Worcestershire Acute Hospitals NHS Trust

5. Miss R complains about aspects of the care her mother received from the Trust between 23 October 2024 and her death on 23 November 2024.

6. Miss R says the Trust failed to make an earlier correct diagnosis of Mrs R’s symptoms and provide appropriate treatment sooner. She says specifically the Trust: • failed to communicate effectively with Mrs R’s cardiologist, who was based in another trust, and her GP both of whom and could have provided information to inform an earlier diagnosis and treatment • inappropriately prescribed six courses of antibiotics in response to the raised markers in her blood tests which caused her condition to deteriorate • delayed arranging a scan for six days which prevented her receiving effective treatment sooner.

7. She also complains that the Trust missed opportunities to discharge Mrs R home after it had treated her.

8. Finally, she complains that on 4 November 2024, staff did not appropriately record Mrs R’s complaint to nursing staff about her care.

9. She says as a result of the Trust’s failure to: • diagnose and provide effective treatment sooner, her mother died an avoidable death as a result of pneumonia • discharge her home in line with her wishes before her death, Mrs R experienced avoidable discomfort and distress during the last days of her life • record her mother’s complaint, Miss R is left with the knowledge that her mother’s voice was not heard.

10. Miss R is left with the uncertainty of not knowing if Mrs R could still be alive if she had received the correct treatment sooner.

11. She is also distressed by the fact that her mother had to spend her last weeks in hospital when this was against her wishes.

12. By making her complaint, Miss R is looking for an apology, service changes and a financial remedy.

13. Mrs R had chronic diagnoses of heart failure and arthritis.

14. On 22 October 2024 Mrs R’s condition deteriorated and she went to the Trust’s Emergency Department (ED). It admitted her to its agile fragile unit (AFU).

15. Whilst on the AFU, Mrs R completed a Recommended Summary Plan for Emergency Care and Treatment (ReSPECT). This document is created in advance for a person’s care in an emergency, especially when they do not have capacity to make decisions. It states their preferences in various situations such as whether they would want to be considered for cardiopulmonary resuscitation if they had a cardiac arrest.

16. Mrs R received treatment for her symptoms which gradually deteriorated.

17. She had a CT scan on 20 November which showed multi organ failure.

18. On 22 November the doctors implemented end of life care and she sadly died the following day.

22. Miss R is concerned that the Trust did not provide appropriate care for her mother as soon as possible for three reasons. We have considered each in turn below.

Communication with Mrs R’s cardiologist and her GP

23. Miss R thinks the doctors at the Trust should have spoken to Mrs R’s GP and the cardiologist at another NHS trust who had previously provided care for her mother’s chronic heart failure. We understand she believes the Trust could have obtained information and advice to better treat her mother’s deteriorating symptoms which resulted finally in multi-organ failure.

24. Domain three of GMC Good medical practice says that doctors should communicate clearly and work effectively with colleagues in the interests of patients. This means that they must be willing to lead or follow as the circumstances require.

25. As such we would have expected the Trust’s doctors to have sought further advice or information from Mrs R’s cardiologist and/or GP if this would have potentially improved the care they could have provided for her.

26. The Trust has explained it would contact other hospitals or GPs if it needed information about a patient’s care. This would include results of investigations or a query about a medication prescription or diagnosis.

27. We understand the Trust asked Miss R for details of Mrs R’s cardiologist and she assumed this meant it would contact them for further information about her mother’s medical history. The Trust says in Mrs R’s case it was not necessary to contact her cardiologist or GP. It says this was because it had access to her most recent blood tests taken at the time of a previous ED admission at the end of September. It was also aware that the cardiologist at the other trust was treating her for heart failure and did not have any queries about the medication they had prescribed her for this diagnosis or her ongoing treatment.

28. Our adviser notes that since the cardiologist at the other Trust was treating Mrs R for a chronic condition of heart failure rather than a complex cardiac condition, there was no reason for the Trust to seek further advice or information.

29. Having considered the available evidence, we have not seen anything to suggest the Trust did not comply with GMC Good medical practice as set out above. We have therefore not found any failings in the Trust not speaking to Mrs R’s GP or cardiologist..

