Manchester University NHS Foundation Trust

6. Ms A complains on behalf of her deceased brother, Mr B, about Manchester University NHS Foundation Trust.

7. Mr B was admitted to hospital on 12 August 2018. Ms A says Mr B had a cardiac arrest on 18 August 2018, however the family were not made aware of this. When the family were waiting in a corridor for visiting time to start, they were told there had been an incident on the ward but were not advised this involved Mr B.

8. Ms A says that a doctor wrongly inserted an NG tube and instructed a nurse to inject 40mls of fluid and medication into his lung. Mr B deteriorated and died on 22 August, a few days later. Ms A says the family were offered no support and following his death, when the family were leaving hospital they were asked if tissue could be taken.

9. Ms A says the events led to Mr B’s death and the family felt distressed and upset. She says the lack of information and poor communication added to this and left the family feeling uncertain. Ms A says the family were not supported and they felt actions were inconsiderate, the family should not have been asked about tissue being taken in a corridor when they were leaving the hospital.

10. Ms A says the first time the family found out about the cardiac arrest was following the Trust’s report twelve weeks after the event, she felt let down by the Trust that she had not been informed of this vital information.

11. Ms A seeks an apology for the impact and service improvements.

12. What follows is a summary of events obtained from the complainant, the Trust and the medical records provided by the Trust. We have not included all of the details as those involved are already aware of the information. However we have included this background to put the complaint in context. The timeline of the period of care provided is as follows:

13. Mr B was admitted to the Manchester Royal Infirmary on 12 August 2018 with breathing difficulties.

14. The cardiology team assessed Mr B and identified serious heart failure secondary to previous undiagnosed heart valve stenosis and acute heart attack. They also identified evidence of pneumonia, and he was given treatment for this.

15. Mr B was supported by way of ventilation and whilst in the acute cardiac ward 40mls of medication was installed into his airways on 16 August 2018. This was following a misplaced NG tube on 15 August 2018.

16. Following its consideration of our provisional report, the Trust sent a letter dated 8 June 2021 with its comments. The Trust said that on 15 August 2018 the correct process was used for the identification of the NG tube position. A portable chest x-ray was used but the position was misinterpreted and the NG tube was thought to be correctly placed in the stomach when in fact it was in the airway. The doctor felt that the tube required further advancement. After further adjustment of the tube, the doctor incorrectly checked the NG tube was located in the stomach by performing the prohibited whoosh test.

17. The inquest on 9 August 2019 said the NG tube was not identified either through the application of the correct method to check its insertion or through review and appraisal of an x-ray.

18. The medication installed was Ticagrelor, a mediation used for the prevention of stroke, heart attack and other events in people with acute coronary syndrome.

19. Mr B deteriorated and suffered several cardiac arrests on 18 August 2018. He died on 22 August 2018. The inquest on 9 August 2019 said that his death resulted from heart failure caused by a combination of his serious identified heart conditions and the impact of the effects of the misplaced medication into his airways.

20. Ms A says that she did not received the outcome of her complaint until the day before the inquest.

Informing the family of Mr B’s cardiac arrest

24. Ms A says that her brother had a cardiac arrest on 18 August 2018 and the family were not informed of this. She said they found out twelve weeks later, when the information was included in the Trust’s investigation report.

25. NICE provide guidance, advice and information services for health, public health and social care professionals. The General Medical Council (GMC) is the public body that maintains the official register of medical practitioners. They also provide standards for decision making in a wide range of situations. The Nursing and Midwifery Council (NMC) is the regulator for nursing and midwifery professionals in the UK. They also provide standards of practice and behaviour for nurses, midwives and nursing associates.

26. There is guidance from The National Institute for Health and Care Excellence (NICE) and medical professional regulators about keeping families informed when a patient lacks mental capacity.

