University Hospitals Birmingham NHS Foundation Trust

5. Ms A complains the Trust failed to arrange a scan and diagnose her father’s abdominal aneurysm at the end of May 2022.

6. Ms A said the events led to her father’s sad and sudden death a few days later. This has caused distress and upset.

7. Ms A seeks service improvements.

8. What follows is a summary of events obtained from the complainant, the Trust, and relevant entries of Mr B’s medical records. We have not included all of the details as those involved are already aware of the information. However, we have included this background to put the complaint in context.

9. Mr B was in his 80s.

10. He was known to have high blood pressure, ischaemic heart disease (blood vessels supplying the heart are narrowed or blocked), transient ischaemic attack (TIA) (mini stroke, where blood supply to the brain is temporarily disturbed), aortic bovine valve replacement (replacement of valve in the heart using a cow valve) and aortic dissection type B (previously repaired tear in the inner layer of the aorta in the chest and abdomen).

11. Mr B attended the Trust’s hospital at the end of May, by ambulance, with abdominal pain and two episodes of diarrhoea. It discharged him home on the same day.

12. A few days later, an ambulance took Mr B to a different hospital, within the Trust, because he had worsening symptoms.

13. Mr B sadly died following a cardiac arrest.

14. The cause of death was noted as a ruptured thoracoabdominal aortic aneurysm.

20. To help us understand what should have happened when Mr B attended the Trust with abdominal pain and diarrhoea, our emergency medicine adviser referred us to RCEM guidance.

21. RCEM best practice guidelines say a clinical diagnosis of ruptured abdominal aortic aneurysm should be considered in patients over the age of 50 years presenting with abdominal or back pain and hypotension.

22. It also says that the clinical diagnosis of ruptured abdominal aortic aneurysm should be considered in patients with a known abdominal aortic aneurysm and symptoms of either abdominal or back pain or hypotension. For patients where an alternative diagnosis is considered more likely on clinical grounds, a ruptured aneurysm still must be excluded, with radiological confirmation made prior to referral.

23. RCEM consultant sign off guidelines say that patients who present to A&E with abdominal pain and are over the age of 70 years are a high-risk patient group with a risk of life-threatening disease that may not be immediately appreciated by less experienced staff.

24. RCEM abdominal pain guidelines say to obtain a senior review of patients over the age of 70 years before discharge because there is a high incidence of important missed pathology, for example a ruptured aortic aneurysm.

25. It also says to adopt a low threshold of suspicion (of ruptured abdominal aortic aneurysm) in any middle-aged or elderly patient with back pain, abdominal pain or collapse. It goes onto say a ruptured abdominal aortic aneurysm can present with a variety of different patterns of pain.

26. RCEM safety alert says abdominal pain in A&E is a significant cause of diagnostic uncertainty and error. Peritonism, abdominal aortic aneurysm, obstruction and ischaemic bowel can be missed. Elderly and diabetic patients often have vague, non-specific symptoms and atypical presentations of potentially life-threatening conditions.

27. NICE guidance refers to the use of CT angiogram for people with suspected rupture.

28. Within its complaint response, the Trust said a doctor examined Mr B and took blood tests which did not show any signs of concern. It gave him pain relief and diagnosed gastroenteritis (stomach flu). It discharged him and explained he should return if his symptoms worsened.

29. The medical records tell us that Mr B attended A&E, and a triage nurse assessed him in the afternoon. Mr B said he had lower abdominal pain with episodes of diarrhoea, nausea and feeling weak.

30. The nurse recorded his clinical observations (temperature, respiratory rate, blood pressure, pulse, oxygen saturations and conscious level) as normal. His National Early Warning Score (NEWS) (a tool to assess the degree of illness) was zero, which meant he had a low clinical risk.

31. When the doctor saw Mr B, they noted that he had experienced two isolated episodes of diarrhoea the previous evening but had no further episodes. The abdominal pain had started after the diarrhoea. He described the pain as seven out of ten and this reduced to three out of ten. He described feeling weak and dizzy on standing from a sitting position.

32. The doctor examined Mr B’s abdomen which was soft and non-tender with increased bowel sounds. During a later examination, the doctor put an annotated cross on the bottom right side of his abdomen, in his medical record.

