Leeds Teaching Hospitals NHS Trust

3. Mr A complains about aspects of the care and treatment provided to his late wife, Mrs A, by Leeds Teaching Hospitals NHS Trust between 2 and 5 September 2023. He specifically complains:

• the Trust misdiagnosed Mrs A with blood clots • there were delays in diagnosing and treating sepsis and pneumonia, including delays in identifying the correct antibiotic • the Trust caused damage to Mrs A’s facial skin following her death.

4. Mr A says the misdiagnosis and delays in diagnosis and treatment led to Mrs A’s premature death. He says Mrs A was relatively fit before her hospital admission, and she deteriorated rapidly. He says he and his family have been left devastated by her death and by the damage to her skin when they saw her at the funeral directors.

5. As an outcome to his complaint, Mr A seeks service improvements and financial remedy.

6. Mr A complains about the care and treatment of his late wife, Mrs A. Mrs A had a history of liver disease. She attended her GP Practice on 1 September 2023 and was prescribed a sachet of antibiotics for a urine infection. On 2 September she began to feel unwell, struggling to breathe and with low blood pressure. She was admitted to the Trust’s Emergency Department (ED) by ambulance at around 5.30pm. On examination, the Trust had concerns Mrs A may have suffered a blood clot.

7. Mr A went home and called ED at around 10pm. The Trust told him Mrs A was ok, comfortable, and awaiting a scan. He called again at around 11pm and the Trust told him everything was ok and it was due to allocate a bed. Mrs A had a CT scan which ruled out a blood clot and pneumonia but confirmed ground glass changes (hazy, grey areas indicating increased density) which had been seen on an earlier X-ray, and a small amount of fluid in her lungs and abdomen. Her condition worsened overnight. Mr A called ED again at around 8am on 3 September and the Trust told him Mrs A had been admitted to the Intensive Care Unit (ICU).

8. Mrs A had a blood test at 7.30pm. At 4am on 4 September she was told she would be put on antibiotics, but Mr A says this did not happen. Mrs A was then diagnosed with pneumonia, organ failure and sepsis. Mr A says he was not informed of her full diagnosis. The Trust put Mrs A into an induced coma to help her rest and recuperate, and she died shortly after.

12. 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 for each component of Mr A’s complaint.

Misdiagnosis of blood clots and delays in diagnosis and treatment

13. Mr A says there were delays in diagnosing Mrs A with sepsis and pneumonia and providing an antibiotic. He says these delays led to Mrs A’s premature death.

14. In its response to Mr A’s complaint, the Trust says antibiotics were not prescribed when Mrs A presented to ED as this is not the treatment for a blood clot and she did not demonstrate any signs of infection.

15. Mrs A was admitted to the ED on 2 September 2023. She described having shortness of breath and sharp chest pains, but no cough or fever. The Trust suspected a pulmonary embolism (a blood clot in the lung) based on her history and an examination. In its complaint response, it explained Mrs A was requiring a significant amount of oxygen but did not have any of the more specific features of a chest infection.

16. The Trust requested a chest X-ray and later a CT scan, which ruled out a blood clot. Mr A says this was a misdiagnosis and caused a delay in a correct diagnosis and appropriate treatment, leading to her premature death.

17. RCEM sepsis guidance recommends patients be screened for sepsis if they have an aggregate score of four or higher on the National Early Warning Score (NEWS), a tool used to detect the deterioration of patients.

18. NICE sepsis guidance notes a new requirement for oxygen to maintain saturations (the amount of oxygen your blood is carrying) at 92% or above as one of the highrisk (redflag) criteria for suspected sepsis.

19. We reviewed Mrs A’s records with our ED adviser. We can see from Mrs A’s medical records she had a NEWS2 score of five on her arrival at ED, which meets the criteria for sepsis screening as per the above guidance. She also needed 10l of oxygen to maintain levels above 92%.