30. We hope our consideration of this matter provides reassurance to Miss R.

Antibiotic prescriptions

31. The Trust prescribed a number of different antibiotics to Mrs R during her admission. Miss R is concerned so many different antibiotics may have negatively impacted her mother’s condition.

32. We have first considered the relevant standards and guidance for the prescription of antibiotics.

33. In 1998 the World Health Organisation recommended that all countries should follow the principles of antibiotic stewardship. This is a healthcare-system-wide approach to promoting and monitoring the use of antibiotics.

34. NICE QS121: Antimicrobial stewardship, April 2016 and WHO Antimicrobial stewardship interventions: a practical guide, April 2021 both outline the principles of antibiotic stewardship.

35. Antibiotic stewardship has two principal goals. Its first purpose is to make sure that patients receive the appropriate antibiotic at the right dose and for the right period of time.

36. Its second purpose is to combat antimicrobial resistance (AMR). AMR happens when clinicians over use or incorrectly use antibiotics and as a result the bacteria change and become resistant to the antibiotics designed to kill them. As a result there is a risk of antibiotics losing effectiveness in routine and emergency treatments.

37. Over use of bacteria also kills healthy bacteria in the body’s gut which increases the risk of conditions such as Clostridioides difficile (C.diff). C-diff causes severe diarrhoea and inflammation of the colon.

38. GOV.UK Guidance: Start smart then focus: antimicrobial stewardship toolkit for inpatient care settings, September 2023 sets out the practical steps considered necessary to promote antibiotic stewardship.

39. Firstly a doctor should only prescribe antibiotics if there is clear clinical evidence of a bacterial infection.

40. Ideally a doctor should only start a course of antibiotics once investigations of cultures have identified the relevant germ or microorganism. This is so they can ensure they treat the patient with the most appropriate antibiotic. However, in practice, this is not always possible because it may mean that the patient is left without any treatment while the doctor waits for test results which could take 48 hours or longer.

41. In the absence of a confirmed diagnosis or test results and where there is evidence of a severe or life threatening infection, the doctor should prescribe the most appropriate antibiotics to treat the patient’s symptoms.

42. They should make a decision based on clinical judgement which will consider the most likely cause of infection from their assessment of the patient, the location of the infection and any local resistance patterns. A local resistance pattern tracks whether specific bacteria are responding to antibiotics in the immediate geographic area or hospital. This is important because bacterial resistance can vary significantly from region to region.

43. In this case a doctor will often choose a broad-spectrum antibiotic. Antibiotics can either have a narrow or broad spectrum of activity. Narrow-spectrum antibiotics are more specific and are only active against certain groups of bacteria whereas broad-spectrum antibiotics act against a wider range of bacteria. As such they are more useful when the doctor does not yet know the exact identity of the bacteria.

44. The doctor should then review the diagnosis and antibiotic treatment within 48 to 72 hours or once test results are available. At this stage they should choose whether to continue with the same treatment, switch to a narrow more targeted treatment or stop the treatment altogether.

45. With the above guidance in mind we have considered what happened in Mrs R’s case.

46. On her admission on 22 October, the doctors prescribed three antibiotics (amoxicillin, metronidazole and gentamicin) to treat her symptoms which suggested possible diagnoses of diverticulosis and/or a urine infection. Diverticulosis is a condition where small pouches in the colon push outwards and can become inflamed or infected. The doctors took swabs to test her urine for bacteria.

47. The doctors were also concerned that Mrs R may have septic arthritis or infection around the knee. This is a serious and potentially fatal diagnosis if not treated urgently. Our adviser explained the combination of the three antibiotics was appropriate to treat suspected sepsis. The doctors referred her to orthopaedics for further investigation of this possible diagnosis.

48. On 23 October the doctors on AFU considered Mrs R’s symptoms were more indicative of just a urine infection. As such they stopped the other antibiotics and prescribed her trimethoprim to treat this potential diagnosis.

49. Later on the same day the doctors reviewed her and made a decision to stop all antibiotics until tests indicated a more definite source of infection. This was because Mrs R’s condition appeared to be stable.

