Northern Care Alliance NHS Foundation Trust

4. Mr A complains about the care and treatment Tameside and Glossop Trust provided to his father from 13 to 18 August 2023. Specifically, he complains:

• the Trust did not recognise the symptoms of his father’s oesophageal tear on admission. Instead, it misdiagnosed him with heart failure and gave him blood thinning medication. Mr A says this caused further damage to his father’s oesophageal injury, and delayed treatment which impacted his recovery.

• the Trust did not carry out a CT scan in a timely manner, which meant it did not identify the oesophageal tear until 18 August.

• the Trust failed to give him any information regarding his father’s condition when he visited the ward on 14 and 16 August. It also failed to tell him it was transferring his father to another hospital on 18 August.

5. Mr A also complains about the care and treatment Northern Care Alliance Trust provided to his father on 29 December 2023 and 1 January 2024. Specifically, he complains:

• the speech and language therapy team (SALT) did not assess his father in a timely manner, when staff transferred him from the critical care unit (CCU) onto a ward on 28 December. Mr A says an earlier assessment would have prevented his father’s vomiting episodes on 1 January.

• the medical team did not review his father after his first vomiting episode at 5.01pm on 1 January. He says a medical review would have prevented the second vomiting episode later than evening.

6. Mr A says collective failings by both organisations caused his father’s sudden and unexpected death on 1 January. He says he had a great bond with his father, and it has been difficult to come to terms with his loss. Mr A also says his experience with both organisations was very traumatic and distressing.

7. By bringing his complaint to our office, Mr A wants an apology, service improvements, and financial remedy.

8. Mr B was admitted to Tameside and Glossop Trust’s Emergency Department (ED) on 13 August 2023, following a fall at home. He had low blood pressure, low oxygen levels, and was confused. He also had a fall two days prior to his attendance but did not seek medical help.

9. The Trust carried out a chest X-ray which suggested he had an infection. The results of his blood tests also indicated he had heart failure. The medical team prescribed him blood thinning medication for this on 17 August.

10. As Mr B did not show signs of improvement despite treatment, the Trust carried out a CT scan on 18 August. This identified the oesophageal tear. The Trust transferred him to Northern Care Alliance Trust on the same day, where he had surgery to repair this.

11. Mr B spent some time in the CCU before staff transferred him onto a ward on 28 December. On 1 January, Mr B suffered two vomiting episodes and sadly died from aspiration.

Diagnosis on admission and CT scan

15. We have seen Mr B was admitted to Tameside and Glossop Trust’s ED on 13 August, following a fall at home. He was confused and had low oxygen levels and low blood pressure. The results of his blood tests showed raised inflammatory markers and high blood acid levels. Our physician adviser said the results of Mr B’s chest X-ray was consistent with a working diagnosis of chest infection.

16. When someone is unwell, doctors should use their clinical knowledge and judgement to assess patients based on their presenting symptoms and the information available to them. The GMC’s good medical practice guidance says doctors must adequately assess a patient’s condition, carry out a physical examination where necessary and promptly arrange suitable advice, investigation, or treatment.

17. We can see the Trust assessed Mr B and treated him for his presenting symptoms. This was in line with GMC guidance. When it appeared Mr B’s condition was not improving, despite treatment, the Trust carried out a CT scan on 18 August. This identified the oesophageal tear.

18. Our physician adviser said there was no clinical indication the Trust should have carried out the CT scan sooner than it did. Between 13 and 17 August, Mr B’s symptoms and test results supported the working diagnoses of chest infection and heart failure. It was only when he failed to respond to treatment that further imaging became necessary.

19. Mr A is concerned the Trust did not recognise his father had an oesophageal tear on 13 August, particularly as it identified this on a CT scan carried out on 18 August.

20. Both the RCS guidance and Medscape review talk about how an oesophageal tear is an extremely rare condition amongst middle aged men with an extensive history of alcohol intake. The classic symptoms are forceful retching and violent vomiting followed by a sudden onset of severe chest pain. Another symptom is subcutaneous emphysema, which is when air gets trapped underneath the skin.

21. We have seen no indications in the medical records to suggest Mr B had these symptoms on admission. In the absence of these symptoms, there was no indication for the Trust to suspect an oesophageal tear as a potential diagnosis.

Heart failure

22. We have carefully considered Mr A’s concerns that the Trust misdiagnosed his father with heart failure and gave him blood thinning medication for this.

23. The results of Mr B’s BNP blood test, which measures the level of B-type natriuretic peptide in the blood to assess heart function and detect heart failure, was extremely high. The results of his troponin blood test, which measures heart specific protein in the blood to detect heart muscle damage, was also high. Both these results were strongly suggestive of heart failure.

24. The Trust said it gave Mr B blood thinning medication as his troponin level was raised which can be indicative of a heart attack. However, we have seen no indications in Mr B’s medical notes to suggest the Trust suspected a heart attack. The notes consistently refer to chest infection, heart failure, raised troponin level and atrial fibrillation, an irregular heart rhythm. It does not refer to a suspected heart attack.

25. NICE guidance NG185 does not recommend the routine use of blood thinners for heart failure alone. It is used when there is a suspected, or confirmed, heart attack. As there is no indication the Trust were treating Mr B for a heart attack, we consider it was a failing to prescribe this to him.

26. This failure impacted Northern Care Alliance Trust’s surgical management of Mr B’s oesophageal tear, as the blood thinning medication was still active in his system on 18 August. Surgeons could not proceed with the standard first choice of repair, an endoscopy, thoracotomy, and laparotomy, as this carried an unacceptable risk of bleeding. Instead, they used an alternative approach using surgical sponges.

27. We recognise this will be difficult for Mr A. Understandably, he feels if Tameside and Glossop Trust had not given his father blood thinning medication, he could have had the standard repair, and this would have led to a different outcome.