20. We have not seen evidence a sepsis screen was completed. Our ED adviser explained while it was reasonable for the Trust to suspect a blood clot as Mrs A displayed no acute symptoms suggesting infection, sepsis should have been considered as a differential diagnosis based on the NEWS2 score and Mrs A’s history of a recent urine infection.

21. Our ED adviser explained based on Mrs A’s presentation, the Manchester Triage System (a clinical risk management tool used across the NHS) would have categorised her as either orange (very urgent) for possible sepsis, with a target to be seen in 10 minutes, or yellow (urgent) under the shortnessofbreath flow chart, with a target of 60 minutes.

22. This would have meant she should have been seen no later than 6.40pm. Mrs A was not assessed until 7.40pm, and the Xray was requested around an hour later than it should have been. Given that the Xray was ultimately performed at 8.46pm, our ED adviser considers there to have been approximately a onehour delay in arranging this investigation.

23. The Trust continued to treat Mrs A with IV fluids and oxygen therapy following her CT scan. Mrs A’s blood pressure dropped, and her condition continued to deteriorate. The Trust prescribed antibiotics at around 5am on 3 September and moved Mrs A to ICU at around 7am.

24. NICE sepsis guidance recommends giving those who are at high risk of severe illness or death from sepsis broad-spectrum intravenous antibiotic treatment, within one hour of calculating the person's NEWS2.

25. The Trust’s sepsis policy says antibiotics should be administered within one hour of an initial NEWS2 score when there is a high risk of sepsis. It defines high-risk as a NEWS2 score of seven, or five to six with additional features such as evidence of organ failure, including acute kidney injury.

26. Our ED adviser noted the Trust was providing volumes of IV fluids expected to see in sepsis treatment from around midnight, however we can see no antibiotics were administered until approximately 12 hours after hospital admission. While the differential diagnosis reasonably included pulmonary embolism, which may have justified initial caution in starting antibiotics, we discussed earlier that sepsis should have been considered based on Mrs A’s NEWS2 score.

27. Our ED adviser explained once the acute kidney injury became apparent on the blood test results (bloods taken at 6.17pm, with results expected around an hour later) Mrs A met the high-risk criteria in line with the NICE guidance and the Trust’s policy due to her oxygen requirement to maintain saturations above 92% and her abnormal kidney function.

28. In line with the above guidance, we consider the Trust should have given Mrs A antibiotics by approximately 7.40pm, an hour after the acute kidney injury became evident on the blood test results. This was around ten hours earlier than the time they were administered at 5am the next day.

29. Our ED adviser explained if the Trust had suspected sepsis sooner, antibiotics could have been given when Mrs A was assessed at 7.40pm, fluids could have been given sooner, and ICU involvement would have been sooner. We consider this delay an indication of a failing by the Trust.

30. The Trust treated Mrs A with levofloxacin, a broad-spectrum antibiotic before she left ED. We reviewed the records with the help of our ED adviser and can see an organism was not identified to determine a specific antibiotic. Our ED adviser noted, however, when treatment with antibiotics began, microbiology carried out an impressive range of tests to look for an organism, which highlights good practice.

31. We must now consider the impact the misdiagnosis and delays in diagnosis and treatment had on Mrs A.

32. Our ICU adviser explained Mrs A was a deteriorating patient presenting with organ disfunction, renal disfunction, evidence of chronic liver failure and low blood pressure. They explained based on her condition they do not consider the earlier administration of antibiotics would have changed the outcome.

33. We recognise it must have been very upsetting for Mr A and his family to see Mrs A deteriorate so rapidly and understand they have been left with unresolved doubts about her care and treatment.

34. We have seen indications of failings by the Trust in its initial misdiagnosis of blood clots and its delay in diagnosis and treatment. Considering the advice provided, we cannot link the events complained about to Mrs A’s death.

35. Our Principles for Remedy say public bodies should acknowledge failures, apologise, make amends, and use the opportunity to improve their services.

