Barts Health NHS Trust

4. Ms B complains the Trust: • discharged her home from same day emergency care (SDEC) on 27 August and did not admit her to hospital on 28 or 29 August 2024 • gave her too much fluid in August and September 2024 • reduced her gabapentin (painkiller) by 70% between September and December 2024 • catheterised her for too long between September and December 2024.

5. Ms B says as a result: • she experienced a deterioration in her physical health • of the Trust giving her too much fluid she developed chronic kidney disease, and her heart failure worsened • of the Trust reducing her gabapentin she experienced more pain and delirium • of the Trust catheterising her for too long she contracted a urinary tract infection, became urinary incontinent, experienced delirium on two occasions and now has permanent mild cognitive impairment.

6. Ms B also says her daughter, Ms D, has experienced significant emotional distress and anxiety and lost trust in the NHS.

7. Ms B would like an acknowledgement, apology, service improvements and a financial remedy.

8. On 27 August 2024 Ms B attended the Trust’s SDEC. This is as an alternative to admitting someone to hospital. It is a service designed to assess, diagnose and treat all in the same day. There is also the option of ongoing clinical care provided by SDEC, primary care or community services.

9. Ms B’s health records say she presented at SDEC with right leg swelling and diarrhoea. The Trust also identified that she had stage two acute kidney injury which means her kidneys were not working properly.

10. Her National Early Warning Score (NEWS) score was one. The 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.

11. 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.

12. The Trust conducted an ultrasound scan of Ms B’s right leg. This is a scan that uses sound waves to create pictures of inside the body. This scan ruled out deep vein thrombosis (DVT). DVT is a blood clot in a vein in the leg which can potentially become life-threatening. After this, the Trust agreed to review Ms B the following day and it advised her to increase her fluid intake.

13. The next day the Trust conducted another ultrasound scan, this time of Ms B’s urinary tract. The scan confirmed there was no blockage stopping Ms B’s kidneys from working properly. The Trust then asked Ms B to return to SDEC on 29 August with a stool sample.

14. When Ms B attended SDEC, the Trust confirmed she did not have a bacterial infection in her stool causing her diarrhoea. The Trust conducted a CT scan of her chest and pelvic region and contacted a gastroenterology doctor for advice. A CT scan is a detailed scan of the inside of your body using a series of X-ray images and a gastroenterology doctor specialises in managing and treating conditions of the digestive system. The Trust asked Ms B to return to SDEC at the beginning of September 2024 for a review.

15. When Ms B returned for a review, the Trust admitted her to hospital due to acute kidney injury, dehydration and diarrhoea. Ms B remained in hospital until the end of December 2024 when the Trust transferred her to a rehabilitation service.

16. Ms B cannot recall all the details of what happened so her daughter has kindly helped her raise her complaint.

SDEC

20. Ms B complains that the Trust discharged her home from SDEC on 27 August and did not admit her to hospital when she reattended on 28 and 29 August. The Trust says it managed Ms B in SDEC because she did not meet the criteria for hospital admission.

21. There is no specific guidance on when to admit someone to hospital or SDEC. Healthcare professionals should make this decision in line with the GMC’s guidance. The GMC is responsible for regulating and setting professional standards for doctors in the UK. Its guidance says doctors must assess, diagnose and treat patients based on their individual needs and your clinical judgement.

22. The Royal College of Physician’s AEC guidance refers to a tool intended to help healthcare professionals with this decision. It is a point-based system called the (ambulatory care) AMB score. According to the AMB score if someone scores five or more they may be suitable for SDEC. If they score less than five they are less likely to be suitable for SDEC.

23. Points are added if the person:

• has access to transport (+2) • is unlikely to need intravenous (IV) treatment (+2) • is not acutely confused (+2) • has a NEWS of zero and is clinically stable (+1) • has not been discharged from hospital in the last 30 days (+1).

24. Points are deducted if the person:

• is male (-0.5) • is 80 years old or older (-0.5).

