Walsall Healthcare NHS Trust

5. Mr N complains about the care the Trust provided for his father, Mr R, between 27 October and 6 November 2024.

6. He says that the Trust: • did not properly diagnose and treat Mr R’s chest infection symptoms • discharged him to a nursing home for rehabilitation before he was fit enough to leave hospital.

7. Mr N believes the failure to properly diagnose and treat Mr R and the early discharge may have contributed to his death less than 24 hours later in the nursing home from bronchial pneumonia. Bronchial pneumonia is a type of chest infection. Mr [name redacted] explains he has to live with the uncertainty of not knowing if a later discharge may have prevented his death.

8. Mr N would like the Trust to pay a financial remedy and acknowledge that it discharged Mr R too soon.

9. Mr R was admitted to the Trust at the end of 27 October 2024.

10. He was treated with antibiotics from for the first five days of his admission for community acquired pneumonia (CAP). CAP is a chest infection picked up outside of a hospital. Symptoms of CAP commonly include a cough, shortness of breath, and a high temperature.

11. At the beginning of November, he was discharged for further rehabilitation care in an intermediate care bed in a nursing home.

12. Mr R sadly died a day later after a cardiac arrest. The death certificate said the provisional cause of his death was bronchial pneumonia.

17. NICE CG191 sets out the recommendations for the assessment and treatment of CAP.

18. In light of the above guidance we have looked at what happened in Mr R’s case.

19. Mr R went to the Emergency Department (ED) in the evening of 26 October with neck and back pain, lethargy, confusion and a high temperature. He had fallen several weeks earlier and again five days previously.

20. The ED doctors made a provisional diagnosis of CAP.

21. NICE CG91 says where doctors diagnose CAP for someone who has presented at hospital, they should carry out a risk assessment using the CURB65 score. The doctor calculates the score by giving one point for each of the following features if they are present. These are confusion, raised respiratory rate, low blood pressure, aged over 65, a raised blood urea nitrogen level. The latter most commonly indicates that the kidneys are not functioning properly or dehydration.

22. The doctor will then use the score to assess the patient’s pneumonia severity and risk of death. This will guide the management of their treatment. A score of one indicates low risk and two is intermediate risk. A score of three to five is high risk or more than 15% chance of death.

23. In this case we have not seen any evidence that the doctors calculated Mr R’s CURB65 score.

24. Our adviser has suggested from their review of Mr R’s records, his CURB65 score would have been three. This is based on Mr R’s age of 87 and his symptoms of confusion and a blood test result showing a raised urea nitrogen level.

25. We consider the Trust not completing a CURB65 score does not comply with the recommendations of NICE CG91. As such this is an indication of failing.

26. We have gone on to look at the impact of this indication of failing on Mr R. We hope Mr N is reassured it does not appear the lack of CURB65 score had any effect on what happened next in his father’s care. We have explained below how we have arrived at this conclusion.

27. We have considered our adviser’s view that Mr R would have had a CURB65 score of three. We have seen evidence he broadly received the appropriate treatment as set out in the guidance for a patient with this score.

28. Firstly NICE CG91 says clinicians should consider hospital based care and a possible intensive care assessment for people with a score of three or more. In this case Mr R received hospital treatment and we have not seen any indication that he required intensive care.

29. NICE CG91 goes on to say that doctors should take blood and sputum cultures from patients with moderate or high risk CAP.

30. A doctor would take a sputum culture when they suspect a lower respiratory tract infection. Sputum is the thick mucus coughed up from the lungs. The culture identifies the specific germ causing an infection so doctors can prescribe the most appropriate antibiotic.

31. It does not appear in this case that the doctors took sputum cultures. However, from the available evidence we see Mr R responded positively to treatment. Therefore it appears the doctors prescribed the appropriate antibiotics despite not taking sputum cultures. We have referred to Mr R’s response to treatment in more detail below.

32. From Mr R’s records we can see the doctors carried out blood tests.

33. These showed he had a white blood cell count of 11.9. This test measures the number of infection-fighting blood cells in the bloodstream. Mr R’s result was slightly above the normal range of 4.5 to 11 which indicated an infection in his body. His C-reactive protein (CRP) blood test result was 267. CRP is a protein in the blood which increases when there is an infection in the body. The normal range of CRP is 0-5. As such 267 is significantly raised.

34. Given that his blood tests indicated an infection the doctors started him immediately on a broad-spectrum intravenous (IV, via a vein) antibiotics to treat a possible chest and/or urine infection. This is also in line with NICE CG191 which says that doctors should provide antibiotic therapy for patients with a diagnosis of CAP. Broad-spectrum antibiotics are medications that kill or stop the growth of a wide range of disease-causing bacteria.

