Trust’s consideration of Ms A’s disability when providing treatment
19. We have seen no evidence of a failing in how the Trust considered Ms A’s needs. We have seen the Trust acted in line with NMC guidance when assessing her care needs and followed the care plans which were created.
20. The relevant standards for assessing the care needs of patients is the NMC Code which sets out the professional standards for nursing staff. This highlights the fundamentals of care as including, but not limited to, nutrition, hydration, bladder and bowel care, physical handling and keeping the patient in a clean and hygienic condition.
21. It was seen that the Trust documented that Ms A had a genetic disorder on admission. Our nursing adviser described though a person with this particular genetic disorder has profound physical needs, the care provided should not focus on the patient’s diagnosis but instead the individual’s needs and care preferences. In line with the NMC Code, the Trust should assess the patient’s care needs in the above areas on admission.
22. We have seen that an assessment of Ms A’s care needs did take place on her admission on 20 December. This identified that she had significant care needs including not being independent in her mobility, being at risk of pressure sore development, being doubly incontinent and that she would require full assistance with personal and oral hygiene. A skin assessment identified that she had ‘red blanching’ on parts of her body which can be a pre-cursor to a level one pressure sore. For nutrition Ms A was referred to the Trust’s dietetics department. She was seen by the dietetic team the following day which agreed a feeding regime using her PEG tube.
23. From these records we have seen that Ms A’s fundamental aspects of care were assessed, and her care needs clearly documented in line with the NMC Code. Our nursing adviser confirmed that from the medical records Ms A’s care plans were followed by the Trust. This included daily provision of hygiene, regular positional changes and regular continence care. It was also seen that the pressure areas identified in the initial skin assessment remained intact throughout Ms A’s admission.
24. Mrs L’s described that she struggled to find nurses at the Trust to assist her and Ms A’s carer with repositioning her and changing her incontinence pads and that there were delays in doing this as a result. Though we do not dispute Mrs L’s account of events and recognise her concerns that the Trust did not account for her sister’s disability, we are required to take an independent view. Our decision, from the evidence we have seen, is that the Trust appropriately assessed Ms A’s care needs on admission and the care plans created from this were followed by the Trust’s staff.
Provision of medication and pain relief
25. We have seen that though there were occasions where the Trust failed to provide medication or pain relief, the Trust has already acknowledged and appropriately remedied these. Our decision is that the delays in medication did not have a significant effect on Ms A’s medical outcome.
26. From what we have seen there was no evidence of missed doses of antibiotics beyond the one missed dose of Clarithromycin on 25 December and two missed doses of Metronidazole on 26 December, which the Trust accepted in its response to the complaint. From this we have considered if Ms A should have been provided with these antibiotics via her PEG feed sooner and the potential impact of these missed doses.
27. Our physician adviser stated that BMJ best practice guidelines describe that the choice of intravenous or oral therapy must be made on a case-by-case basis depending on the patient’s condition and ability to tolerate oral therapy. Given that Ms A was having problems with vomiting early in her admission, oral antibiotics may have been less effective if there was a risk of Ms A regurgitating these. As such we consider that intravenous antibiotics were the most appropriate at the early part of Ms A’s admission.
28. With regard to the Trust’s decision to trial administering Clarithromycin but not Metronidazole by Ms A’s PEG feed on 24 December, our physician adviser described that Clarithromycin is known to commonly cause side effects of pain and inflammation at the injection site when given intravenously.
29. As it is recorded that Ms A was experiencing agitation when receiving Clarithromycin intravenously, it was appropriate for the Trust to change how this medication was administered if it considered the known side effects were causing this agitation. Metronidazole is not known to have the same side effects and, as it is recorded that Ms A still had intermittent problems with vomiting, we consider it was appropriate for the Trust to continue to administer this intravenously.
30. With the missed doses of Metronidazole on 26 December we have not seen any evidence that the Trust attempted to site the cannula in an unsuitable location. As it was appropriate for Ms A to receive this antibiotic intravenously rather than by PEG feed at this time our decision is that, though there were missed doses, these were not due to a failing by the Trust.
31. The Trust accepted that the missed dose of Clarithromycin on 25 December that had been omitted was due to a mistake by its ward staff in overlooking that this should have been administered via PEG. Our decision is that this missed dose was a failing by the Trust when compared to the NMC code.
32. In terms of the potential impact of the missed dose, our physician adviser described that the standard for treating community acquired pneumonia is NICE guideline NG138. This describes that antibiotics should usually be given for five days, after which antibiotic treatment would usually stop.
33. Our adviser described that the effectiveness of an antibiotic course is likely to be in the first few days of treatment as the medication stabilises in the body. We have seen that Ms A had already received antibiotic treatment for five days from her admission on 20 December. We can see that the administration of Clarithromycin intravenously on 25 December would have caused Ms A some unnecessary pain and agitation. However, our decision is that, on the balance of probabilities, the impact of the missed dose did not have a significant effect on Ms A’s medical outcome as Ms A had already received five days of antibiotic treatment before this happened.