27. NICE guidance CG138 (Patient experience in adult NHS services: improving the experience of care for people using adult NHS services section 1.3.11) says that if the patient cannot indicate their agreement to share information, ensure that family members and/or carers are kept involved and appropriately informed, but be mindful of any potentially sensitive issues and the duty of confidentiality.

28. GMC Good Medical Practice, Paragraph 38 says if a patient lacks capacity to make the decision, it is reasonable to assume the patient would want those closest to them to be kept informed of their general condition and prognosis, unless they indicate (or have previously indicated) otherwise.

29. The NMC Code, Section 5.5 says share with people, their families and their carers, as far as the law allows, the information they want or need to know about their health, care and ongoing treatment sensitively and in a way they can understand.

30. From review of the medical records they confirm that Mr B did have a cardiac arrest on 18 August 2018 and there is no record of the family being informed of the cardiac arrest. The medical record on this date only says that an update was provided about his condition.

31. The Trust sent a letter to the complainant on 25 June 2019, the Trust said that they should have informed the family. The letter included the paragraph ‘Dr B confirmed that you should have been told and apologised that you were not. He explained there may often be delays but we always aim to inform relatives of such important events’.

32. Following its consideration of our provisional report, the Trust sent a letter dated 8 June 2021 with its comments. The Trust said that Mr B’s son and grandson were informed of the cardiac arrest within three hours of the events occurring. The Trust said that this was recorded within the medical records, although the cardiac arrest is not mentioned specifically. The medical records said that the family have been updated about his clinical condition. The Trust said in their letter, that they are unable to verify exactly what was communicated to the son and grandson.

33. In their letter the Trust accept that the way this was communicated with the family could have been clearer. They acknowledge that the documentation of the communication, specifically in relation to the cardiac arrest was not good enough which has left the family doubting that they were informed.

34. The Trust also said that prior to the incident the critical care team had been able to communicate well with Ms A and the family, which the family confirmed in a meeting held on 18 June 2019. They acknowledge that the communication following the NG tube incident was poor and fell below the usual standards.

35. In accordance with guidance set out by NICE and standards set out by professional regulators, the family should have been informed about Mr B’s cardiac arrest. The Trust said that they did inform the son and grandson but they have no evidence of exactly what was communicated to them. The medical records do not assist in verifying this information, only that an update about the medical condition was provided. Ms A maintains that the family were not informed.

36. In their letter dated 8 June 2021 to us, the Trust acknowledge that Ms A was not personally informed and the way the information was presented to the son and grandson should have been better as they have no detailed records about this communication. Therefore, the quality of the conversation fell below the Trust’s usual standards and contributed to the family saying they were not informed. We have decided that the communication of the information relating to Mr B’s cardiac arrest on 18 August 2018 was not to the standards expected and this amounts to a failing.

NG tube wrongly inserted

37. Ms A said that on 15 August 2018 a doctor wrongly inserted an NG tube and 40mls of fluid and medication entered Mr B ’ lungs on 16 August 2018.

38. Our adviser explained that the Trust should have used either pH testing of the aspirate or an x-ray if the first method was not successful. This would have indicated whether the NG tube was placed correctly or not. The guidance for placing and checking the position of an NG tube is contained in the NICE Enteral Feeding tube pathway. The pathway states:

39. The position of all nasogastric tubes should be confirmed after placement and before each use by aspiration and pH graded paper (with x-ray if necessary) as per the advice from the National Patient Safety Agency (NPSA, 2011; further patient safety alerts for nasogastric tubes have also been issued in 2013 and 2016. The medical records say that on 15 August 2018 the doctor used a stethoscope to check the tube position after a readjustment. The correct process was used for the first identification of the NG tube position. A portable chest x-ray was used but the position was misinterpreted and the NG tube was thought to be correctly placed in the stomach when in fact it was in the airway. The doctor felt that the tube required further advancement. After further adjustment of the tube, the doctor then incorrectly checked the NG tube’s location by performing the whoosh test.