50. After stopping antibiotics on 23 October, Mrs R developed symptoms which the doctors considered indicative of a possible chest infection and on 26 October they prescribed a week’s course of amoxicillin.

51. On 8 November the doctors prescribed Mrs R a one off dose of gentamicin. The purpose of the prescription was to prevent infection when her catheter was removed and replaced. The changing of a catheter bag carries a risk of infection because the procedure temporarily breaks the otherwise sterile closed system.

52. On 14 November the doctors prescribed tazocin for five days in response to Mrs R’s further clinical deterioration. From her symptoms, the doctors suspected hospital acquired pneumonia (HAP). A diagnosis of pneumonia is called HAP when it develops after at least 48 hours of being in hospital while being treated for another condition. They referred her for a CT scan to further investigate her symptoms

53. Having reviewed what happened, we consider that the decisions to prescribe antibiotics during Mrs R’s admission were line with the principles of antibiotic stewardship.

This is because we can see that doctors used clinical judgement to prescribe appropriate antibiotics during her admission, to treat symptoms of bacterial infection pending further investigations. In Mrs R’s case it was important not to leave her without treatment because she was a vulnerable patient due to her chronic diagnoses and frailty.

54. We also see that the doctors changed antibiotic treatment after reviewing their initial diagnosis within 72 hours and recognising a change in her symptoms. They subsequently stopped antibiotics when Mrs R’s symptoms resolved and it appeared that antibiotic treatment was no longer necessary.

55. Finally we see that on one occasion they prescribed antibiotics to prevent Mrs R from developing an infection. As a general rule, WHO recommend against using antibiotics for preventative purposes since it is likely to increase the risk of AMR. However our view is in this case the prescription complied with the essential principal of antibiotic stewardship which is to only prescribe an antibiotic if there is likely to be a clear clinical benefit.

56. We see Miss R has referred to six different courses of antibiotics in her complaint. We hope our consideration helps her to understand that the doctors did not prescribe six full course of antibiotics but rather changed the prescription on five different occasions in line with the guidance set out above.

57. We understand Miss R is concerned the antibiotic prescriptions caused her mother harm and we hope she is reassured that the principles of antibiotic stewardship are specifically intended to promote the safe and effective use of antibiotics.

58. For the reasons given, we consider the Trust complied with these principles as set out above. As such, we do not see any failings here and we hope Miss R is reassured that the doctors prescribed antibiotics, in line with relevant guidance, to provide the most effective care for her mother.

CT scan

59. After Mrs R developed symptoms of HAP on 14 November, the Trust requested an urgent CT scan of her thorax, abdomen and pelvis to further investigate her symptoms. The Trust carried out the scan on 20 November.

60. Miss R complains the Trust should have done more to make sure the scan took place sooner. She is concerned the delay may have held up her mother’s treatment and prevented her recovery. We have considered the available evidence and relevant standards to better understand why the Trust did not carry out the scan before 20 November.

61. When a patient has a CT scan, contrast dye is injected into the bloodstream. This dye contains iodine and allows areas of the body to light up and make any abnormalities visible. However contrast dyes are known to damage the kidneys and it is important that kidneys are healthy enough to adequately excrete the dye from the body. If they cannot do so, there is a risk of damage to the kidneys. This is more likely to happen if the kidney function is already poor.

62. Therefore it is important to carry out a renal function blood test to assess kidney function before the scan takes place.

63. The blood test measures the estimated Glomerular Filtration Rate (eGFR). eGFR is a measure of how well the kidneys are filtering waste and excess fluid from the blood. NICE guidance on acute kidney injury (NG148) recommends the eGFR should be at least 30 to complete a CT scan safely.

64. From a renal function blood test dated 13 November, Mrs R’s eGFR was 29.

65. The radiology team requested a repeat blood test because her eGFR was not high enough to carry out the scan safely in line with NG148.

66. Mrs R had this second test on 15 November and her eGFR was 28.

67. The radiology team requested a further repeat test on 17 November. This was carried out on 19 November showing her level was 27.