28. We acknowledge the surgical sponges was a different and more complex treatment pathway, which required repeated visits to theatre for sponge changes. Whilst it might not be the first choice of repair, it is still an acceptable method and recognised in the RCS guidance.

29. While the inappropriate use of blood thinning medication affected how Northern Care Alliance Trust managed the oesophageal tear, we have seen no indications to suggest the failing affected the overall outcome.

30. Oesophageal tear is a life-threatening condition, and its repair carries one of the highest rates of mortality, particularly where treatment is delayed. Medscape review says if surgery is not carried out within 48 hours, the mortality rate is 90% which means that only 10% of patients survive, regardless of which type of repair they have.

31. By the time Mr B had surgery, his prognosis was already poor regardless of the surgical technique used. Although he survived the operation itself, he remained too unwell to recover. We cannot say the inappropriate use of blood thinning medication, or the resulting change in surgical management, caused or contributed to his death.

Communication on 14, 16 and 18 August

32. Mr A says the doctors did not give him any information regarding his father’s condition when he visited the ward on 14 and 16 August. He also says staff did not tell him it was transferring his father to Northern Care Alliance Trust on 18 August. We recognise how upsetting this must have been for Mr A.

33. GMC guidance says that, where a patient has capacity to make decisions about their care, doctors must not disclose confidential information to others without the patients consent. We have seen no indication in the notes to suggest Mr B did not have capacity to make his own decisions.

34. In its response to Mr A’s complaint, Tameside and Glossop Trust explained the clinical team would have been happy to provide him with updates regarding his father’s condition with his father’s consent. We have seen no indication in the notes Mr A specifically requested to speak to clinicians. In any event, staff would not have been able to share confidential information without his father’s consent.

35. On 18 August, the notes indicate clinicians explained to Mr B how unwell he was, including the possibility that he might not survive, and asked whether they should contact Mr A. Mr B declined, saying he did not want staff to contact his son. Similarly, the nursing notes also indicate staff asked Mr B if they should contact Mr A to let him know about his transfer, and Mr B again declined. In these circumstances, the Trust acted in line with GMC guidance by respecting Mr B’s wishes. We would not expect staff to disregard the clearly expressed wishes of a patient with capacity by sharing confidential information without their consent.

SALT assessment

36. Mr A is concerned there was a delay in his father receiving a SALT assessment after staff transferred him from the CCU to the ward.

37. The records show Mr B arrived on the ward on 28 December at 9.50pm. As it was late evening, SALT assessed him the following day. This indicates SALT reviewed Mr B promptly after his transfer from the CCU.

38. At the time of his assessment, Mr B was not interested in eating or drinking orally. He was nil by mouth and was receiving all nutrition through a jejunostomy feeding tube. The SALT team decided to try again after the bank holiday weekend.

39. Our surgical adviser said even if SALT had done the safe swallow assessment on 29 December, this would not have sped up his recovery of swallowing or eliminated the risk of aspiration. Given the nature of Mr B’s condition, the risk of aspiration would have remained.

Medical review after vomiting episode

40. Mr A is concerned Northern Care Alliance Trust did not appropriately manage his father’s vomiting episode.

41. The records show Mr B was nil by mouth and receiving all nutrition through a jejunostomy feeding tube. At 5.01pm, the nursing records state that he looked distressed and suddenly felt sick. He vomited 100ml of fluid, which looked like a mixture of water and phlegm.

42. The nursing observations taken before and after this episode suggests this was a sudden and unexpected event. There is no indication in the records to suggest that, before this episode, Mr B had complained of nausea or had experienced repeated vomiting that would have prompted clinicians to consider giving him anti sickness medication. There was also no indication to suggest he was at increased risk of vomiting again.

43. The notes state nursing staff informed doctors about this vomiting episode. While we have not seen evidence of a documented medical review, we have also seen no indication his condition required urgent intervention. The nursing record describes Mr B looking distressed during the vomiting episode itself but does not suggest that he continued to feel distressed afterwards.

44. Mr B suffered another vomiting episode at 11.18pm that evening and sadly died. This also occurred suddenly and without any warning signs.

45. Although the immediate circumstances of Mr B’s death was sudden and unexpected, his overall prognosis was not. Throughout his admission, Mr B remained seriously unwell. The records document several discussions with Mr B’s family about the severity of his condition and the significant possibility that he would not survive the admission.

46. We appreciate how difficult it is for Mr A to reconcile the fact that his father appeared to have survived major surgery, only to die suddenly afterwards. We have seen no indications the Trust did anything that caused his death or could have prevented it.

47. We understand how upsetting this is for Mr A. We have not seen any indications to show Mr B’s death was due to any failings in the Trust’s actions. For this reason, we do not consider we need to carry out a detailed investigation or make any recommendations.

48. We were sorry to hear the circumstances of his complaint and offer our sincere condolences on the loss of his father. We appreciate this was a difficult time for Mr A and we thank him for sharing details of his experience with us.

49. We hope this statement provides reassurance that we have considered the evidence carefully. We hope this clearly explains the reasons for our decision.

1. We have carefully considered Mr A’s complaint about Tameside and Glossop Integrated Care NHS Foundation Trust (Tameside & Glossop Trust) and Northern Care Alliance NHS Foundation Trust (Northern Care Alliance Trust). We were sorry to hear his concerns about the care his father, Mr B, received at both organisations before he died.

2. Having considered all the available information in relation to Mr A’s complaint, we have decided we cannot link the events complained about to Mr B’s death.

3. We recognise how deeply Mr A has been affected by what happened. We do not underestimate how difficult this time has been for him. Although we are unable to investigate his concerns further, we thank him for taking the time to raise them with us.