Nottingham University Hospitals NHS Trust

3. Mr L complains about aspects of the care and treatment of his father, Mr C by Nottingham University Hospitals NHS Trust between 16 and 27 November 2024. He specifically complains the Trust:

• treated Mr C’s symptoms as stroke-related and did not properly investigate his abdominal pain or monitor his bowel function.

4. Mr L says these events led to a delay in diagnosing a bowel obstruction, resulting in his father's death. He says if appropriate investigations had been carried out, a diagnosis would have been confirmed and enabled a chance of treatment. He says he and his family have been left devastated, distressed and in immense grief following Mr C’s death, and are struggling to come to terms with it all. He says he has been left in debt due to funeral expenses, and his mother has been pushed into financial hardship, as Mr C contributed significantly to household bills.

5. Mr L is seeking answers and an acknowledgement from the Trust, an apology, and financial remedy.

6. Mr C had leg weakness and fell at home on 16 November 2024. He was taken to the Trust’s Emergency Department (ED) by ambulance. The Trust suspected decompensation of an old stroke which occurred 15 years earlier. It carried out a scan of Mr C’s arm and a CT head scan, which showed no evidence of a new stroke. Mr C’s family raised concerns about his stomach pain and the fact he was not opening his bowels properly and requested a scan. The Trust transferred Mr C to a stroke ward and explained he needed physiotherapy for his legs.

7. Mr C’s abdominal pain persisted while on the stroke ward and the Trust prescribed laxatives as required. Mr C’s family raised further concerns about the size of his stomach and ongoing bowel issues on 22 November.

8. Mr L says on 25 November, Mr C had still not eaten and had ongoing bowel issues. He visited the next day, and Mr C was complaining of stomach pain. He also had a swollen stomach. Mr C’s stomach pain increased in the evening, and at 11.44pm the Trust told Mr L a doctor had seen him and a CT scan had been requested.

9. The Trust called Mr L the next morning to say there was a sickness bug on the ward and no visitors were allowed. The Trust arranged an urgent CT scan at 8.16am on 27 November. The results showed Mr C had a small and large bowel obstruction.

10. The Trust called Mr L a second time to tell him Mr C had suffered a cardiac arrest. An hour later, the Trust called Mr L to inform him Mr C had sadly died. The cause of death was spontaneous bowel obstruction.

15. Before we decide if we should conduct a detailed investigation of a complaint, we look at whether there are signs the organisation has got something wrong. We do this by comparing what should have happened with what did happen. We have done this and have not found any indications that something has gone wrong.

Emergency department

16. An ambulance brought Mr C to the Trust’s ED on 16 November 2024 after he fell at home. Mr C had also had symptoms of a cough and fever for two days. The Trust carried out a CT head scan which ruled out a new stroke, and it established the working diagnosis was decompensation of an old stroke (temporary return of previous stroke symptoms) from 15 years prior and urosepsis (when a urinary tract infection (UTI) goes to the kidneys).

17. Mr L says Mr C was experiencing stomach pain while in the ED and the Trust promised a scan of his stomach. The Trust says there is no record of this in his medical notes. Mr L considers the Trust misdiagnosed Mr C’s symptoms as stroke related.

18. NICE sepsis guidance recommends for adults with suspected sepsis who meet only one moderate to high-risk criterion, a clinical review should be arranged within one hour of meeting criterion for clinical assessment in an acute hospital setting, and blood tests should be performed if indicated.

19. NICE stroke guidance recommends performing brain imaging immediately with a non-enhanced CT for people with suspected acute stroke if certain symptoms apply, including unexplained progressive or fluctuating symptoms, and severe headache at onset of stroke symptoms.

20. We reviewed Mr C’s medical records with the help of our ED adviser. The ambulance service assessed Mr C at home. The records note Mr C’s symptoms included a headache and reduced mobility. We can see the Trust assessed him in the ED at approximately 10.30am. It noted Mr C was not in pain, and documented history and clinical examination findings with weakness on the right upper and lower limb. It described the abdomen as soft, non-tender and noted the presence of an umbilical hernia.