34. We can see that the Trust has apologised that the instruction regarding administering the Clarithromycin by PEG was missed and that this was discussed in a ward meeting and with the staff members involved to take learning. Considered against our Principles for Remedy we consider that the action taken by the Trust to put this right was reasonable and proportionate as it was a one-off incident, not a wider systemic matter and of short duration which did not have an ongoing impact. In consideration of the Trust’s actions in response to this, we are satisfied there are no further recommendations to make.
35. In terms of providing pain relief, the Trust accepted in its response that one dose of paracetamol was given late on 22 December, which meant the next dose had to be missed to maintain a four-hour gap between doses. We saw from the records there were two occasions on 25 December where paracetamol was not given, however it was recorded that this was not given because Ms A’s medication had been stopped pending a doctor’s review.
36. From the evidence we have seen when the Trust or Ms A’s carers identified that she was in pain, appropriate action and medication was provided to address this. The only identified instance where Ms A was left in uncontrolled pain was on 22 December. This occurred when the Trust planned to administer Oramorph as pain relief, but Ms A’s family refused for this to be given as she had experienced problems with aspiration and vomiting with this medication previously. We saw that the nursing staff escalated this concern to a doctor, which our nursing adviser described was in line with what would be expected in the NMC code.
37. From the evidence we have seen, the only failing we have identified in administering Ms A with pain relief was the missed dose of paracetamol on 22 December. The Trust was not able to explain why the delay happened but apologised for this and stated that its pharmacy team would review the incident to improve standards. Considering this with our Principles for Remedy, our decision is that the Trust’s action is proportionate to put this right. Therefore, we are satisfied there are no further recommendations to make.
Trust’s management of Ms A’s nutrition
38. Our decision is that Ms A’s nutrition was appropriately managed by the Trust in line with the relevant clinical standards and that the Trust followed the feeding regime set out by its dietetic department.
39. Our physician adviser described that the standard approach for aspiration pneumonia, as set out in BMJ best practice, is to try and stop further material entering the lungs to allow any debris to be cleared and any inflammation to reduce. BMJ best practice also advises that if a patient aspirates due to an intolerance for nasogastric/PEG feeding, then tube feeding should be discontinued. Our decision is that the Trust’s decision to temporarily pause Ms A’s PEG feeding between 20 - 23 December was in line with this guidance.
40. We have seen that the dietetic plan set out by the Trust was for Ms A to receive PEG feeds three times a day with fluids between feeds and medication. It was documented that the feed should be stopped if there is any vomiting and that the patient should be at a 45 degree angle during feeds to reduce the risk of aspiration. It is also recorded that the feeds should be administered over a 20 minute period and the rate of feed should only be increased if the patient is tolerating the current rate.
41. Ms A was nil-by-mouth from 20 to 23 December. It is recorded that Ms A vomited during her first feed on 24 December and she was placed as nil-by-mouth again. She was given two feeds on 25 December with the morning feed omitted. From the evidence we have seen there was a clear rationale why the feed on 25 December was not given as it is documented there were concerns about Ms A vomiting further on the evening of 24 December and that she had loose stools. Ms A is documented as receiving three feeds a day each day of her admission after 25 December. Ms A was prescribed intravenous fluids for hydration whilst she was nil-by-mouth in line with the NMC’s Standards for medicines management, our nursing adviser has confirmed this was the relevant clinical standard at the time of Ms A’s admission.
42. It is documented in her records that Ms A was upright whilst the feeds were given, in line with the dietetic plan. It is not specified in the records how long it took to administer the feeds. Our decision though, on the balance of probabilities, is that there is no evidence of a failing by the Trust, it is clear that the Trust’s dietetic team recognised the risk of Ms A aspirating when it recommended the feeds take place over a 20 minute period.
43. Ms A is only recorded as vomiting once as a result of the feed being administered, during the initial feed on 24 December and the Trust stopped the feed in line with the feeding plan. There is no evidence that there were any concerns about the possibility of aspiration in later feeds, suggesting that Ms A was able to tolerate the rate at which these were administered. We recognise Mrs L may have a different view of events, but we do not consider that there is further evidence we could obtain about the rate of feeding which would enable us to take an independent view of this complaint.
Insertion of cannulae into Ms A
44. Our decision is that is no evidence of failings by the Trust in how it cannulated Ms A during her admission.
45. From the records provided we have seen that Ms A had four cannulae throughout her admission. A cannula was placed in her right thumb on her admission on 20 December, though this was repositioned to her left leg on 22 December due to concerns around blistering at the original site. The cannula was replaced on 25 December and repositioned the following day in her left shoulder. Finally, the cannula was replaced and repositioned to Ms A’s right thumb from 30 December until the end of her admission.
