no longer able to cope with the scarring, and it leads to serious complications. The decompensated cirrhosis bundle is a tool created by the British Association for the study of the liver (BASL) and the British society of Gastroenterology (BSG) to guide clinicians on the necessary investigations and early management of patients admitted with decompensated cirrhosis. The first section of the bundle focusses on the necessary investigations including blood cultures and vital sign observations. It says to ‘perform ascitic tap in all patients with ascites’.

15. Mr G presented to hospital on Thursday 7 March with shortness of breath and ascites, which is when too much fluid builds up in the abdomen. The duty medical consultant and speciality doctor assessed him and noted his abdomen was distended (swollen) and he was likely for an ascitic drain. An ascitic drain (or tap) is a procedure to drain fluid that is trapped in the abdominal cavity to help with diagnosis. Clinicians admitted Mr G to the emergency assessment unit in the early hours of the following morning,

16. A gastroenterologist reviewed Mr G at 8:30am on Friday 8 March and noted the clinical impression was decompensated advanced liver disease. The plan included arranging daily blood tests, diagnostic ascitic tap, a CT scan and a transfer to the gastroenterology ward.

17. The medical team continued to review Mr G over the weekend and monitored his blood test results. His observations were stable on 9 March, and he did not have a fever or vomiting. Clinicians initially gave Mr G vitamin B infusions to prevent nerve damage (which occurs with alcohol dependence) and treated him for potential alcohol withdrawal. Mr G’s haemoglobin (protein in red blood cells) was dropping, which can be due to blood loss. Our adviser says this would not have triggered any urgent investigations or consultant input over the weekend.

18. Mr G also had hyponatremia (low sodium) which clinicians treated with fluid restriction (limiting the amount of fluid intake). Our adviser says was clinically appropriate given his serum creatinine (a blood test used to check how well the kidneys are filtering blood) was normal and he had ascites. Clinicians performed an ascitic tap to drain and test the fluid in Mr G’s abdomen on 9 March. This did not show any signs of infection.

19. The notes show clinicians also monitored Mr G for signs of hepatic encephalopathy. Hepatic encephalopathy occurs when the liver cannot adequately filter toxins from the blood. These toxins accumulate and impair brain function, causing changes in mood, behaviour, cognition, and motor skills. The notes say Miss A mentioned her finance had some confusion on 9 March. Nurses assessed Mr G and found he was orientated at that time. Our adviser explains Mr G may have had some mild encephalopathy and sadly this would be expected given he had extremely severe liver disease. Monitoring this was the appropriate response and there’s no indication anything further needed to be done at this stage.

20. Mr G was transferred to the gastroenterology ward during the early hours on Sunday 10 March. The gastroenterologist reviewed him later that morning as part of the ward round. They noted he appeared well and reported he had been jaundiced for the previous couple of months. The plan included awaiting the scan report once the CT scan had been performed and to continue daily blood tests and fluid restriction.

21. Mr G had the CT scan later that day which showed ‘evidence of portal hypertension and ascites in keeping with decompensation’. Portal hypertension refers to elevated pressure in the portal vein that runs through the liver. It is a complication of liver cirrhosis.

22. A liver specialist assessed Mr G for the first time on Monday 11 March. We understand Miss A questions why this did not happen sooner. Our adviser tells us the liver specialist became involved at the appropriate time. The usual practice is for the weekend general cover teams to take care of medical inpatients, rather than specialist teams. Specialist gastrointestinal care is available, in particular for out of hours endoscopy, but there was no clinical reason to seek an out of hours liver consult in Mr G’s case. He was seen by the gastroenterologist on the Friday and the Sunday and the weekend team was carrying out appropriate investigations and providing care and treatment in line with BSG guidance.

23. The liver specialist noted Mr G’s low haemoglobin and suspected he may have an upper gastrointestinal (GI) bleed. The BSG care bundle says where an upper GI is suspected, fluid resuscitate, prescribe IV terlipressin, prescribe preventative antibiotics, arrange a blood transfusion and arrange an endoscopy. Fluid resuscitation is the therapeutic administration of fluids to correct physiological parameters, such as blood pressure and urine output. Terlipressin is a medication to improve kidney function in patients with hepatorenal syndrome (kidney problem that occurs in patients with severe liver disease). An endoscopy is procedure where a tube is inserted into the body to visually examine the upper digestive system.

