Blackpool Teaching Hospitals NHS Foundation Trust

3. Mrs P complains about the care and treatment Blackpool Teaching Hospitals NHS Foundation Trust (the Trust) provided to her father, Mr G from December 2023 to 15 February 2024. She says the Trust failed to diagnose and treat her father’s urinary tract infection (UTI) and did not appropriately escalate his care.

4. Mrs P says because of the Trust’s failure to recognise and treat her father’s UTI, he developed sepsis, and this led to his very sad death. She says this has caused significant upset and distress to her and the rest of the family.

5. By bringing the complaint to us, Mrs P would like an explanation and a financial remedy.

6. Mr G was in his early seventies, and he had a history of heart failure. Heart failure is a long-term condition where the heart cannot pump blood around the body properly. On 5 November 2023, Mr G was admitted to hospital (hospital A). Clinicians discharged him home on 18 November 2023.

7. On 25 November 2023, Mr G was readmitted to hospital A after falling and breaking his hip at home.

8. On 15 December 2023, Mr G was transferred to a different hospital to continue his rehabilitation (hospital B).

9. On 16 February 2024, Mr G was discharged home from hospital B. He went back to A&E same day and was transferred to another hospital for further treatment (hospital C).

10. Mr G sadly died a month later whilst he was still an impatient at hospital C.

13. Mrs P says clinicians at hospital B failed to diagnose and treat her father’s urinary tract infection (UTI) which later led to kidney damage and sepsis. She says hospital B did not appropriately escalate her father’s care.

14. The Trust explains the first sign Mr G had urosepsis (sepsis caused by infection of the urinary tract) was on 25 February 2024 (when he was at hospital C) and clinicians immediately started him on a strong antibiotic. It says there is no evidence to suggest Mr G had signs of sepsis prior to leaving hospital B.

15. GMC Good Medical Practice guidance says:

‘15. You must provide a good standard of practice and care. If you assess, diagnose or treat patients, you must:

a. adequately assess the patient’s conditions, taking account of their history (including the symptoms and psychological, spiritual, social and cultural factors), their views and values; where necessary, examine the patient b. promptly provide or arrange suitable advice, investigations or treatment where necessary c. refer a patient to another practitioner when this serves the patient’s needs

16. In providing clinical care you must:

a. prescribe drugs or treatment, including repeat prescriptions, only when you have adequate knowledge of the patient’s health and are satisfied that the drugs or treatment serve the patient’s needs b. provide effective treatments based on the best available evidence c. take all possible steps to alleviate pain and distress whether or not a cure may be possible’

16. Annex D of the Department of Health and Social Care hospital discharge guidance sets out the criteria for a patient to reside in hospital. It says:

‘Every person on every general ward should be reviewed on a twice daily ward round to determine the following. If the answer to each question is ‘no’, active consideration for discharge to a less acute setting must be made:

• requiring ITU or HDU care?

• requiring oxygen therapy/NIV?

• requiring intravenous fluids?

• NEWS2 greater than 3? (clinical judgement required in persons with AF and/or chronic respiratory disease) • diminished level of consciousness where recovery realistic?

• acute functional impairment in excess of home or community care provision?

• last hours of life?

• requiring intravenous medication (including analgesia)?

• undergone lower limb surgery within 48 hours?

• undergone thorax-abdominal/pelvic surgery with 72 hours?

• within 24 hours of an invasive procedure? (with attendant risk of acute life- threatening deterioration)

Clinical exceptions will occur but must be warranted and justified. Recording the rationale will assist meaningful, time efficient review’.

17. The notes show Mr G fell at home and broke his hip on 25 November 2023. He had surgery and was admitted to hospital A for three weeks. During this admission, Mr G had regular input from the therapy teams the clinical team treated him for pneumonia and sepsis. Clinicians decided he was well enough to be discharged and continue his rehabilitation at hospital B (a nurse led therapy unit) and arranged for him to be transferred there on 15 December.

18. When Mr G arrived at hospital B, the notes say his rehabilitation goals were to increase his activity tolerance. He was taking several medications to treat his heart failure including bisoprolol, ramipril and dapagliflozin. He was also taking furosemide, which is a diuretic medication to treat fluid retention. Fluid retention is where the body holds too much fluid and it leads to symptoms like swelling and bloating. It is a common issue in patients with heart failure.

19. Mr G also had a urinary catheter in place when he arrived at hospital B, and this continued during his admission. A urinary catheter is a flexible tube used to empty the bladder and collect urine in a drainage bag.