21. Our ED adviser explained based on the symptoms and clinical signs, it was appropriate to have a differential diagnosis of urosepsis or a recurrent stroke. They told us appropriate investigations were requested in the form of blood tests and a CT scan of the head. This is in line with NICE sepsis guidance and NICE stroke guidance and we have not seen evidence of failings in the care provided in the ED.

Stroke ward

22. The Trust transferred Mr C to a stroke ward on the evening of 16 November. A physiotherapy assessment recognised Mr C was not fit enough for discharge as he needed to work on transferring from his bed to a chair.

23. Mr L says Mr C’s stomach pain continued for the duration of his time on the ward, and he requested a scan for his father on 22 November. He says Mr C was not opening his bowels and wasn’t eating properly. The Trust prescribed a laxative on a ‘when required’ basis. On 26 November, Mr L says his father was complaining of severe stomach pain, and his stomach was large and painful. The Trust arranged an urgent CT scan on 27 November.

24. Mr L says the Trust did not properly investigate Mr C’s abdominal pain or monitor his bowel function during his time on the ward.

25. In its response, the Trust explained it carried out a pain assessment with each set of observations, which was described as ‘mild’ until the evening of 26 November when there was a significant increase in pain and abdominal distention. It says Mr C opened his bowels seven times during his admission, and there is a period of three days (21-23 November) where no bowel movements are recorded. It says it prescribed codeine which can cause constipation which may lead to bowel obstruction in some cases, however Mr C was having his bowels open and there was no faecal collection or impaction documented in the report following the CT scan.

26. GMC guidance says you must provide a good standard of practice and care, and in providing clinical care you must:

• adequately assess a patient’s condition • carry out a physical examination where necessary • promptly provide (or arrange) suitable advice, investigation or treatment where necessary • propose, provide or prescribe drugs or treatment • refer a patient to another suitably qualified practitioner when this serves their needs

27. Our stroke adviser reviewed the medical records up until 26 November. They noted there was therapy input, daily medical reviews, and explained there does not seem to be any major treatment issues or gaps identified. They said Mr C seemed to be generally stable, and explained the abdominal pain was attributed to constipation for which the Trust prescribed laxatives. We have also seen the medical team sought advice from the surgical team on the evening of 26 November when Mr C’s condition deteriorated.

28. From the evidence we have seen, we consider the Trust acted in line with the above guidance in its care and treatment of Mr C while on the stroke ward.

29. We can see the Trust documented Mr C’s bowel movements with a stool chart, and no movements were recorded between 21-23 November. Our stroke adviser explained regardless of the days no bowel movements were recorded, Mr C had a bowel movement on 25 November, meaning it is unlikely he had bowel obstruction prior to 26 November. We understand why Mr L was concerned about this and hope that our explanations provide some reassurance to him. We have seen no indications of failings in the Trust’s monitoring and recording of Mr C’s bowel movements.

Bowel obstruction

30. Mr L says if appropriate investigations had been carried out sooner, a diagnosis would have been confirmed and enabled a chance of treatment.

31. Mr C’s condition worsened on the evening of 26 November. The Trust says a nurse referred Mr C for a medical review due to a significant increase in abdominal pain and distention. It says the impression at the time suggested an obstruction or strangulated hernia should be eliminated and an abdominal CT scan was requested at 11.36pm. The doctor requested a surgical review.

32. We reviewed the medical records from 26 November onwards with the help of our surgical adviser. They explained there was adequate escalation from the nursing staff. Due to increasing pain, the doctor was called, then escalated to the surgical team, and then a scan was organised.

33. A surgeon reviewed Mr C at 12.06am on 27 November. Their impression was a possible faecal impaction, and that it was unlikely that Mr C had an obstruction, perforated bowel or hernia. They supported the request for the CT scan for confirmation. The Trust reviewed Mr C again at 7.35am and it was agreed an urgent CT scan would be completed. The provisional results were available at 9.52am which showed a small and large bowel obstruction.