25. From the information in her health records on 27 August, it appears Ms B’s AMB score on 27 August would have been seven. This is because:

• she had access to transport (her health records about her previous social history say she was ‘independent’) (+2) • the Trust did not anticipate she would need IV treatment (her health records say the Trust ‘advised to increase fluid intake’) (+2) • she did not report being acutely confused (her health records do not refer to her suddenly being more confused than usual and say she was ‘awake and alert’ which suggests she was conscious, responsive and aware of her surroundings) (+2) • her NEWS score was one (0) • she had not been discharged from hospital in the last 30 days (+1) • she is female (0) • she was under 80 years old (0).

26. This indicates it was suitable for the Trust to treat her in SDEC. While the Trust had identified Ms B had acute kidney injury, NICE guidance on acute kidney injury says if someone is clinically stable they can have a clinical review within 24 hours.

27. The Trust had assessed Ms B in SDEC and her NEWS score was one, indicating she was clinically stable. The Trust had advised her to drink more fluids and planned to review her further the following day. This was in line with NICE guidance on acute kidney injury which recommends a clinical review within 24 hours. Considering this and that her AMB score would have been seven we do not see indications of failings in the Trust discharging her home from SDEC on 27 August.

28. Creatinine is a waste product from the muscles that the kidneys filter out. High levels of creatinine can indicate the kidneys are not working well. For women the normal range of creatinine in the blood is 45 to 84mmol/L. The phrase mmol/L stands for millimoles per litre. It is a measurement of how much of a substance there is in one litre of liquid.

29. On 28 August Ms B’s creatinine was 184mmol/L. This was high, and higher than it had been the previous day (178mmol/L). Her increased creatinine levels indicated she was dehydrated and her kidney function was worsening despite the Trust’s previous advice to increase her oral fluid intake. The Trust gave her IV fluids to begin to address this making SDEC less suitable for her.

30. Ms D also supported Ms B that day and gave more detail about Ms B’s severe diarrhoea. She also explained that Ms B had been passing less urine and drinking less than usual for a few weeks. She told us that it had become impossible to get her mother to eat or drink, she had become bedbound and she told us she was sleeping all the time.

31. Our adviser told us these findings should have raised concerns for the Trust.

32. While Ms B’s AMB score may still have been five, the Royal College of Physician’s AEC guidance is very clear that the AMB score is just a tool to help health professionals decide whether to admit someone to hospital or not. It should not replace clinical judgement.

33. When Ms B returned to SDEC on 28 August the Trust had new information about how she was coping at home and her worsening kidney function. This suggested managing her under the SDEC pathway was not working. We think there are indications of a failing in the Trust not admitting Ms B to hospital on 28 and 29 August when her presentation was worse.

34. In terms of impact, Ms B says she experienced a deterioration in her physical health. She says she came out of hospital a completely different person so we can understand why she is concerned.

35. The Trust admitted Ms B to hospital only five days later, on 2 September. She then received continuous hospital care for over three months. We therefore think it is unlikely that the Trust’s decision not to admit her to hospital on 28 or 29 August had any significant effect on Ms B’s long term deterioration. The gap between the two events is too long, and her condition was managed in hospital throughout that time making it difficult for us to link what happened in August to what happened later. Our adviser also agrees it is unlikely that this would have affected subsequent events or Ms B’s ultimate outcome.

36. As we have not seen indications of significant claimed impact from this matter we do not propose to take any further action on it.

Fluid

37. We then went on to consider Ms B’s concerns that the Trust gave her too much fluid in August and September 2024.

38. The Trust says it gave her IV fluid to treat her dehydration. It says it gave her no more fluids after 11 September because her dehydration and diarrhoea were improving. Ms B’s health records say the Trust also gave her one litre of IV fluid on 28 August when she attended SDEC.

39. On 28 August when she attended SDEC Ms B reported she had diarrhoea and had not been drinking much. This was despite the Trust telling her the previous day to drink more.

40. NICE guidance on IV fluids says if someone is experiencing dehydration and diarrhoea these are reasons for a doctor to consider giving them IV fluids.