35. NICE CG191 also recommends that doctors should commence treatment of CAP and arrange X-rays to allow diagnosis within four hours of presentation to hospital.

36. From Mr R’s records he arrived at ED at approximately 10.30pm on 26 October and started antibiotics at 4am.

37. Mr R had a CT scan approximately an hour later. The purpose of the CT scan was also to look at his back pain and provides a clearer image than an X-ray.

38. We acknowledge treatment and the CT scan took place around six hours after Mr R’s presentation. We cannot say the 6 hours amounts to a failing as there is no evidence of significant delay overall and there is evidence staff were trying to do the right things promptly.

39. The CT scan showed his lung was not inflating fully but did not clearly show any infection. A second CT scan later in the day also showed that the lung had partially collapsed. Our adviser explains this indicates that there was definitely an infection developing in the lung by this stage.

40. From the above evidence it appears the Trust appropriately assessed Mr R’s chest infection and commenced him on appropriate treatment when he presented at ED. We have explained why we do not consider the failure to complete a CURB65 score has resulted in any impact since the investigations the Trust carried out were still in line with NICE CG191 for a patient like Mr R.

41. We have then looked at the ongoing management of Mr R’s chest infection.

42. NICE CG191 recommends antibiotic therapy and we can see from Mr R’s records that the doctors initially changed the first broad spectrum antibiotic treatment prescribed over the first couple of days to an antibiotic treatment more targeted for a chest infection. In all he received IV antibiotic treatment for five days.

43. Mr R also initially received oxygen therapy which was later stopped due to an improvement in his condition. He also had intravenous fluids for the first couple of days of his admission and then his notes report that he was eating and drinking.

44. NICE CG191 recommends monitoring of CRP levels to check the degree of infection and we see that this took place during Mr R’s admission.

45. From our review of the evidence it appears the Trust provided ongoing management and treatment of Mr R’s chest infection during his admission in line with NICE CG191. We have not therefore seen any indications of failings here.

46. We understand Mr N is very concerned that Mr R was not ready for discharge to the rehabilitative nursing home.

47. We have carefully reviewed his records with our adviser. These show that he completed his antibiotic treatment and his symptoms improved.

48. From his records: • at the beginning of November he was much brighter and alert • four days later his CRP had reduced to 91 and white blood cell count was within the normal range • another day later, his CRP had reduced further • on the day before his discharge he was eating and drinking normally and there were no medical concerns.

• on the day of his discharge his temperature, blood pressure heart and respiratory rate were normal.

49. NICE CG191 says that people with CAP should not be discharged if, in the past 24 hours, they have had two or more of a: • temperature higher than 37.5°C • respiratory rate 24 breaths per minute or more • heart rate over 100 beats per minute • oxygen saturation under 90% on room air • abnormal mental status • inability to eat without assistance • systolic blood pressure 90 mmHg or less.

50. Systolic blood pressure is the first, or top, number in a blood pressure reading. It measures the peak pressure of blood pushing against your artery walls when your heart beats and pumps blood.

51. From our review of Mr R’s records and discussion with our adviser, the plan to discharge appears to be in line with the above. There is no indication that Mr R was not fit for discharge and it appears his symptoms had resolved. As such we have seen no indications of failings in the decision to discharge Mr R on 7 November.

52. Mr R died after suffering a cardiac arrest. Our adviser explains a range of conditions can cause cardiac arrest and without a post mortem, it is not likely we can say what caused it in Mr R’s case.

53. We understand Mr N is very concerned his father died so soon after his discharge. The timing of his father’s death and the death certificate which referred to bronchial pneumonia as possible cause of death has understandably increased his anxiety.

54. We have explained above that there is no indication that Mr R had not positively responded to treatment for his chest infection.

55. Our adviser notes Mr R had a lot of risk factors which increased the chances of a cardiac arrest. These included his fragility, age and his existing diagnoses of heart disease and type 2 diabetes. Our adviser explains that the latter significantly increases the risk of cardiac arrest. This means he could potentially have suffered a cardiac arrest at any time.

56. We hope our consideration has reassured Mr N it appears the Trust provided appropriate care to his father and made the correct decision to discharge him on 7 November.

1. We have carefully considered Mr N’s complaint about Walsall Healthcare NHS Trust (the Trust).

2. We are sorry for his loss and to hear about the sad circumstances of his father’s death.

3. We have reviewed the available evidence and for the most part it appears the Trust provided treatment to his father in line with relevant standards and guidance. Where we consider this has not happened we have not seen any impact on his father.

4. As such we do not intend to take any further action. We have explained our thinking in more detail below.