Our findings about the Ambulance Trust
19. Mr R complains that the Ambulance Trust did not prioritise Mrs R and she was left waiting for over four hours before an ambulance arrived. To assess whether the Ambulance Trust took appropriate action when Mr R telephoned 999 on 19 July 2019, we considered whether it acted in line with its own protocols and NHS England Ambulance Response Programme (the NHS England Ambulance Response Targets). In doing this, we have taken account of what the Ambulance Adviser told us.
20. The Ambulance Trust uses a system called the Medical Priority Dispatch System (MPDS) to decide the clinical priority for emergency calls. The Ambulance Adviser told us that the system is recognised by NHS England as an appropriate system for NHS ambulance services to prioritise and categorise emergency calls. It uses structured questions to place the patient into one of four response categories – each with its own performance standard developed by NHS England (the NHS England Ambulance Response Targets). These performance standards are based on the clinical needs of the patient and are:
· Category 1 – immediately life threatening – with an average response time of seven minutes and 90 per cent of patients responded to within fifteen minutes
· Category 2 – emergency – with an average response time of eighteen minutes and ninety per cent of patients responded to within forty minutes
· Category 3 – urgent – with 90 per cent of patients responded to within 120 minutes
· Category 4 – less urgent – further telephone assessment within ninety minutes to identify the most appropriate care plus ninety per cent of patients responded to within 180 minutes.
21. The prioritisation of the call (and the corresponding response time) cannot be influenced by the call-handler, and is based entirely on the answers given to the structured questions. It is the MPDS which decides the prioritisation of the patient. The Ambulance Adviser told us that there are three initial questions to establish whether the patient is breathing and conscious. If this was not the case, the patient would be placed in category 1. Once breathing and consciousness have been established, the type and extent of injury or illness will decide which of the next three categories are assigned to the patient.
22. The records show that Mr R’s telephone call was received at 11:43:59 and answered at 11:44:04. He told the call handler his wife had ‘fallen and banged her head’. Because Mrs R had fallen, the call handler selected protocol 17 (falls) and asked further questions to establish the extent of her injuries. The call handler noted she was conscious and breathing. The MPDS then allocated the appropriate response outcome for Mrs R. The code was 17B01G (Fall with possibly Dangerous Area injuries - still on the Ground). The Department of Health priority for this code is Category 3, which meant that an ambulance should have been with Mrs R within two hours.
23. Our advice is that the call handler managed Mr R’s emergency telephone correctly. Mrs R’s details were collected and the reason for the call was established. Mr R was asked appropriate further questions that allowed a priority category to be allocated to his wife. However, Mrs R’s ambulance did not arrive within the two-hour target. Records show it arrived at her house at 16.19hrs – a response time of over four and a half hours. This was not in line in with NHS England Ambulance Response Targets. We fully acknowledge how distressing for Mr and Mrs R this must have been.
24. It is clear the Ambulance Trust did not attend to Mrs R within the appropriate time scale. However, we have seen evidence that Ambulance Trust staff allocated an ambulance to Mrs R on five separate occasions. Unfortunately, those ambulances had to be diverted to patients in higher priority categories. Our advice is that this was in line with Ambulance Trust protocols. This subsequently led to Mrs R being allocated a higher priority due to the amount of time she had been waiting. This was also in line with Ambulance Trust protocols. Because we have not identified any failings, we do not uphold Mr R’s complaint about the Ambulance Trust. We do understand, however, how upsetting the delay was for him.
Our findings about the Trust
25. Mr R complains about several aspects of the Trust’s care and treatment that was provided for his wife in 2019. In considering, Mr R’s complaints, we will assess whether the Trust acted in line with relevant standards. We will also take account of what the clinical advisers have told us about Mrs R’s care.
Complaint A – the complaint that Trust doctors did not take the right actions in response to Mrs R’s liver tests, and/or CT scan, in June 2019.
26. To assess whether Mr R is correct in his belief that the Trust took incorrect actions in response to Mrs R’s investigations in June 2019, we consider whether the Trust acted in line with NICE Colorectal Cancer: Diagnosis and Management guidelines (NICE Colorectal Cancer Guidelines).