40. The Trust prepared a ‘never event’ report on 23 August 2018 and the summary said that the doctor used the ‘whoosh’ test. Our adviser explained that this is where air is blown into the NG tube and the doctor listens for the sound of air bubbles in the stomach with a stethoscope.

41. The NHS improvement resource set, initial placement checks for nasogastric and orogastric tubes, July 2016 was produced to support the 2016 NPSA safety alert and this states in table 1 that clinicians must not use the whoosh test or bubble test.

42. Our adviser explained that in accordance with NICE guidance, an x-ray should have been performed to confirm the correct positioning of the tube if aspiration of gastric fluids could not be confirmed by pH testing.

43. An inquest on 9 August 2019 said:

44. ‘Mr B died from heart failure as a consequence of the combination of serious heart conditions and the instalment of medication into his airways via a misplaced nasogastric tube. The latter resulted from an absence of knowledge as to the correct procedure to be used to check the position of the tube and an incorrect interpretation of radiological input that was requested. Those matters collectively amounted to a gross failure and such that Mr B’s death was contributed to by neglect.’

45. The Trust should have used either aspiration and pH testing or an x-ray to confirm the position of the NG tube following adjustment. This is in line with NICE guidance and NPSA. The Trust wrongly used the “whoosh” test. The Trust said that pH testing was unavailable. We have decided that the incorrect method was used to check for the correct adjustment of the NG tube on 15 August 2018. An x-ray had previously been used and could have been used again to check the tube following its adjustment.

46. The method used to check for the correct position was explicitly not to be used in line with multiple guidelines for the placement of NG tubes. This resulted in 40mls of fluid and medication entering the lungs. We have decided that this action fell so far below guidance and standards that this was a failing. The impact of this will be considered further on within this report.

Communication and lack of support offered to the family following Mr B’s death

47. Ms A says the family were offered no support following the death of her brother on 22 August 2018. She says there was poor communication. Ms A says that the family were asked about tissue donation in a corridor when they were leaving the hospital.

48. NHS England have produced guidance for the national quality board “Learning from deaths” published in July 2018. This says:

49. ‘Families should be offered access to bereavement services. These should include practical advice and support on: collecting death certificates, how to register a death, collecting personal belongings and where to find local bereavement support or counselling’.

50. The GMC guidance on managing and protecting personal information says:

51. ‘You should not share personal information about patients where you can be overheard’.

52. The NMC code section 5.5 says:

53. ‘share with people, their families and their carers, as far as the law allows, the information they want or need to know about their health, care and ongoing treatment sensitively and in a way they can understand’.

54. The Trust sent a letter to the complainant on 25 June 2019, where it said that the communication which the family experienced was not as good as it should have been. The Trust said it had not been able to identify the staff member who raised tissue donation with the family but they apologised for what had happened. They said a lot of work had been completed on the ward to improve communication with families. The Trust were unable to provide any further information about the discussion that took place and the medical records do not indicate where this discussion took place.

55. Our adviser explained that a discussion about tissue donation is a sensitive, confidential subject and therefore not suitable for a corridor conversation. Although the Trust have not been able to provide any additional information regarding this, they accept that it should not have happened.

56. From review of the medical records there are no entries relating to local bereavement support being offered following Mr B’s death 22 August 2018. The Trust accept that communication could have been better and they have apologised about the discussion about tissue donation taking place on a corridor.

57. We have decided that the family were not provided with any bereavement support following Mr B’s death. It is also our view that a discussion surrounding tissue donation should have taken place in a private location, in line with guidance provided by the medical professional regulators. We have decided that both of these communication issues amount to a failing.

Impact:

58. Ms A says the events led to Mr B’s death on 22 August 2018 and the family felt distressed and upset. She says the lack of information and poor communication added to this and left the family feeling uncertain. Ms A says the family were not supported and they felt actions were inconsiderate, the family should not have been asked about tissue being taken in a corridor when they were leaving the hospital.

59. Ms A says the first time the family found out about the cardiac arrest was following the Trusts report, she felt let down by the Trust that she had not been informed of this vital information.