68. The radiologist proceeded with the scan on the following day despite the eGFR results. Our adviser comments they likely made the decision to do so because it was important to obtain information from the scan which could potentially help treat Mrs R’s symptoms.

69. We have considered the available evidence and there are no failings associated with the time taken to arrange the scan. We have explained why below.

70. Initially Mrs R’s eGFR was not high enough, as set out in NG148, and therefore it was reasonable to delay the scan pending further blood tests to see if her kidney function improved.

71. After the third blood test showed that her kidney function had further deteriorated, we consider it reasonable that the scan went ahead. We have taken into account our adviser’s view it had become more important to find out what was causing Mrs R’s symptoms than to wait for her kidney function to reach an appropriate level.

72. We have also taken into account that although Mrs R’s kidney function was below 30, the Trust hydrated Mrs R both before and after the scan. This is in line with NG148’s recommendations for reducing the risk of kidney damage in high risk patients which include patients with an eGFR of less than 30 like Mrs R.

73. We understand the delay has worried Miss R and we hope that this explanation clarifies why the scan did not happen sooner.

Discharge

74. Miss R was anxious that the doctors should discharge her mother home as soon as possible. She has explained that even when her mother stopped responding to treatment, she wanted her to spend her last days at home rather than in hospital.

75. We also know from Mrs R’s ReSPECT that she wanted to receive care at home rather than hospital when this was possible. It said: • she wished to be comfortable and cared for and to not be in any pain • wherever possible care should be managed by her GP or community teams • a hospital admission may be appropriate for potentially treatable conditions.

76. We would expect the Trust to prioritise Mrs R’s stated wishes and therefore plan for her discharge. This is in line with domain one of GMC Good medical practice which says when a doctor assesses a patient’s condition, they must take account of their views, needs and values.

77. From both the Trust’s response and Miss R’s account, the first discussion about Mrs R’s discharge home with a full package of care took place three days after her admission on 25 October. Staff suggested Miss R should try and set up the necessary arrangements at home over the coming weekend so that everything was ready for Mrs R when she was clinically fit for discharge. As such it appears the doctors and ward staff were mindful of Mrs R’s wishes from early on in her admission and considered it likely that discharge would take place.

78. On 29 October staff had further discharge planning discussions with Miss R. However at this time it appears Mrs R continued to need hospital care. This was because she had not responded to initial treatment for the suspected urinary infection and chest infection and her symptoms continued to deteriorate.

79. On 31 October staff had another discussion with Miss R about her mother’s discharge. They said Mrs R was not fit for discharge yet but explained they would still continue to plan and prepare for her discharge home.

80. Miss R says Mrs R’s condition had improved by 1 November and she believed her mother was fit for discharge since she appeared to be back to her baseline state. The doctors’ view at this stage was that she would be fit for discharge once the pain in her knees was under control and she had completed her antibiotics. They referred her to the orthopaedic team for advice on how to best manage her knee pain.

81. Miss R says there were further discussions about discharge on 3 November and from the ward round on this day Mrs R said she felt better. The ward round notes for this week referred to possible discharge and the doctors planned to trial removing Mrs R’s catheter so she could be discharged without it. However at the same time they were concerned about Mrs R’s abdominal pain and high C-reactive protein (CRP) level. CPR is a protein in the blood and high levels typically indicate an infection. The doctors organised investigations to try and locate the source of the infection and pain.

82. On 8 November Mrs R went into urinary retention. This is the inability to completely or partially empty the bladder which can lead to discomfort, severe pain, urinary tract infections, and potentially kidney damage. In order to relieve her symptoms, her catheter had to be changed. By Monday 11 November, the replacement catheter was draining well and the doctors decided it would be better for Mrs R to keep the catheter bag in place when she was discharged. At this stage Mrs R no longer had a fever and her CRP had decreased, although it was still significantly higher than the normal range. The doctors planned to recheck her CRP later in the week.

83. On 13 November a blood test showed Mrs R’s CRP had increased again. It also showed her kidneys were not functioning efficiently. On 14 November her condition had deteriorated further with symptoms of HAP for which she was given antibiotics. The doctors requested a CT scan to try and establish the source of infection.