33. Our emergency medicine adviser helped us understand that a doctor would usually do this to identify an area of tenderness. Further records show that pain relief eased Mr B’s symptoms.

34. The doctor planned to take a blood test, take lying to standing blood pressure readings and a urine sample. Mr B’s blood test results were normal other than moderate anaemia and increased urea, which can be caused by an issue with the kidneys or dehydration.

35. Our emergency medicine adviser helped us understand that these results on their own would not result in further investigation.

36. Ms A told us the ambulance paramedic commented that he heard a rumbling noise in her father’s stomach. She said the doctor did not consider this. The ambulance handover note does not record this information.

37. We have decided the Trust did not miss this information because it was not aware of it. Our emergency medicine adviser also explained a rumbling noise from the stomach may be indicative of gastroenteritis or bowel obstruction but would not be indicative of an aortic aneurysm.

38. Ms A also told us that she had concerns that the Trust did not take a urine sample. We have seen no evidence that the Trust completed this.

39. Our emergency medicine adviser explained that the results of a urine test would not have identified a rupture aortic aneurysm or altered the decision to discharge Mr B. We recognise this has been a worry for Ms A and we hope this reassures her that it would not have made a difference to the sad outcome.

40. The medical records show the doctor thought gastroenteritis was the cause of Mr B’s symptoms. They advised him to go home and to return if his abdominal pain worsened or if he had further dizziness. An emergency medicine consultant reviewed Mr B prior to discharge, which was in line with the RCEM guidelines.

41. Our emergency medicine adviser told us that it would be unusual for gastroenteritis to cause only two episodes of diarrhoea with no vomiting and cause continuing abdominal pain 12-24 hours later. We have decided the Trust should have considered other causes for this pain.

42. The A&E records from the second attendance note a medical history of previous TIA, large aortic aneurysm, previous thoracic aneurysm dissection repair and known 5.7cm infrarenal aortic aneurysm.

43. We were uncertain where the 5.7cm measurement came from. We therefore asked the Trust about this.

44. We know that Mr B had a thoracoabdominal aortic aneurysm repair in 2016. This is in the aorta that spans both the chest and abdominal regions.

45. The Trust sent us a CT report for a CT aorta scan performed in October 2020. It detailed that the descending thoracic aorta (the segment of the aorta that extends to the diaphragm) was dilated to a maximum of 57mm.

46. This was the part of the aorta in the chest which had previously been operated on for a dissection in 2016.

47. It also described the diameter of the native abdominal aorta (the segment of the aorta that continues from the diaphragm to the lower abdomen) as approximately 43mm.

48. The 2020 scan would have been accessible to the assessing doctor on Mr B’s first attendance.

49. This was not a clear-cut presentation of ruptured aortic aneurysm. Mr B’s normal clinical observations and improving abdominal symptoms with pain relief were reassuring. However, we note from the various RCEM guidance that older adults who present with abdominal pain are a high-risk group and can present with subtle symptoms and signs.

50. We know Mr B had significant vascular disease, in terms of hypertension, ischaemic heart disease and cerebrovascular disease. Our emergency medicine adviser explained that these all put him at significantly increased risk of abdominal aortic aneurysm.

51. We also know Mr B had a previous thoracic aortic dissection which had been repaired in 2016. Our emergency medicine adviser explained he would have increased risk of complications of a leak and significantly increased risk of other co-existing vascular abnormalities, such as an abdominal aortic aneurysm.

52. We have decided that Mr B was at significantly increased risk of a ruptured abdominal aortic aneurysm causing the symptoms which led to his attendance at A&E. We recognise Ms A was worried about her father, and the events have caused her distress.

53. We have found the Trust should have considered a ruptured aortic aneurysm before it discharged Mr B. The Trust should have arranged a CT angiogram and/or referred to the vascular surgical team for further management. This would be in line with the various RCEM guidelines and is a failing.

Impact

54. Ms A said the events led to her father’s sad and sudden death. We recognise this was a very worrying time and how deeply distressing this was for her.

55. Our emergency medicine adviser said Mr B was clinically stable when he attended A&E during his first attendance. We have found the management of his symptoms should have consisted of a CT angiogram, and a referral to the vascular surgical team.

56. Mr B called an ambulance a few days later when he experienced chest and abdominal pain. He had a cardiac arrest on his way to hospital and despite resuscitation attempts, he sadly died in hospital.

