Lewisham and Greenwich NHS Trust

3. Miss K complains about the care and treatment Lewisham and Greenwich NHS Trust (the Trust) provided to her mother, Miss A, between 1 and 3 May 2024. Specifically, she says the Trust did not: • put her mother into a side room to manage her infection risk • continue the laxative treatment she received from A&E • attempt to help her when she was choking.

4. Miss K says failing to put her mother into a side room caused her to pick up an infection due to her low immune system as a result of the chemotherapy she was receiving. By stopping the laxatives, Miss K says her mother became constipated, developed an infection and choked on her own faeces. Miss K says these failings, and the Trust not helping her mother when she was choking, led to her mother’s death.

5. Miss K is seeking a sincere apology, service improvements and an acknowledgement of failings. Miss K is also seeking a token financial remedy.

6. Miss A was admitted to Lewisham hospital on 2 May 2024 from another local hospital. Miss A presented with pain and infection.

7. Miss A had pancreatic cancer. She was on a palliative care pathway with the aim to make her end-of-life as comfortable as possible by managing her pain and other distressing symptoms.

8. On 3 May 2024 Miss sadly died of sepsis.

12. Before we decide if we should conduct a detailed investigation of a complaint, we look at whether there are signs the organisation has got something wrong. We do this by comparing what should have happened with what did happen. We have carefully considered this in Miss K’s complaint.

Not putting Miss K into a side room 13. Miss K says Miss A was constipated and suffering with symptoms of diarrhoea and vomiting. She says her mother was in and out of consciousness throughout, saying she would sit up, talk, and drink, but had no appetite, and would then be barely conscious and unable to speak for herself.

14. Miss K requested for Miss A to be put into her own room multiple times due to infection control as Miss A had pancreatic cancer and was undergoing chemotherapy. Miss K says staff kept saying that Miss A didn’t meet the criteria for this, and they didn’t have a spare room.

15. Miss A’s medical records show on 2 May, Miss A’s family requested a side room for Miss A. The Trust explained side rooms were in high demand and are used for patients with infections. The Trust then informed Miss A’s family they would notify the site manager of the family’s request. The Trust also explained that whilst Miss A was unwell it was better for her to be in a bay where close monitoring could be maintained.

16. Miss A’s medical records show that a blood sample was sent on 2 May 2024, and Miss A had a slightly elevated white cell count.

17. White Cells are a type of blood cell produced by the body to fight infection. A person normally has circulating levels of white cells. White Cells can increase in the blood for a number of reasons. A slightly elevated white cell count may be an indication of an acute infection or, in the case of Miss A, as a result of her underlying cancer.

18. If a patient has recently had chemotherapy, as Miss A did, then the white cell count can fall to very low levels. This would put the patient at risk of developing an infection.

19. As Miss A’s white cell count was slightly elevated. She had diarrhea. Her stool was tested on 2 May. The Trust determined there was no infectious cause to the diarrhea.

20. GMC guidance states when providing clinical care, doctors must, ‘adequately assess a patient’s condition, taking account of their history, including symptoms, relevant psychological, spiritual, social, economic, and cultural factors, the patient’s views, needs, and values’.

21. NHS guidance states patients must be assessed for their potential to transmit infection within the care setting. Those at risk of transmitting infection include; • ‘with diarrhoea, vomiting, an unexplained rash, fever or respiratory symptoms • known to have been previously positive with multidrug-resistant organisms (MDRO) e.g., methicillin-resistant Staphylococcus aureus (MRSA), carbapenemase-producing enterobacterales (CPE) • who have been an inpatient in any hospital in the UK or abroad or are a known epidemiological link to a carrier of CPE • who have a known or suspected infection or colonisation’.

22. The NHS guidance advises isolation and single room facilities to be prioritised for patients who are at risk of transmitting their infection to others, not for those most vulnerable in becoming infected.

23. The Trust assessed Ms A in line with GMC and NHS guidance when it considered she may have an infection. When it identified she did not have an infection, and so did not present a risk of transmitting an infection to others, in line with NHS guidance it did not need to prioritise a side room for her.

24. We have seen no indications of failings in this part of Ms K’s complaint. For this reason, we will be taking no further action.