24. The liver specialist noted the plan was to arrange a blood transfusion and an endoscopy within 12 hours. Mr G was given IV fluids and terlipressin was added once the team considered he had received adequate fluid resuscitation. This follows the BSG guidelines.

25. Mr G then deteriorated early in the afternoon, and a medical emergency call was put out. ICU staff attended and found Mr G unresponsive and hypotensive (low blood pressure). They decided he should be transferred to the ICU for further monitoring. The endoscopy was delayed because he was too unstable.

26. Mr G arrived in the ICU at approximately 2:55pm and he was intubated and put on a ventilator by 5:30pm to help him breathe. He quickly became very unwell requiring substantial support for his blood pressure. He had an endoscopy later in the evening which did not show any evidence of a bleed. Following discussion between the intensive care and liver consultant, they decided not to escalate his care as sadly nothing further could be done. He very sadly died at 8:45am on 12 March.

27. We are truly sorry to hear Miss A’s concerns about the level of care and treatment her fiancé received towards the end of his life. We do not doubt how difficult this time has been for and the rest of Mr G’s family. Overall, having considered the available evidence so far, we consider the Trust acted in line with the BSG guidance and provided appropriate care and treatment for Mr G.

Communication:

28. Miss A says the Trust did not appropriately communicate the seriousness of her fiancé’s condition to the family, so they were unable to prepare themselves for the very sad outcome. She says she and Mr G’s family were not expecting him to die when he did, and this came a massive shock to them, which was incredibly traumatising, especially as they were planning on getting married a short time later.

29. The Trust has acknowledged it was not appropriate for ward staff to give Mr G’s family false reassurances when they asked about his condition. It says the ITU consultant spoke to Mr G’s family on 11 March and delivered the sad news that nothing further could be done and no concerns were raised at the time.

30. GMC Good Medical Practice guidance s ‘you must give patients the information they want or need to know in a way they can understand (paragraph 32)...you must be considerate to those close to the patient and be sensitive and responsive in giving them information and support (paragraph 33)’.

31. There is nothing in the notes from the first few days of the admission to show what information clinical or nursing staff were providing to Mr G or his family about his condition. Miss A says when Mr G was first admitted, clinicians said he should be discharged early the following week. She says if clinicians knew about the seriousness of his condition they should have told the family.

32. When Mr G’s condition deteriorated on 11 March, a doctor noted they updated Miss A and explained he was ‘very poorly and needs to go to ICU’. Later that evening, the notes show ICU consultant spoke with Mr G’s family to discuss his condition and prognosis. The consultant noted they explained that despite best efforts, Mr G was sadly likely to die within 24 hours.

33. Although Mr G was extremely unwell, his condition was stable until Monday 11 March. Sadly, Mr G’s deterioration was extremely sudden, and he was transferred to the ICU when his organs began to fail. We appreciate Miss A must have been shocked and understandably had questions about why clinicians did not warn her this was a possibility when he was first admitted. Our adviser explains there are risk prediction tools that can provide broad estimates of life expectancy such as three or six-month survival, but not to predict such sudden declines. Had a liver specialist been involved sooner, they may have been able to give a more accurate picture of Mr G’s prognosis, but they would not have been able to predict with any certainty. We are not critical of the timing of the liver consultants’ input because as discussed above, there was no clinical reason to request specialist support over the weekend.

34. We recognise this was an extremely traumatic and distressing time for Miss A and the rest of the family. Having considered the available information, we consider the Trust acted in line with GMC guidance. We are sorry to hear Miss A felt ward staff gave them false hope and did not adequately prepare them for what would happen. Sadly, it is not always possible to predict when a person will deteriorate. When Mr G’s condition worsened on 11 March, the ICU consultant had a conversation with the family about his prognosis. We are incredibly sorry to hear about the distress this caused and how this came as a shock to the family.

35. We recognise Miss A’s understandable strength of feeling about her complaint and we thank her for bringing it to us. We hope she is reassured by our findings.