60. Ms A says the events led to Mr B’s death and the family felt distressed and upset.

61. Ms A seeks answers to questions, an apology for the impact and service improvements.

62. Our adviser explained that Mr B was very ill and there were a number of contributing factors to his death. The record of inquest dated 9 August 2019 also noted that there was more than one factor contributing to Mr B’s death. The medical cause of death was: 1a Acute heart failure b Senile calcific stenosis of the aortic valve with recent valvuloplasty together with coronary artery atheroma with critical stenosis and diffuse alveolar damage to the lungs associated with the installation of medication to the airways via a misplaced nasogastric tube

63. The inquest on 9 August 2019 said:

64. ‘Mr B died from heart failure as a consequence of the combination of serious heart conditions and the instalment of medication into his airways via a misplaced nasogastric tube. The latter resulted from an absence of knowledge as to the correct procedure to be used to check the position of the tube and an incorrect interpretation of radiological input that was requested.’

65. The inquest determined that it was a combination of his serious heart conditions with the impact of the misplaced medication that resulted in death. Following its consideration of our provisional report, the Trust sent a letter dated 8 June 2021 with its comments. The Trust said that there were differences in the Trust’s investigation findings and the coroner’s conclusion relating to the significance placed on the NG tube. The Trust’s finding was that the instillation of medication into the lungs had a minor or insignificant effect on the outcome. It was the coroners view that it was one of several significant factors that caused the death.

66. The coroner accepted that the cause of death provided in the post-mortem report did not fit with the clinical picture, but based its conclusions on the fact that the pathologist saw an effect on the right ventricle at post-mortem and therefore concluded that medication into the lungs did have an effect on the heart sufficient to contribute directly to the heart failure that led to death.

67. Our adviser explained that if the NG tube had not been misplaced, this combination of factors would not have occurred. Without this combination of factors, on the balance of probabilities, the chain of events leading to death would not have occurred. How long Mr B may have lived without the tube misplacement would have been dependent on the prognosis of his heart disease. The medical records show that the cardiology consultant assessment on 21 August 2018 said that Mr B had heart failure secondary to previous undiagnosed heart valve stenosis and acute heart attack.

68. The Trust sent a letter to the complainant dated 25 June 2019. The Trust said Mr B came into hospital with pneumonia and acute heart failure causing the lungs to be flooded with fluid, as well as having a heart attack. At the time of his death his oxygen and ventilatory requirements were not excessive and remained stable for the day prior to his death. The Trust said that Mr B’s response over the following days after the event was not huge but certainly would have had a negative effect on both his heart and lungs. Mr B had a number of episodes of abnormal heart rhythm which resulted in a cardiac arrest on 22 August 2018.

69. Following its consideration of our provisional report, the Trust sent a letter dated 8 June 2021 with its comments. The Trust said Mr B was in an advanced and critical condition prior to the instillation of medication into the lungs.

70. It was recognised that from admission by the medical team that survival to hospital discharge from cardiogenic shock with critical aortic stenosis, severe proximal coronary disease, an acute heart attack and pneumonia was highly unlikely. Mr B suffered repeated cardiac rhythm abnormalities which evolved rapidly into a cardiac arrest, as would be expected in the context of severe valvular heart disease. These events were contemporaneous with a period of static and stable mechanical ventilation of the lungs and the accidental instillation of medication into the airways was not followed by an increase in oxygen or ventilation requirements in the following hours. These parameters remained relatively static other than a temporary increase in requirements two days later.

71. We are unable to say that the events were the sole cause of Mr B’s death. We have decided that the misplaced NG tube did contribute to his death on 22 August 2018. While we do not underestimate the impact of the misplaced NG tube, the evidence from the medical records and the inquest report show that Mr B had suffered from a heart condition which resulted in a heart attack. This is why we cannot reach a view that the misplaced NG tube was the sole cause of death.