84. Prior to the scan on 20 November, Mrs R’s condition continued to deteriorate. On 15 November the doctors put her on intravenous fluids to help with her poor kidney function and on 19 November implemented an Amber care plan. This is a plan for patients whose recovery is uncertain but who are still receiving active treatment.

85. The CT scan results showed that Mrs R had severe heart failure and a serious deterioration in the function of her right lung. On 21 November the doctors believed that ‘given her severe decline.. and background of frailty it was likely’ she was approaching the end of life and on 22 November started last days of life care.

86. We do not underestimate how important it was to Miss R that her mother should go home. We see the discussions about discharge may have suggested this was imminent and caused her frustration when it did not happen. We also understand that when Mrs R’s condition deteriorated she still wanted her mother to spend her last days at home rather than in hospital.

87. From Mrs R’s medical records we can see the doctors continued to review and respond to Mrs R’s changing symptoms with a view to eventual discharge. However it does not appear they considered she was well enough at any point to go home and continued to be of the view that they could more effectively treat her in hospital. This was still the case when they implemented the Amber care plan. At that stage she was waiting for the CT scan to further investigate her HAP symptoms which potentially may have been treatable. Our adviser is also of the view that at no point following Mrs R’s admission, was she fit for discharge home.

88. We understand it was very upsetting for Miss R to see her mother remain in hospital at this time.

89. When Mrs R commenced last days of life care, the records refer to Miss R’s and Mrs R’s wishes which were that Mrs R should go home with palliative care. They also refer to the doctors’ explanation that Mrs R had multi-organ failure and was too seriously ill to safely transport home.

90. From the Trust’s and our adviser’s evidence and given the severity of Mrs R’s condition, the decision to keep Mrs R in hospital during her final days was a reasonable one.

91. In summary from the available evidence we consider the doctors continued to consider Mrs R’s discharge throughout the admission. However for the reasons stated above, we have also seen that they continued to believe it was in her best interests to stay in hospital. As such, for the reasons given above, it acted in line with GMC Good medical practice and therefore we have not found any failings.

Mrs R’s complaint

92. Miss R says when she arrived at the hospital on 4 November, the nurse looking after Mrs R said she had refused to have any breakfast or take her medication until Miss R arrived. They said Mrs R had said to the nurse, ‘you wouldn’t treat an animal the way you are treating me in hospital’.

93. Miss R says the nurse told her when this kind of incident occurs, they will report it to a senior member of staff. Miss R asked the nurse to escalate the matter but she did not hear anything further about it.

94. The Trust explained what should have happened when Mrs R complained to the nurse. It would expect the nurse to try and resolve matters with the patient but if this was not successful they should escalate the matter to a line manager or ward matron to resolve. If the nurse considers an incident or lapse in care has occurred they should raise an incident via Datix. Datix is the Trust complaint risk and incident management system.

95. The above in line with the Trust’s complaints policy and procedure which says that all staff should be: • familiar with our complaints process • seek to resolve concerns and anxieties at initial point of contact to reduce patient anxiety and worry.

• escalate where this is not successful to an appropriate responsible person.

96. We do not discount Miss R’s account of what happened and we are sorry for any upset caused to her. There is nothing in the records which refers to the incident or tells us what the nurse did or did not do to resolve the matter. As such we cannot make a decision here since we cannot say whether the Trust complied with its own complaint policy in this case. This means that we cannot take this matter further.

97. We have listened to Miss R’s account of her mother’s admission and we acknowledge it was an incredibly upsetting time for her. We hope our consideration of her complaint has provided some clarification and understanding of the Trust’s actions and decisions.

1. We have carefully considered Miss R’s complaint about Worcestershire Acute Hospitals NHS Trust (the Trust).

2. Having reviewed all of the available evidence, we have not seen any failings in the Trust’s care of Miss R’s mother, Mrs R and as such we do not uphold the complaint.

3. We are sorry for Miss R’s loss and understand the events of Mrs R’s admission have caused her significant upset and worry.

4. We have explained our thinking in more detail below and hope our detailed consideration will provide reassurance to Miss R in regard to her concerns about her mother’s care.