46. Our nursing adviser described that when intravenous access is needed the most appropriate site should be selected, avoiding areas which would be inconvenient for the patient (e.g. the inner elbow where the patient would be unable to bend their arm). Where venous flow is poor the Trust would have to prioritise a suitable vein, which could take fluids and medication, over one which the patient or their carer would find most convenient, to minimise the risk that fluids and medication are not received.
47. All four cannulae were suitable for receiving fluid and medication. We can see that the Trust had difficultly placing a working cannula on 26 December, but we have not seen any evidence that this was due to a failing by the Trust. The decision to reposition the cannulae was in line with the Trust’s policy of removing and replacing cannulae three days after insertion and, as described earlier, we consider that was appropriate for Ms A to receive antibiotics intravenously at the start of her admission. As such our decision is that the Trust’s actions in inserting cannulae into Ms A were appropriate.
Moving/repositioning of Ms A
48. Our decision is that the Trust’s actions to reposition Ms A were in line with the relevant clinical standards and appropriately took account of her injury when doing so.
49. Our nursing adviser confirmed that the relevant clinical guidance around repositioning patients to prevent pressure ulcers is NICE guideline CG179. This described that patients assessed as being high risk of developing a pressure ulcer should be repositioned at least once every four hours.
50. Ms A was assessed as being at ‘very high risk’ of pressure damage on her admission. We have seen from the Trust’s intentional care records that Ms A was repositioned around every two to three hours. As such we have found that the Trust acted in line with the relevant NICE guideline.
51. It was documented in Ms A’s nursing records that she cannot be on her left side due to a broken arm. From the intentional care documentation, it is recorded on occasion that Ms A was changed to a left-hand side position. However, this is accompanied each time by a ‘K8’ code which signifies that the patient is ‘rolled or stood to relieve pressure but can only return to the previous position’. Our nursing adviser confirmed that from the records Ms A’s pressure area remained intact throughout her admission. Consequently, our decision is that the Trust took account of Ms A’s injury when repositioning her and the limitations on how she could be moved did not cause her to develop any pressure damage.
Request for an air mattress
52. Our decision is that there was not a failing by the Trust in not providing Ms A with an air mattress and its actions were in line with the relevant clinical standard.
53. Our nursing adviser confirmed that the relevant clinical standard for whether a patient requires an air mattress is NICE guideline CG179. This states that for adults who are assessed at being at high risk of developing a pressure ulcer, a high-specification foam mattress should be used. The NICE guideline only states that an air mattress (referred to as a ‘dynamic support surface’ within the guideline) should be considered where the patient has an existing pressure ulcer and where a high-specification foam mattress is not sufficient to redistribute pressure.
54. As described earlier we have seen that Ms A’s pressure areas remained intact during her admission and she did not develop a pressure ulcer. Consequently, there was no requirement for the Trust to provide Ms A with an air mattress in line with the NICE guideline. We recognise from Mrs L’s account that her sister may have ordinarily used an air mattress at the care home to prevent pressure sores. However, as the Trust acted in line with the relevant clinical guidance, we do not consider that this was required for her admission.
Communication with Ms A’s family
55. Our decision is that the Trust’s communication with Ms A’s family about her condition was in line with the professional standards the Trust’s staff were expected to follow.
56. For the nursing staff, the NMC code sets out professional standards for communication with patients and their families. We saw from the nursing records that it is documented that there were frequent discussions with Ms A’s family about the ongoing plan of care and specific concerns to manage Ms A’s nursing needs. As such we consider the Trust’s communication was in line with the NMC code.
57. From a clinical perspective, our physician adviser stated that the relevant professional standards, the GMC’s ‘Good Medical Practice’, do not set a requirement for how frequently clinicians should discuss a patient’s care with them or their family.
58. From Mrs L’s account of events, one of Ms A’s family or carers was with her at all times. It appears likely that some conversation would have happened between the doctors and whoever was present with Ms A when she was being assessed or being provided with treatment, though these conversations are not documented in the clinical notes. We recognise Mrs L’s view that doctors at the Trust were unwilling to speak to her about her sister’s condition. However, we do not consider there will be further evidence we can obtain which would enable us to take a view on whether these conversations were in line with the standards for communication set out by the GMC’s Good Medical Practice.
59. From the clinical notes we have seen there were discussions with Ms A’s family on 22 and 24 December about the plan for treating her aspiration pneumonia. After Ms A’s condition began to deteriorate from 29 December, we have seen that a full conversation with the family about end-of-life care is documented on 31 December. This is what we would expect to see in line with the GMC’s Good Medical Practice. On the balance of probabilities, our decision is that the Trust’s clinicians communicated in line with the relevant professional standards.