72. This event left the family feeling distressed and upset. The further lack of communication and support added to this and left the family feeling uncertain, causing further distress. The family felt let down by the Trust.

73. We recognise that this time was a very traumatic for Ms A and her family. We also recognise that finding out about a further cardiac arrest, which was previously not communicated at the time to Ms A, would cause her to relive the trauma and distress of Mr B’s death, and further undermine her trust and confidence in the Trust. The Trust accept that the way this was communicated with the family could have been clearer. They acknowledge that the documentation of the communication, specifically in relation to the cardiac arrest was not good enough which has left the family doubting that they were informed. The Trust acknowledge that Ms A was not personally informed and the way the information was presented to the son and grandson should have been better as they have no detailed records about this communication. Therefore, they must assume the quality of the conversation fell below their usual standards and contributed to the family saying they were not informed.

74. We understand that this was already a difficult time for Ms A and her family as they were grieving and the Trust should have provided support during this upsetting time. In a letter dated 8 June 2021, the Trust said that they recognise the anxiety and distress caused to Ms A and her family.

75. In her complaint to us, Ms A says she seeks an apology for the impact and service improvements.

76. When considering the injustice, we have considered what actions the Trust has taken to put this right. The Trust sent a letter dated 25 June 2019 to the complainant. The Trust have made an apology for the events. The Trust explained that all doctors, consultants, and nurses underwent retraining following event. The doctor involved had been working in the country for three months. The Trust said that robust training and competency check for evaluation of NG tube position did not exist for new doctors coming into the unit. The doctor stopped working after the event and did not return to the Trust.

77. We have considered the actions taken by the Trust further below when setting out our recommendations.

1. We have decided that the Trust misplaced a nasogastric (NG) tube on 15 August 2018. Information relating to Mr B’s cardiac arrest on 18 August 2018 was not communicated to the family to the standards expected. Following Mr B’s death on 22 August 2018 the Trust did not support the family and discussed private information about tissue donation in a public corridor.

2. We find, on the balance of probabilities, the misplaced NG tube contributed to Mr B’s death. Medication was installed into the lung on 16 August 2018. The events led to Ms A and her family feeling distressed and upset. We recognise that this was a traumatic time for Ms A and her family.

3. We have decided to uphold this complaint. We explain the full reasons for this in this report.

4. We have made recommendations for an apology to acknowledge the impact and the service improvements the Trust have already made to be shared with the Care Quality Commission (CQC), NHS Improvement and the complainant.

Our role

5. Our role is to decide on unresolved complaints about the NHS in England. We do this by looking to see whether there has been a service failure and whether this has caused injustice or hardship. If we decide the organisation got things wrong, we may recommend ways for it to put them right, if it has not done so already.

78. In considering our recommendations, we have referred to our Principles for Remedy. These state that where poor service or maladministration has led to injustice or hardship, the organisation responsible should take steps to put things right.

79. Within our provisional report we said that the Trust should send a written apology to Ms A to acknowledge the impact of the failings we identified in this report. Following its consideration of our provisional report, the Trust sent a letter dated 8 June 2021 with its comments. The Trust said the critical care team met with the family on 18 June 2019 and apologised in person for the distress and anxiety the events caused. They acknowledge this should have occurred earlier. The Trust said they would like to offer a sincere apology to the family for the distress and suffering caused. We therefore recommend that within one month of the date of the final report, the Trust should send a written apology to Ms A to acknowledge the impact of the failings identified in this report. A copy of this should be sent to PHSO.

80. Our Principles say that public organisations should seek continuous improvement and should use the lessons learnt from complaints to ensure they do not repeat maladministration or poor service. Within our provisional report we recommended that within three months from the date of the final report, the Trust should prepare a detailed plan of action. This should include consideration of the failings identified within this report and the following: • Ensure all medical staff are trained and up to date with the guidance relating to NG tubes, specifically NICE Enteral Feeding tube pathway.