36. NHS complaint standards say wherever possible, staff explain why things went wrong and identify suitable ways to put things right for people.

37. We mentioned earlier that Mr A is seeking service improvements as an outcome to his complaint. We therefore approached the Trust to ask whether it was willing to take some further steps in relation to the failing we have seen.

38. The Trust has agreed to take learning and implement service improvements in relation to the misdiagnosis of blood clots and delay in diagnosis and treatment. The Trust will share an action plan with us by 7 August setting out how it will achieve this.

39. Mr A explained he also seeks financial remedy as an outcome. We mentioned earlier that although we have seen indications of failings, we cannot link these events to Mrs A’s death.

40. We appreciate the impact the distressing events had on Mr A and his family, and the heartbreak they felt following the death of Mrs A. As we cannot link the events complained about to Mrs A’s death, we are satisfied an action plan outlining the steps the Trust will take to make service improvements is appropriate to resolve this part of the complaint.

41. We hope this will provide Mr A reassurance that his concerns have been taken seriously and that lessons will be learned.

Damage to Mrs A’s skin

42. Mr A says before he visited the chapel of rest following Mrs A’s death, he was warned she had sores on either side of her face, caused by a throat tube which had been secured to her cheeks. Mr A says it looked as though had been roughly pulled off her face. He says she was not treated with care following her death.

43. In its complaint response, the Trust explained the device used to secure the breathing tube sticks securely to the patient’s face and when removed it can cause irritation and on occasion damage to the skin. It apologised that Mr A did not feel Mrs A was treated with compassion or care in ICU. It says the tube was removed as carefully as possible, but skin damage can occur especially when a patient’s blood pressure has been low for some time.

44. GMC guidance say you must provide a good standard of practice and care, and you must make sure that formal records, including patients’ records are clear, accurate, contemporaneous and legible.

45. Our ICU adviser told us Mrs A’s care in ICU is well documented and the records indicate she received a good standard of care. This is in line with the above guidance.

46. We have seen the Trust carried out pressure ulcer risk assessments on 2 and 3 September, which noted Mrs A had vulnerable skin. Our ICU adviser explained Mrs A had an underlying clotting disorder, which would mean she was more at risk of ulcers and/or sores.

47. They told us in ICU it is good clinical practice to use a stable fixation device when using a breathing tube. This is in line with product information from medical equipment company Hollister, which says oral endotracheal tube fasteners help address intubated patient risks. Most will involve adhesive which will stick to the cheeks providing an anchor point to keep the tube in place.

48. We do not underestimate how upsetting it must have been for Mr A to see the damage to Mrs A’s skin at an already difficult time.

49. Based on the evidence we have seen, we are satisfied the Trust acted in line with guidance and have seen no indications of a failing regarding the damage caused to Mrs A’s skin. We will take no further action on this part of the complaint.

50. In summary, we have seen indications of failings in the Trust’s initial misdiagnosis of blood clots and its delay in diagnosis and treatment. We are satisfied the Trust has agreed to take learning and implement service improvements.

51. We recognise the events leading up to the death of Mrs A have been very difficult for Mr A and his family and we were very sorry for their loss. We thank him for bringing his complaint to us and we hope the hope actions taken by the Trust ensure appropriate improvements are made.

1. We have carefully considered Mr A’s complaint about Leeds Teaching Hospitals NHS Trust (the Trust). We were very sorry to hear about the sad circumstances which led Mr A to approach us. We recognise Mr A and his family have been through a very distressing experience and offer our sincere condolences following the death of his wife, Mrs A.

2. We have seen no indications that anything went wrong regarding Mr A’s complaint about the damage caused to Mrs A’s skin following her death. We have seen indications of failings by the Trust in its diagnosis and treatment of Mrs A, but we cannot link the events complained about to Mrs A’s death. We will therefore not be considering Mr A’s complaint further and explain the reasons for our decision below.