Decision Report 201203289

Summary

Mrs C's late husband (Mr C) was admitted to hospital, having been referred there by his GP for rectal bleeding and diarrhoea. His symptoms were attributed to his known history of diverticulitis (a common disease of the digestive system), but he was also found to have an abdominal aortic aneurysm (ballooning of part of the aorta, the body's largest artery). His symptoms settled and he was discharged after three days. However, a CT scan (a special scan using a computer to produce an image of the body) carried out during his admission showed that his aneurysm required urgent treatment and he was readmitted within two weeks for surgery, in which a graft was used to repair the aneurysm.

Mr C recovered well and was discharged six days later with arrangements for him to be reviewed in another six weeks. Around five weeks after his surgery, however, Mr C began coughing up blood. He attended the accident and emergency department, and was readmitted to hospital. Tests were carried out to check for a blood clot in his lungs or a chest infection, and he was treated for a presumed chest infection. Mr C's kidney function was also impaired and he became septic (with infection in the bloodstream), but the cause of the sepsis was unclear. He was referred for review by a surgeon who arranged another CT scan. This showed evidence of air pockets around the graft that had been used during his aneurysm repair. Mr C was treated with antibiotics, then had further surgery to remove and replace his infected graft. After the operation,

Mr C was taken to the intensive care unit (ICU) and high dependency unit (HDU), but was transferred back to the main ward three days after his operation. He developed oedema (swelling) and kidney failure. He was transferred back to the ICU, but suffered two heart attacks and died three weeks after the surgery.

Mrs C complained that the board discharged Mr C too soon after his initial operation. She also felt they failed to identify the source of his infection, despite his recent operation wound being a likely site and that the vascular surgeon who carried out his operation was not informed of his re-admission soon enough. Mrs C also complained that Mr C was transferred out of the ICU/HDU too soon.

After taking independent advice from our medical advisers, we upheld Mrs C's complaints about her husband's first discharge from hospital, and the move out of ICU/HDU, but not her other complaints. We found that the board failed to follow their own discharge planning policy properly and, although there was no clear evidence to suggest that Mr C was not fit for discharge after the first operation, a lack of records meant we were unable to be certain of this. We noted that the board took appropriate action when Mr C developed a rash over his entire body, but we criticised the decision to transfer him back to the main ward after his last operation. Our adviser said that his fluid balance was poorly managed and that staff on the main ward would not have been qualified to provide the close monitoring and treatment that he required. We were, however, satisfied that the board took reasonable steps to identify the source of Mr C's infection. As he initially presented with respiratory symptoms, there was no cause to involve the vascular surgeon or to investigate his operation site as the source of infection. However, as potential sources were ruled out, the vascular surgeon was contacted for his view.

Recommendations

We recommended that the board:

• audit their performance in relation to their discharge from acute care policy with particular emphasis on record-keeping and ensuring patients are reviewed daily;
• apologise to Mr C's family for the additional discomfort caused by his premature discharge to the main ward; and
• arrange for their ICU and HDU staff to review Mr C's case with specific reference to fluid balance management to identify any points of learning.