• Ensure that an appropriate process is in place for any new medical staff to be trained and up to date with the guidance relating to NG tubes, specifically NICE Enteral Feeding tube pathway. This should include the consideration of a competency check.

• Ensure that all policies relating to general communication with patients and family members are up to date.

• Ensure that all policies relating to bereavement support with family members are up to date.

• Consideration of any ongoing training needs.

81. Following its consideration of our provisional report, the Trust sent a letter dated 8 June 2021 with its comments. The Trust confirmed the following information: • Immediate training of all critical care staff who insert NG tubes and correctly identify the tube position has been put in place across all sites in Manchester. This training continues today as staff change and rotate through the units.

• A package for training and assessment of competency to correctly verify the position of NG tubes is used on induction days for all new starter medical staff and a Trust wide new NG tube confirmation form with a detailed protocol has been implemented.

• A process for all consultant staff to complete a training package and competency assessment has been implemented since 28 September 2018.

• A series of meetings with senior nursing teams and practice education teams from all of the critical care units were arranged. At the first meeting on 23 August 2018 a process was agreed for all critical care nursing staff to undertake a training update in relation to NG tube placement confirmation this included individual competency assessment. Meetings were held every two weeks to monitor progress. Weekly audits were also instigated and reviewed.

• NG tube competencies are now completed on nurse induction and annually thereafter. The education teams across each unit currently have action plans in place to capture staff who are overdue annual training updates due to time limitations as a result of the Covid pandemic. All new staff who started in post during the pandemic have completed the competency assessment during the induction process.

• From 2018, weekly audits of NG tube documentation took place and once assurance was provided that compliance was high, these stepped down to monthly audits and are ongoing. During the Covid pandemic a decision was made to reduce the frequency of audits however these have now been re-established as part of the monthly audit programme. The audits look at documentation and also staff awareness, these are undertaken by the senior sisters and practice-based educators for the area.

• A new matron was appointed in 2019 who has worked closely with the nursing team to ensure standards of communication are improved. The electronic patient record in use now incorporates a specific section for documenting details regarding communication with families. This documentation includes identifying who was present and ensures that the details of the information provided are recorded.

• One to one meetings and appraisals have been utilised to ensure the senior nursing teams understand their responsibilities in relation to open and transparent communication with both patients and families. An away day was also held for the band 7 nursing team to discuss the concerns raised by the complaint and how the lack of transparency and poor communication had made the family feel.

• Policies, guidance, and standard operating procedures are currently in development within the Trust bereavement team but they were delayed due to service pressures during the recent Covid pandemic. A review of the bereavement service to release time to care is underway to provide additional bereavement support for staff training and to support families in the future. Staff on CICU have been supported to improve their communication relating to end of life care and were made aware of the inappropriateness of discussing sensitive information in a public area. Training has taken place to incorporate end of life care, awareness of the role of the bereavement service and also bereavement communication skills. These sessions are supported by the specialist organ donation nurses and are incorporated as part of the induction programme for new starters.

• MFT Human Factors Academy (HFA) led at the Trust group level was set up in 2021 to focus on a number of areas. This includes maximising learning, system thinking and reliability, look at patient safety through a different lens, support the assessment of engineered safety solutions, influence policy and support service transformation and quality improvement. A Trust wide programme to review NG tube management and safe insertion is one of the areas being explored. This extensive programme of work commenced in 2021, will inform any future leaning relating to safe insertion of NG tubes. The Governance team are working with other hospitals within Manchester to learn more rapidly from when things go wrong and also how they can share learning when thing go right. This includes hearing outcomes from complaints, incident investigation’s and claims made against the Trust. This programme is supporting the identification of themes as they move towards Patient Safety Incident Respond Framework in 2022.

82. We are satisfied that this provides compliance with service improvements as set out within our provisional report. Evidence of these service improvements should also be shared with the Care Quality Commission (CQC), NHS Improvement and the complainant within two months of the date of our final report.

83. This concludes our final report.