Diagnosis on 13 July 2018
12. Mrs B says that the Trust wrongly assumed the problem was related to her husband’s previous hip replacement. She says that shortly before he died staff apologised that they had focused on his hip when her husband’s pain was a well-known symptom of a ruptured abdominal aorta.
13. Section 15 of the General Medical Council’s ‘Good Medical Practice’, 2013, states that if a doctor assesses, diagnoses or treat patients they 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.’
14. We found nothing to suggest that the Emergency Department (ED) doctors missed an obvious diagnosis. An abdominal aortic aneurysm is a bulge or swelling in the aorta, the main blood vessel that runs from the heart down through the chest and stomach. In Mr A’s case the swelling eventually burst and sadly led to his cardiac arrest and death. Before that happens the swelling can leak and then seal itself off. Our adviser said that from the evidence available it is likely that that is what happened here.
15. With the benefit of hindsight it is perhaps easy to think that this should have been identified. However Mr A’s presentation was highly unusual. Normally a patient with leakage of blood from an abdominal aortic aneurysm would experience pain in their back or abdomen. Our adviser said that groin pain is a far rarer presentation of a ruptured aortic aneurysm. Mr A had a history of a previous hip replacement and had had physiotherapy the previous day. Our adviser said that both of these suggested a potential musculoskeletal cause for his pain.
16. Also a clinical suspicion of leakage from a ruptured aneurysm would be triggered by ongoing signs of shock – persistent low blood pressure and high heart rate from blood loss. Our adviser said that these signs were not present, further reassuring the ED doctors of a less serious cause for Mr A’s hip pain.
17. The junior doctor who assessed Mr A discussed their findings with a senior doctor (an ED consultant) who advised that they admit him for further observation overnight. Our adviser said that this reinforces the evidence that the diagnosis was not clear in view of the very unusual presentation and lack of clinical signs present.
18. We found no evidence to suggest to the ED doctors that there was a more serious cause for Mr A’s pain.
Whether the management of Mr A’s treatment (including pain relief) was appropriate and timely
19. Our adviser said that based on Mr A’s presenting symptoms (acute groin pain and nausea) and his medical history (hip replacement and recent physiotherapy) it was justifiable for the ED doctor to diagnose a right hip problem. The doctor then arranged blood tests and an X-ray to investigate this further. We found that the management of the perceived right hip problem was appropriate and evidence-based and in line with section 15 of the GMC’s ‘Good Medical Practice’, referred to above.
20. With regard to pain management the relevant guidelines are The College of Emergency Medicine’s Best Practice Guidelines: ‘Management of Pain in Adults’ 2014. These state that patients attending the ED should have their pain assessed within 20 minutes of arrival.
21. The records show that Mr A arrived at 5.38pm and the triage nurse assessed his pain at 5.51pm. This was within 20 minutes of arrival and in line with the guidance. Mr A’s pain score was recorded as 3 (pain is recorded on a scale of 0 = no pain to 10 = worst pain ever felt). Pain relief (intravenous paracetamol) was prescribed at 6.08pm. However Mr A did not receive pain relief until 7.20pm, over one hour later. Our adviser said that although there was a delay here it does not amount to a significant failing in view of Mr A’s low pain score. He had also had previous pain relief administered at home (paracetamol) and in the ambulance (morphine and entonox).
22. The guidelines say that patients should have the effectiveness of pain relief re-evaluated within 60 minutes of the first dose of pain relief. There were two further sets of observations recorded. The observations recorded at 7.43pm do not include a pain assessment. This is not in line with the guidance. However, the observations recorded at 9.45pm document that his pain score was 0. Our adviser said that this provides evidence that the pain relief given earlier had had a beneficial effect.
23. They then transferred Mr A to the Emergency Department Decision Unit (EDDU). At about 10pm they gave him paracetamol. At 10.35pm and 10.45pm they gave Mr A morphine and the records show that this resulted in ‘relief of pain’.
24. In summary we found that pain assessment should have been more frequent with more pain scores recorded. The Trust has acknowledged that the pain score management could have been more timely. It said that it is currently working on a guideline for this in the ED. Nevertheless from what we have seen regular pain relief was administered to Mr A with evidence of improvement of pain.
Whether the Trust monitored Mr A’s blood pressure appropriately
25. When the paramedics initially took Mr A’s blood pressure at 2.31pm in the ambulance it was low. However, his blood pressure was measured twice more in the ambulance and then a further three times in the ED. All of these measurements were normal.
26. The Trust used the national early warning score (NEWS) to guide further measurement of observations. NEWS is a tool developed by the Royal College of Physicians which improves the detection and response to clinical deterioration in adult patients and is a key element of patient safety and improving patient outcomes.
27. Our adviser said that Mr A’s NEWS was 2 at his initial triage assessment. This score requires further observations to be taken every four to six hours as a minimum. Further observations taken at 7.43pm and 9.45pm recorded NEWS scores of 0. These scores require further observations to be done at a minimum of 12 hourly intervals.
28. We found that the Trust carried out observations in line with the national guidance. There is no evidence to suggest that they should have recorded Mr A’s blood pressure more frequently.
Communication with Mrs B when her husband’s condition deteriorated
29. Section 33 of the GMC’s ‘Good Medical Practice’ states that doctors must be ‘considerate to those close to the patient and be sensitive and responsive in giving them information and support.’
30. The clinical records show that Mr A suddenly became extremely unwell at 1.45am on 14 July 2018. Our adviser said that it is likely that this was when the aneurysm burst. In this situation the overwhelming priority is to try and manage the patient’s critical illness.
31. Mrs B’s complaint letter states that the hospital contacted her at about 2.10am. Our adviser said that from the information available the ED staff were busy taking action to try to help Mr A, a rapidly deteriorating patient. This included a transfer to the resuscitation area of the ED. It is also important to note that this occurred in the early hours of the morning when there are fewer staff and resources available.
32. We understand how upsetting it was for Mrs B not to be with her husband when he died. The Trust’s staff contacted Mrs B within half an hour of her husband’s acute deterioration. In the circumstances the Trust informed Mrs B promptly. We have seen nothing to suggest that this contact should have been made earlier.
Local resolution meeting on 4 June 2019
33. Mrs B complains that the local resolution meeting on 4 June 2019 was inadequate. She says that no-one involved in her husband’s care attended.
34. The 2009 NHS Complaint Regulations provide a high-level framework for how NHS organisations are expected to handle complaints. Many NHS organisations have their own local policies for handling complaints but there are no national guidelines for carrying out investigations, including local resolution meetings.
35. The purpose of a local meeting is usually to discuss what the complainant remains unhappy about or to answer any questions. From the information available it appears that the ED doctor involved in Mr A’s care and treatment no longer worked for the Trust. Therefore the Trust arranged for a suitably experienced doctor to attend.
36. The Trust’s staff who attended the local meeting included a Consultant of Emergency Medicine/Deputy Chief of Service for Emergency Medicine and the Matron for the Emergency Department. These were appropriate individuals to explain the treatment provided.
37. The Trust’s representative from the ED appeared to have reviewed the clinical records and provided an explanation of the management of treatment. Although Mrs B may have been disappointed that the doctor involved in her husband’s care was not present, we have seen nothing to suggest that there was anything wrong with the way that the Trust managed the meeting.