25. We are sorry to hear of the distress the family suffered when trying to get Miss A a side room. We hope our investigation helps the family move forward.

Stopping Miss A’s laxative medication 26. Miss A’s medical records show she was taking the laxative Macrogel when she was admitted to the Trust. This is a type of oral medication that is available to buy without prescription.

27. Miss A’s medical records show she presented with abdominal pain, diarrhea, and vomiting when she was admitted to the Trust on 1 May. Miss A’s medical records show the Trust stopped Miss A’s laxative medication while it assessed her on 1 May.

28. After the Trust assessed Miss A on 1 May, it detailed a plan to put her back on laxatives. The Trust noted Miss A had constipation which may have been contributing to her vomiting. The Trust also noted Miss A did not have a bowel obstruction. This is a condition in which the bowels cannot work properly due to a narrowing of the bowel. Food content is not able to pass through the bowel.

29. Miss A’s medical records show, based on its initial assessment of Miss A, the Trust planned to treat her with IV fluids and laxatives.

30. We can see the Trust continued to administer the Senna she had previously been taking and also administered the laxatives Docusate and Macrogol from 2 May.

31. GMC guidance states when providing clinical care, doctors must, ‘adequately assess a patient’s condition, taking account of their history, including symptoms, relevant psychological, spiritual, social, economic, and cultural factors, the patient’s views, needs, and values’.

32. In line with GMC guidance, the Trust assessed Miss A’s symptoms. Our adviser tells us It was not unreasonable for the laxatives to be stopped whilst the Trust did this. Miss A was on laxatives and presented with diarrhea. It was therefore appropriate to stop the laxatives as they may have been contributing to Miss A’s diarrhea whilst she was undergoing investigation.

33. We have seen the Trust acted in line with GMC guidance in its assessment of Ms A and its decision making was clinically appropriate. As we have not seen any indications of failings in this part of the complaint, we will be taking no further action.

34. We appreciate how difficult it must have been to witness Miss A’s significant pain and worry. We hope our findings address Miss K’s concerns.

Not attempting to help Miss A when she was choking 35. Miss K says, early in the morning on 3 May 2024, Miss A needed to go to the toilet. The nurse helping Miss A decided she was too drained and weak to use the commode as she began shaking each time she used it. Miss A therefore used a bed pan.

36. Miss K says within a few minutes the alarm went off, and Miss A was having a seizure and was choking. Miss K says the nurses and doctors did not arrive for about a minute or two after the alarm sounded. Miss K says staff set up a suction but did not use it. A suction device can be used to vacuum a patient’s mouth. It can be used when a patient loses consciousness and they may vomit.

37. Miss K said her mother was choking on faeces, and a liquid was leaking from her mouth. She complains the Trust did not help her mother when she was choking. She then sadly died. Miss K was not present when Miss A died, her brother was.

38. Miss A’s medical records show she had metastatic pancreatic cancer. She was admitted to the Trust on May 1. On admission Miss A was X rayed. The X ray showed there were no overtly dilated loops of the small or large bowel (a physical blockage or a localised paralysis of the gut muscles). The radiologist reported there was no radiological evidence Miss A had bowel obstruction. No further imaging was done.

39. Miss A’s records show she had an unspecified infection on 2 May. Her inflammatory markers were up; she was nauseous and vomiting. The medical records show Miss A’s vomiting settled with anti-sickness medication. The Trust began treating her for sepsis.

40. In their initial complaint response, the Trust explained Miss A’s son requested a nurse assist Miss A to transfer to a commode. As Miss A was not able to safely transfer to the commode, the nurse offered a bed pan instead. Miss A agreed.

41. The Trust said after placing Miss A on the bed pan, she became unresponsive and the nurse noted fluid was coming out of her mouth. The nurse put out a peri-arrest call by pulling the emergency cord and the NIC and the Critical Care Outreach Team arrived promptly.

42. There is therefore consensus from both accounts from Miss K and the Trust that Miss A needed to use the toilet. Both accounts detail that Miss A used a bedpan instead and soon started to choke and fluid began coming out of Miss A’s mouth.