41. As Ms B had not been able to increase her fluid intake orally we think it was in line with NICE guidance on IV fluids for the Trust to give her IV fluids at the time to try to address her diarrhoea, dehydration and acute kidney injury.

42. When the Trust admitted her to hospital in September Ms B was very dehydrated. Dehydration can negatively impact kidney function and was most likely the cause of her acute kidney injury. This is because the kidneys conserve water when someone is dehydrated. This can cause increased workload for the kidneys which then have to manage concentrated urine.

43. Between 2 and 11 September Ms B’s health records say the Trust gave her one to two litres of IV fluids at a rate of 100 to 125ml per hour. It then stopped her IV fluids, gave her a diuretic and restricted her fluid intake to 1.5 litres per day. A diuretic is a medication that helps the body remove excess fluid by increasing urine production.

44. Our adviser told us it was particularly difficult to manage Ms B’s fluid levels because of her poor oral intake, her diarrhoea and her fluid build-up in spaces outside the cells and blood vessels. This meant the fluid the Trust was giving Ms B was not all going where it needed to, to help Ms B get better. Rather it was being lost in other places.

45. Ms B needed fluid to replace what she was losing and to correct abnormal fluid distribution. NICE guidance on IV fluids does not require doctors to give people a certain amount or rate of fluid in this situation. Our adviser has told us in this case how much fluid the Trust should have given Ms B is down to clinical opinion. There is no formula to work this out accurately. Their view is it was appropriate to give Ms B fluid until her fluid was replaced. This can take up to several weeks to achieve.

46. NICE guidance on IV fluids says healthcare professionals should conduct ongoing monitoring of the effect of IV fluids. This is done by checking a person’s NEWS, fluid balance charts and weight. We can see the Trust was doing this but unfortunately, giving her IV fluids still contributed to Ms B having fluid build-up.

47. We recognise that the unintended build-up of fluid was understandably worrying for Ms B and her daughter. It is natural for them to want to raise concerns in such circumstances.

48. Our adviser’s view, which we share, is the amount of IV fluid the Trust gave Ms B in August and September was a reasonable approach. The evidence suggests Ms B needed IV fluid and there is no national guidance on how much the Trust should have given her.

49. The Trust was monitoring the amount of fluid it was giving Ms B and the amount she was expelling through urine. Due to the complexity of her condition, it was challenging to manage. When her diarrhoea and dehydration began to improve the Trust stopped giving her IV fluids.

50. We have not seen indications of failings in the amount of fluid the Trust gave to Ms B.

Gabapentin

51. Another concern Ms B has is that the Trust reduced her gabapentin (pain medication) by 70% between September and December 2024. Ms B’s daughter says the reduction was too drastic and the Trust only began to increase it once she asked it to do so.

52. The Trust agrees it reduced Ms B’s gabapentin. It says it did this to prevent further kidney damage when her kidney function was already low. It says when the kidneys are not working properly the levels of toxins in the body increases as it is less effective at secreting the medication.

53. Ms B’s health records show the Trust gave Ms B her usual 3600mg daily dose of gabapentin until 4 October when it reduced her dose from 3600mg to 900mg. It then began to gradually increase her dose back to 3600mg between 6 and 20 November. The Trust then maintained this dose for the rest of Ms B’s hospital stay.

54. According to MHRA’s gabapentin drug safety update, gabapentin carries a rare risk of severe respiratory depression. This is a life-threatening condition where breathing becomes very shallow leading to low oxygen levels.

55. The risk of breathing problems is higher for people whose lungs and kidneys are not working as well as they should and who are older. While MHRA’s gabapentin drug safety update does not explain what age it classes as older, NHS England defines older people as those aged 65 and over.

56. MHRA’s gabapentin drug safety update recommends adjusting the dose of gabapentin for people with these risk factors to reduce the risk of respiratory depression.

All these risk factors applied to Ms B. She was in her 70s at the time. She had recently had stage three lung cancer and surgery to remove part of her lung, so her lungs will not have been working as well as they should. She also had acute kidney injury which means her kidneys were not working as well as they should have been.

