Case 29 A cantankerous recluse

Mr Peacock is a 78-year-old reclusive man who has lived alone in a static caravan in rather precarious circumstances for many years. He drinks about 60 units of alcohol a week and is a heavy smoker. He is admitted to hospital somewhat reluctantly after a fall which he thinks occurred when he slipped climbing up the steps to his home. He is unable to mobilize because he feels generally too weak and he is in pain. When he is first assessed he is uncooperative and abusive to staff and refuses to get out of his bed. It is clear that he is unkempt and he has bilateral leg ulcers which have not been dressed adequately for some time but which he denies cause him pain. He has a probable fracture of his right arm and he appears to be in urinary retention.

Are there any particular diagnoses that it would be important to consider?

After reassurance and some tea and food he agrees to be undressed, cleaned up and for some investigations to be done. X-rays show hyper-expanded lung fields, and a fracture of his right humerus. He has a raised white count and CRP and no other significant abnormalities. He agrees to analgesia (paracetamol and codeine), a sling for his arm, and to urinary catheterization. Just over a litre of urine is drained and dip testing shows leucocytes and nitrites so he is also given co-amoxiclav orally for five days.

The Consultant who sees him on the post-take ward round adds in intravenous B vitamins and some regular chlordiazepoxide to cover likely alcohol withdrawal. Mr Peacock remains suspicious of staff and refuses to be examined again and will not get out of bed. Overnight he becomes more aggressive and confused and falls again when he tries to get up. The next morning things have settled, but Mr Peacock remains mildly confused which is put down to his infection and alcohol withdrawal. The GP is contacted in order to get a fuller picture, but it is clear that Mr Peacock has kept away from the practice for some years and has a reputation locally for being eccentric.

Over the weekend Mr Peacock seems to improve and he becomes less suspicious of people trying to help him and he no longer seems confused. The nursing notes record that he is constipated and the cover FY1 is asked to write up a laxative.

Are you content with Mr Peacock’s management to date?

On Monday the hospital is very busy and as a bed has become available in a nurse-led local community hospital, Mr Peacock is moved from the acute ward. A rushed handover note is written by a junior doctor who has not met Mr Peacock before.

A week later the nursing staff in the community hospital ask the GP to visit because they cannot persuade Mr Peacock to get out of bed or cooperate with any rehabilitation. The GP is worried that Mr Peacock cannot raise his legs from the bed, he remains constipated (despite stopping the codeine and having regular laxatives) and now has developed pressure sores on his heels. He is referred back to acute hospital and seen again on-take, 12 days after the initial fall at home. The admitting registrar is concerned that Mr Peacock has spinal cord compression and he arranges an MRI scan which shows severe lumbar spinal stenosis and cauda equina compression from an L4/5 disc protrusion. Surgical decompression is undertaken the next day but Mr Peacock’s recovery is incomplete. Several months later he remains permanently catheterized, and is unable to stand unaided. He develops severe recurrent urinary sepsis with vancomycin resistant enterococci, and his pressure sores are very slow to resolve.

The GP writes a letter to the Chief Executive of the hospital saying he believes that the diagnosis was so delayed that the chances of recovery were compromised. He also complains about the pressure sores, the poor quality of the handover, the rushed circumstances of the transfer to the community hospital and the hospital acquired infection. The hospital responds by designating this as a serious incident requiring investigation (SIRI) and arranges an internal enquiry.

Expert opinion

The overriding sense one gets with the management of Mr Peacock is that no one appears to have taken his symptoms seriously because he was rude and difficult with staff. Attempts to undertake a functional assessment on admission were indeed thwarted by the confusion and lack of engagement but it is clear that no neurological examination was undertaken and inadequate thought given to the possibility that the retention, constipation and reluctance to mobilize might have had a more serious underlying cause. Any delay in resolving cord and cauda equina compression may contribute to suboptimal long-term recovery.

Mr Peacock’s attitude to staff almost certainly made it more difficult to reach a diagnosis and also for nursing staff to undertake simple but essential monitoring of his pressure areas but both the medical and nursing notes fail to document adequate attempts to look beyond his behavioural difficulties and identify the underlying problem.

Legal comment

The GP’s letter of complaint will receive a formal letter of response from the Chief Executive under the Trust’s Complaints Process. Since all aspects of Mr Peacock’s care have also been subject to a SIRI investigation, the formal complaint response letter may enclose a copy of the final SIRI report as this will include a factual chronology of events and confirmation of the Trust’s completed action plan.

The GP would not have any locus standi (i.e. no legal position) to initiate legal action on behalf of the patient against the Trust. Mr Peacock would need to instruct solicitors himself. A motivating factor for civil action would be the ongoing symptoms and care that Mr Peacock requires.

The assessment of liability would focus on the issue of causation. No neurological examination was undertaken and there was therefore a delay to definitive management. Expert evidence will be required to assist in determining whether, on balance of probability, earlier diagnosis might have permitted improved long-term recovery.

Mr Peacock’s inpatient fall should have triggered the Trust’s incident reporting process and retrospective root cause analysis. However, it is well known that only a minority of incidents are reported through formal systems which makes it difficult to know the true incidence of patient harm.

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