43. Miss A’s medical records show that her consciousness levels at the time were persistently marked as alert. Miss A’s observation charts show she was alert and there was not a problem with her airways up to the moments of Miss A’s death. From the records, Miss A’s choking was sudden. Our adviser explained it could not have been predicted.

44. Miss A’s records state in the early hours of 3 May, Miss A was in a peri-arrest when the doctor arrived. This is the time immediately before or after a heart attack. The Critical Care Outreach Team (CCOT) were present and were clearing her airway with suctioning. Miss A had vomit around her mouth. When the doctor assessed her, she had no response, no heart sounds on when they listened with a stethoscope, no carotid pulse and her pupils were fixed and dilated. Miss A’s records show she had a clear airway and was speaking in full sentences.

45. Miss A’s medical records show she suffered with aspiration, where stomach contents go into the lungs and can be a cause of cardiorespiratory arrest.

46. It is also not possible to say from the medical records if Miss A’s vomiting was followed by cardiac arrest or if Miss A first had cardiac arrest and then experienced vomiting.

47. In the Trust’s complaint response, the staff nurse recalled there was some confusion with the CCOT; whether to begin resuscitation or not. This may have contributed to some hesitancy.

48. Miss A’s medical records show that Miss A passed away at 3:20 am on 3 May of sepsis. She had a Do Not Attempt Resuscitation (DNAR) in place at the time.

49. Our adviser told us there are no national standards for managing the airways of alert patients such as Miss A.

50. GMC guidance states when providing clinical care, doctors must promptly provide, or arrange, suitable advice, investigation or treatment where necessary.

51. Miss A’s medical records do not detail what exactly happened in the early hours of 3 May. We asked our adviser if the Trust’s record keeping was clinically sufficient. They explained for a ward-based patient over the 48-hour admission, the documentation is sufficient. They said records concerning ward-based patients will be limited where the initial part of the patient’s decline is not witnessed by the medical team.

52. We have seen Miss A’s choking was sudden and could not have been predicted. From the available evidence we cannot robustly determine if there was delay in the Trust using suction.

53. We have seen there may have been some hesitancy with the CCOT whilst it decided whether or not to begin resuscitation given Miss A had a DNAR in place.

54. Our adviser tells us there may have potentially been a delay in using the suction as there can be confusion in an emergency situation. They say, if there was a delay in this situation, it would have been reasonable and in keeping with normal practice.

55. They also said if there was content in the mouth, it is unlikely the Trust could have cleared this out due to Miss A’s weakness and her level of consciousness. We do however note Miss A had clear airway.

56. Miss K may be reassured to know, our adviser said, if there was a delay in using the suction, any delay did not contribute to Miss A’s death as unfortunately Miss A had already aspirated and had a heart attack.

57. We have also been unable to determine what Miss A was choking on. The body produces two litres per day of bile, which is green, and can be vomited. This can be mistaken for faeces. Our adviser also told us, if a patient develops a small or large bowel obstruction, they may vomit faecal content.

58. We have seen Miss A’s X ray from 2 May did not show any bowel obstruction. We have not seen any reason the Trust should have or could have x rayed Miss A again. Our adviser told us the Trust’s actions in treating Miss A’s presentation in the early hours of 3 May were clinically appropriate and in line with GMC guidance.

59. We have not identified any indications of service failure in how the Trust responded to Miss A on 3 May. For this reason, we will not be taking any further action on this part of the complaint.

Conclusion

60. We have seen the Trust acted in line with guidance in its care and treatment of Miss K. We know our report will not change what happened, but we hope Miss K is reassured by our findings.

61. Complaints give us valuable insight into the organisations we investigate, so we would like to thank Miss K for sharing Miss A’s experience with us. It is also important to acknowledge that finding no indications of service failure does not detract from Miss A and Miss K’s experience, or the upset and worry these events caused.

1. We have carefully considered Miss K’s complaint about Lewisham and Greenwich NHS Trust (the Trust). We were sorry to hear how her mother, Miss A, died in hospital. It is clear the sudden death of Miss A, and how she passed away, has been very difficult and upsetting.

2. Having carefully considered Miss K’s complaint, we have seen the Trust provided Miss A care and treatment in line with national guidelines. We have not seen any indications things went wrong. We will explain our reasons for this decision below.