57. Our adviser says it may have been possible for the Trust to reduce Ms B’s gabapentin more gently. However, they told us the need to reduce gabapentin is urgent in situations where someone has acute kidney injury and there is no specific guidance on how this reduction should be done. In these situations, decisions are made on an individual basis weighing up risks and benefits.

58. Even with the risk of reduced pain control, to reduce the risk of breathing problems, we think it was in line with MHRA’s gabapentin drug safety update for the Trust to reduce Ms B’s gabapentin.

59. There are no specific guidelines relating to Ms B’s situation to say how a reduction in gabapentin should be done. While we acknowledge other clinicians may have acted differently, we have not seen sufficient information to indicate the amount of the reduction was wrong.

60. Ms B had a lot of risk factors for respiratory depression, the consequences of which could have been fatal, especially after recently having surgery for lung cancer. Taking account of all these risk factors, we have not seen indication of a failing.

Catheter

61. A catheter is a thin, flexible tube placed in the bladder to drain urine into a drainage bag.

62. Ms B complains that the Trust catheterised her for too long between September and December 2024. Ms B’s daughter said she asked the Trust to remove her mother’s catheter when she experienced delirium. Ms D described how when her mother came home from hospital she could no longer read, write or walk and she was incontinent.

63. The Trust says it gave Ms B a catheter from 3 September to monitor her urine output when she had acute kidney injury. It also noted she had moisture lesions in her groin. This happens when the skin breaks down because it has been too wet for too long for example because of urine.

64. It explains it removed the catheter on 11 September when her kidney function improved.

65. The Trust says Ms B needed three people and a support frame to transfer her. It explains it gave her a catheter from 27 September because it was giving her a high dose of an IV diuretic. The Trust says it removed the catheter on 18 November after the medical team requested a successful trial without one.

66. We have reviewed Ms B’s health records and we have not seen sufficient information to indicate the Trust catheterised Ms B after 18 November. We queried this with Ms D, and she helpfully shared the notes she wrote from the time Ms B was in hospital. Unfortunately, these notes do not provide any more evidence of the Trust catheterising Ms B after 18 November.

67. While we are not disputing Ms D’s recollection, based on the information available to us we cannot conclude the Trust catheterised Ms B after 18 November.

68. The NHS website explains that treatment for acute kidney injury may include catheterisation. This is because having a catheter helps to drain the bladder which can protect the kidneys. Also, a catheter makes it easier to measure how much urine someone is producing. This helps health professionals assess how well the kidneys are working and adjust their treatment accordingly, making treatment safer.

69. Our adviser told us the decision to catheterise someone is made on clinical judgement and should be done in a patient’s best interests based on balancing any potential risks with any benefits.

70. Their view, which we agree with, is there were good reasons for the Trust to catheterise Ms B.

71. While catheters can increase the risk of urinary tract infections, in Ms B’s case there was also a risk of her developing moisture lesions. As well as being at risk of moisture lesions Ms B also had reduced mobility meaning she would find it challenging to use the toilet independently. Additionally, she was taking a high dose of a diuretic which makes the kidneys produce more urine than usual.

72. We think this meant it was reasonable for the Trust to catheterise Ms B for the time it did and the Trust has provided sufficient rationale for doing so.

73. It is important to say we are very grateful to Ms B for raising her concerns with us. Especially when we recognise raising complaints is not always easy and she and her daughter have already been through so much and are still managing the impact of that now.

1. We are sorry to hear about Ms B’s long hospital stay and the concerns she has about her care. It is clear these events have significantly affected her.

2. We have carefully considered Ms B’s complaint about the Trust. We have seen indications of failings in the Trust not admitting Ms B to hospital on 28 and 29 August. We empathise with Ms B’s concerns, we think it is unlikely that this had any significant effect on her long term deterioration.

3. We have not seen indications of failings in any of her other complaints about her care. We have explained our reasons for this below.