20. To diagnose a UTI, clinicians often use a urine ‘dipstick’ test and/or a sample of urine can be sent to the microbiology laboratory to check for the presence of infection. Our adviser explains that diagnosing UTI’s in patients with urinary catheters like Mr G is more complex. This is because urine collected from a catheter bag will always test positive for UTI characteristics on a urine dipstick test and will consistently show bacterial growth if sent to the lab. Consequently, urine dipstick tests and urine microbiology are not useful for diagnosing UTI’s in patients with urinary catheters and clinicians would therefore primarily depend on clinical indicators of infection to make a diagnosis.

21. The main clinical indicators of infection include fluctuations in temperature and the elevation of inflammatory markers on blood tests such as the white cell count and c-reactive protein (CRP). Another indication somebody may have an infection is if they have signs of acute illness, such as any sudden decline in their overall condition or appearance. This is particularly in older individuals, where symptoms of infection can be unclear. Symptoms or signs indicative of a UTI are discomfort or pain in the bladder area or the loins, or tenderness (pain when pressed) in these areas.

22. While simple UTI’s typically do not cause kidney failure, untreated UTI’s can lead to serious complications, including kidney failure. Our adviser explains kidney problems can be categorised into acute kidney injury (AKI), which is a sudden and often temporary decline in kidney function that occurs within hours or days, and chronic kidney disease (CKD), a long-lasting condition characterised by damaged kidneys that are unable to function properly. Our adviser explains most patients in Mr G's age group, particularly those with numerous comorbidities, are likely to have some degree of CKD, indicating that their kidney function is not as effective as it was in their younger years when they had fewer comorbidities and were prescribed fewer medications.

23. From the information in Mr G’s medical records, we cannot see any clinical features to suggest he had a UTI during the time he was an inpatient at hospital B. He did not report any discomfort or pain in the bladder area and there was no sudden decline in his overall condition. Mr G did have an elevated temperature on 29 January but the evidence available at that time indicated he had a chest infection (cough with increased sputum). Clinicians treated this with on co-amoxiclav which is a broad-spectrum antibiotic and would be effective against most urinary infections as well as the suspected chest infection. We consider the Trust adequately assessed Mr G in line with paragraphs 15 and 16 of the GMC guidance on providing good clinical care.

24. Mr G also had a mildly elevated white cell count during his admission. Whilst this can sometimes be an indication of infection or inflammation, our adviser explains it is also common in patients with heart failure, which Mr G was known to have. Our adviser tells us Mr G’s blood tests during this period do not indicate a significant likelihood he had impaired kidney function beyond what would typically be expected, given his age and medications. There is no evidence in the notes he had any worrying deterioration of his kidney function during his admission.

25. We appreciate Mrs P is concerned her father’s care should have been escalated to another hospital for specialist input. Our adviser says there are no specific guidelines when to transfer a patient from a rehabilitation hospital to a general hospital. As per paragraph 15c of the GMC guidance, doctors should refer a patient to another practitioner when this serves the patient’s needs.

26. Although hospital C is a nurse-led service, we can see doctors regularly reviewed Mr G and were actively involved in his care. The notes show Mr G consistently had low blood pressure throughout his admission. While a sudden drop in blood pressure typically raises concerns, in the context of Mr G’s heart failure, the medications he was taking and the fluid restriction he was under, our adviser says this was not alarming. Mr G had a rise in temperature on 29 January, and clinicians started him on intravenous (IV) antibiotics. The plan was to have a low threshold for transfer to hospital A, meaning that if there was any deterioration he should be transferred to the regional general hospital. Mr G improved following the IV antibiotics and that was not required. We cannot see there was a clinical need for Mr G’s care to be escalated during his admission at hospital C.

27. In the lead-up to Mr G's discharge, the medical and nursing records do not indicate he was unwell and his observations remained stable. He did not meet any of the criteria set out in the department of health guidelines above to remain in hospital and we consider the decision to discharge him was appropriate.

28. We understand Mr G presented in the ED at hospital A with breathing issues the day after he was discharged. He was subsequently transferred to hospital C and his condition sadly deteriorated. Overall, we have found hospital C provided appropriate care to Mr G in line with GMC and department of health guidelines and we cannot see something went wrong. We recognise this was a truly devastating time for Mrs P and her family and we are so sorry to hear about the impact of Mr G’s very sad death. We thank her for bringing her complaint to us.

1. We have decided not to uphold this complaint. We are very sorry to hear about Mr G’s very sad death and recognise this has been an incredibly distressing and upsetting time for Mrs P and her family.

2. We have found the Trust acted appropriately and in line with relevant guidelines and there were no indications he had a UTI or kidney injury before he was discharged from the rehabilitation hospital.