A practice in the East Hertfordshire area

4.Mrs O complains doctors at the Princess Alexandra Hospital NHS Trust (the Trust) doubled her husband’s steroid dose in October 2019 and did not communicate the risks of this.

5.Mrs O thinks this contributed to Mr O’s premature death which caused her and the family significant upset and distress.

6.Mrs O is seeking for the Trust to make service improvements and pay a financial remedy.

7.In late August 2019, Mr O lost the use of his arm in Menorca. Mr O presented to ED on his return home. A CT scan found a tumour on his brain and Mr O had surgery. A further CT scan revealed more tumours at the base of Mr O’s spine. Mr O had an enlarged bladder, and so a catheter was fitted.

8.In early September, the Trust discharged Mr O. In late September, Mrs O telephoned the oncology consultant to advise Mr O was not receiving any support in the community.

9.In late September, Mr O attended the ED. The ED diagnosed a mild urine infection and a possible diagnosis of mild sepsis. The ED provided Mr O with IV antibiotics and discharged him. In early October 2019, Mr O attended the ED again. The ED diagnosed constipation and provided laxatives and pain relief before discharging Mr O.

10.In Mid-October, an oncologist assessed Mr O and admitted him to hospital immediately. The Trust completed an MRI scan of Mr O’s spine and increased his dose of steroids to alleviate his symptoms. Shortly after, Mr O sadly died from a gastrointestinal bleed.

14.Mrs O is unhappy that the Trust decided to increase Mr O’s steroid dose in October 2019. She explains that Mr O died of a gastrointestinal bleed and feels the steroids contributed to this. We are very sorry this happened and understand the significant distress these events caused Mrs O and her family.

15.Mr O was admitted to the Trust’s emergency department (ED) in mid-October with severe back pain and limb weakness. Mr O was acutely unwell, suffering from lung cancer with liver and brain metastasis (secondary growths).

16.In its complaint response, the Trust explained it carried out an MRI scan of Mr O’s spine to investigate the symptoms he was suffering with and to exclude a diagnosis of spinal cord compression. The MRI scan confirmed that Mr O did not have spinal cord compression.

17.The relevant NICE guidance says:

‘If dexamethasone is given before imaging, and spinal metastases and MSCC are subsequently ruled out, discontinue it.’

18.The above guidance is clear in that in the absence of metastatic spinal cord compression, dexamethasone (steroid) should be discontinued. We know that despite Mr O’s MRI scan confirming there was no spinal cord compression, clinicians increased his dose of dexamethasone to 8mg a day. This decision appears to not be in line with the above guidance, and therefore we can fully appreciate why Mrs O has strong concerns over why this decision was made.

19.The Trust explained that because of Mr O’s history of cancer, staff consulted with the acute oncology team who suggested increasing dexamethasone to 8mg a day. It explained steroids reduce swelling and were prescribed to Mr O to reduce his pain and ease his distressing symptoms.

20.Our adviser said it is possible that in the absence of spinal cord compression, Mr O may have been suffering from nerve root compression, in which case a trial of steroids to improve his pain may have been reasonable.

21.As part of our investigation, we obtained the imaging and reports from Mr O’s MRI scans from the time of the events.

22.The radiology report from Mr O’s MRI scan comments on stenosis of the neural exit foramen and the possibility of nerve root impingement. Foraminal stenosis is a condition where narrowing parts of the spine cause compression of the spinal nerves.

23.Our adviser said that the MRI imaging does appear to show that Mr O was suffering from nerve root compression, and if that finding was in line with the symptoms Mr O was suffering with, then increasing his steroid dose was a clinically reasonable decision.

24.The relevant MAYO clinic guidance on pinched nerve (non-medical term for a compressed nerve) says that symptoms include:

• Numbness or less feeling in the area supplied by the nerve.

• Sharp, aching or burning pain, which may radiate outward.

• Tingling, or a pins and needles feeling.

• Muscle weakness in the affected area • Often feeling as if a foot or a hand has ‘fallen asleep’.

25.When Mr O was admitted to the ED, he was suffering with severe back pain and limb weakness, which is consistent with the symptoms listed in the above guidance. We therefore consider the decision to increase Mr O’s steroids to relieve his pain and symptoms to be reasonable.

26.We understand that Mr O’s cause of death was a gastrointestinal bleed. Mrs O explained she had been led to believe the steroids could have caused this. In the complaint response, the Trust acknowledged that a side effect of steroids is gastric bleeding, and therefore we appreciate this would have added to Mrs O’s concerns.

27.Case studies from the BMJ and NLM suggest that the risk of gastric bleeding with steroid treatment is small, with the absolute risk being somewhere between 2.3% and 3.8%. The study shows that people who weren’t taking steroids had a risk of somewhere between 1.8% and 2.6%.

28.The Trust said it prescribed Mr O with another medication (omeprazole) which lines the stomach and reduces acid production to reduce the risk of a gastric bleed. Omeprazole is a Proton Pump Inhibitor (PPI). PPIs are a class of medication that reduce the amount of acid the stomach produces. The relevant NICE CKS on corticosteroid management (specifically on how to reduce the adverse effects in people taking corticosteroids) says:

‘Consider prescribing a proton pump inhibitor (PPI) for people with risk factors for gastrointestinal (GI) bleeding or dyspepsia.’

29.We therefore consider the Trust acted appropriately in giving Mr O a PPI to reduce any risks, such as a gastric bleed.

30.Our adviser said that Mr O was seriously unwell during the time of the events and therefore was at risk of complications such as a gastrointestinal bleed regardless of whether he was on steroids.

31.We consider the Trust’s decision to increase Mr O’s steroids to be appropriate. Based on guidance and case studies, we also consider the chances of the steroids causing Mr O’s gastric bleed was small.

32.Given Mr O’s condition and diagnoses of metastatic cancer, we cannot say with any certainty it was the increased steroid dose that caused the gastrointestinal bleed. We do however acknowledge there was a small chance the steroids did cause the bleed and we apologise to Mrs O for not being able to provide a definitive view here and for any distress this causes. Significantly, the decision to increase Mr O steroids was clinically justified. When giving any medication, clinicians need to weigh up the risks and benefits. The evidence we have seen supports that staff caring for Mr O felt steroids could be successful in managing his pain and distressing symptoms.

33.In summary, we are very sorry to learn of the difficult experience Mr O, Mrs O and their family endured during the time of the events. We appreciate these events must have been very distressing at what was an already challenging time during the end of Mr O’s life. We have found the Trust’s decision to increase Mr O’s steroids to be clinically appropriate. We have found that the chances of the steroids causing a gastric bleed to be small, and the Trust took actions to further reduce this risk. For these reasons, we do not uphold this complaint, and we are sorry if our decision causes any additional distress to Mrs O.

1.We are very sorry to learn of the events which led Mrs O to make a complaint. We acknowledge the difficult experience Mrs O, her husband Mr O, and their family went through. We understand the importance of Mrs O’s complaint, and we thank her for giving us the opportunity to look at it.

2.We have found the Trust’s decision to increase Mr O’s steroid dose was appropriate, given his condition and symptoms.

3.Our final decision is to not uphold this complaint.