57. An autopsy confirmed that his ‘death was due to a large ruptured thoracoabdominal aortic aneurysm which had previously been stented’.

58. To consider the impact, we looked at what would have happened if the Trust had arranged a CT scan and/or referred to the vascular team during his first attendance. We also considered if any of these actions, could have prevented Mr B’s cardiac arrest and death a few days later.

59. Mr B was known to have a complex thoracoabdomnal aortic aneurysm secondary to a type A dissection of the ascending aorta. He had a dissection flap extending into the abdominal aorta.

60. Our vascular surgeon adviser helped us understand that he had a previous repair of his aneurysm and imaging had reported the size of the thoracic and abdominal components to be stable and well below the threshold for intervention.

61. Our vascular surgeon adviser explained that if the Trust had requested a CT scan during the first attendance, it may have shown an expansion of the aorta, however it may not have revealed any significant change to the appearance of the aorta in the abdomen.

62. Depending on the size of the abdominal aorta, this may have triggered referral to the vascular team. But as Mr B was asymptomatic, the Trust might still have discharged him.

63. Our vascular surgeon adviser explained if he had had a CT scan during his first attendance and it had shown enlargement of his abdominal aorta, it is unlikely that he would have had any therapeutic intervention before his second attendance.

64. Extension of his repair into his abdominal aorta would have required a complex reconstruction with a BEVAR (branched extensions into the arteries of the kidneys and vessels to the bowel).

65. These are complex procedures that require planning and ordering a made to measure device. They need a thorough pre-operative assessment to confirm suitability for this complex and risky procedure. A medical team cannot usually arrange this in just three days.

66. Our vascular surgeon adviser helped us understand that when Mr B attended A&E the first time, he did not have symptoms suggestive of impending rupture.

67. He reported lower abdominal pain, with nausea and diarrhoea. He was feeling weak. His blood tests showed him to be mildly anaemic but were otherwise normal.

68. We are unable to say, even on the balance of probabilities, that a CT scan and/or referral to the vascular team would have confirmed an expansion or rupture and changed the outcome. The Trust could still have discharged Mr B after arranging this.

69. At this stage, we do not consider the rupture and cardiac arrest leading to Mr B’s death was avoidable.

70. We recognise this will be difficult for Ms A to read and do not underestimate how upsetting this will be. We know it must have been concerning to not be aware of the extent of her father’s condition at the time.

71. We consider the failings led to some avoidable distress to Ms A and the lost opportunity for a different outcome for her father. In coming to this view, we acknowledge he may still have died even had the failing not occurred.

72. The missed opportunity leaves her with uncertainty about her father’s care. We know this has caused her worry and distress.

73. Ms A seeks service improvements. The Trust did not accept it did anything wrong so has not considered any improvements and learning. The injustice is therefore unremedied.

1. We are sorry to hear about the events that led to Ms A’s complaint and her father’s death. We recognise this has been and still is an upsetting time for her.

2. We have found University Hospitals Birmingham NHS Foundation Trust (the Trust) should have considered a ruptured aortic aneurysm before it discharged Mr B.

3. We are unable to say, even on the balance of probabilities, that a CT scan and/or referral to the vascular team would have confirmed an expansion or rupture and changed the outcome. The missed opportunity to consider the possibility of an aneurysm leaves Ms A with uncertainty about her father’s care.

4. We have decided to partly uphold the complaint and make recommendations.

74. We make recommendations in line with our Principles for Remedy which say public bodies should acknowledge failures, apologise, make amends, and use the opportunity to improve their services.

75. Our Principles for Remedy are reflected in the NHS Complaints Standards which say organisations should offer fair remedies to put things right and identify learning and use it to improve services.

76. With this in mind we recommend the Trust:

• writes to the complainant within one month to acknowledge and apologise for the impact of the failings we have identified • explains what action it will take, or has taken, to address these failings within three months. It should do this in the form of an action plan which should be shared with us, the complainant, Care Quality Commission (CQC) and NHS England too.

77. We are sorry to learn of the tragic events that led to Ms A’s complaint and her father’s death. We know this was and still is a deeply distressing and upsetting time. We are mindful of how important her complaint is and the difficult experience she has had. This concludes our final report.