34. The BJS article says large bowel obstruction commonly presents to acute surgical services and may have malignant or benign causes. Prompt clinical assessment and rapid imaging via CT is key to obtaining a diagnosis and allowing an informed multidisciplinary approach to treatment.

35. RCS commissioning guidance says abdominal CT is invaluable in the assessment of bowel obstruction.

36. Our surgical adviser explained initial management is the same for all types of obstruction and includes conservative measures such as making the patient nil by mouth, carrying out blood tests including electrolytes, infection markers and inflammation markers, providing fluids to prevent dehydration, and considering a nasogastric tube.

37. We have seen the Trust carried out blood tests throughout Mr C’s admission. We have also seen the surgical team advised the ward team to only allow sips of clear fluid and to insert a nasogastric tube if Mr C vomited following the review on 27 November. They said they would follow up and review if this was required following the CT scan results.

38. Our surgical adviser explained the next step would typically be a CT scan of the abdomen and pelvis. This is the recognised test that should be done in cases of suspected bowel obstruction in line with the BJS article and RCS guidance.

39. They explained if a patient has a large bowel obstruction that is not decompressing back into the small bowel, this is a surgical emergency. If a scan shows loss of blood flow to the bowel, this would also be an indication for an operation. They consider in Mr C’s case, there were no signs of mechanical bowel obstruction with bowel compromise (where the bowel is physically blocked and the blood supply to part of the bowel is being reduced or cut off) and therefore emergency surgery was not indicated straight away.

40. They told us the large bowel distension was decompressing back into the small bowel. Part of the transverse colon (the middle section of the large bowel) was in the abdominal wall hernia. This part of the colon was partially reducible, meaning some of it went back into the abdomen, and there were no signs of loss of blood supply to that segment of colon.

41. Based on this, there was a possibility that conservative measures alone would allow the bowel to decompress and the colon to reduce fully into the abdominal cavity, therefore avoiding an emergency operation.

42. RCS good surgical practice guidance says you must ensure that patient treatment is prioritised according to clinical need.

43. Medical notes recorded on the morning of 26 November note no concerns and suggest Mr C was ready for discharge. We mentioned earlier that Mr C’s condition worsened on the evening of 26 November.

44. We have seen Mr C presented with abdominal distention (swelling) prior to 26 November. We have also seen the Trust was giving enemas and Mr C was opening his bowels on some days but not others.

45. On review of the records there is nothing to suggest the bowel obstruction was present earlier than 26 November based on examinations by the medical team. Our stroke adviser explained abdominal distention can be caused due to circumstances in hospital such as not going to the toilet as frequently.

46. If a scan was carried out days earlier, it would likely have shown a slightly bloated stomach without any acute problems. As the Trust was giving enemas and Mr C was opening his bowels, we do not consider earlier imaging would have changed management. While the hernia was already there, the blockage was a sudden onset and was not present when Mr C attended hospital. We have not seen failings in the way in which the bowel obstruction was investigate or managed.

Summary

47. Based on the evidence we have seen, we consider the Trust investigated Mr C’s symptoms appropriately and started the correct treatment when it recognised Mr C had developed an acute problem, in line with RCS good surgical practice guidance. We will therefore not consider the complaint further.

48. We know this complaint is very important to Mr L, and the events complained about have been extremely difficult for him and his family. We do not wish to underestimate the pain he has experienced due to the circumstances around his father’s death. We hope this statement provides reassurance that the care and treatment was appropriate and we thank him for bringing his complaint to us.

1. We have carefully considered Mr L’s complaint about Nottingham University Hospitals NHS Trust (the Trust). We understand this has been an incredibly difficult time for him and his family. We offer our sincere condolences on the death of his father, Mr C.

2. We have seen no indication that anything went seriously wrong with the care or treatment of Mr C. We have therefore decided to take no further action. We explain the reasons for our decision below.