27. On 3 June 2019, Mrs R had a CT scan at the Trust to see if her cancer treatment (chemotherapy) was working. She also had a series of blood tests in June, including a test to check how well her liver was functioning and a test to establish the amount of tumour markers in her blood (to see how well the cancer treatment was working). The results of the liver function tests showed significantly elevated and rising levels of alkaline phosphatase (ALP - an enzyme found throughout the body that may leak into the bloodstream when the liver is damaged indicating liver disease or bone disorders).
28. A note dated 4 June 2019 described the CT scan showing ‘effectively stable disease within the lungs and liver and in fact slight improvement in the right sided pelvic lymphadenopathy (abnormal lymph nodes)’. However, the note also documented that Mrs R was still experiencing ongoing vaginal and rectal discharge as well as being fatigued. The documented plan was to give her a break from chemotherapy and give palliative radiotherapy to the pelvis instead.
29. Our advice is that the plan to stop chemotherapy and give Mrs R palliative radiotherapy to her pelvis was in line with good clinical care. The Oncology Adviser told us that the aim of giving Mrs R palliative treatment was to prolong the quantity and quality of her life. He said her CT scan did not show that her cancer was getting worse. However, it did show that her symptoms of pelvic disease were worsening. Therefore, it was appropriate in those circumstances to stop the chemotherapy and move to palliative pelvic radiotherapy for symptom management – but with a view to considering chemotherapy afterwards.
30. This is in line with NICE Colorectal Cancer Guidelines. Moreover, our advice is that Mrs R’s abnormal liver function test results would have made further chemotherapy inappropriate in any event. The next chemotherapy regimen advised by NICE would have included Irinotecan, which needs a near normal liver function to be tolerated by the patient.
Complaint B – the complaint that doctors did not tell Mr R that Mrs R had liver damage, or why her legs were swollen, in June 2019
31. Mr R told us that he recalled his GP telephoned him in the second week of June 2019 and told him that his wife’s liver function was abnormal. He said Trust doctors never told him this, or that his wife’s legs were swollen in June due to liver damage. Good medical Practice says: ‘doctors must give patients (or their carers) the information they want or need to know in a way they can understand’.
32. We can see that Mr R discussed the results of his wife’s blood test, including the liver function tests, with Mrs R’s oncologist at a complaint meeting on 13 September 2019. A letter sent to Mr R after the meeting said that Mrs R’s GP told Mr R that his wife’s ALP was 900 units per millilitre, and this was the result of a blood test on 20 June 2019.
33. The records show that during Mrs R’s admission to hospital between 23 and 27 June, her ALP rose from 941 to 1175 units per millilitre. It is not clear from the records what information was given to Mr R at the time about these results during her hospital admission. However, it is standard practice for test results (and their significance) to be shared with the patient or carer by their GP. This appears to have happened in the case of the ALP results of 20 June 2019. This was in line with Good Medical Practice.
34. We have not seen any evidence in Mrs R’s clinical records that confirm she had swollen legs. The Physician Adviser also confirmed that the notes relating to the hospital admission between 23 and 27 June 2019 do not mention swollen legs. He said the clinic letter from the oncologist on 4 June 2019 does not mention this issue either. We do not doubt Mr R’s account that his wife had swollen legs due to her condition. However, we find that there is insufficient evidence in the records about this to allow us to make a finding on this aspect of his complaint.
Complaint C – the complaint that doctors, in A&E and on ward A and ward B, did not do an ultrasound or CT scan during Mrs R’s admission to hospital in July 2019
35. We investigated whether the Trust should have done an ultrasound scan and CT scan when Mrs R was admitted to hospital in July 2019. In doing so, we considered whether the Trust acted in line with Good Medical Practice and NICE Care of Dying Adults in the Last Days of Life guidelines (NICE End of Life Guidelines). We have also taken account of what the Physician Adviser and Oncologist Adviser have told us.
36. The records show that Mrs R was admitted to ward A at 22.30hrs from A&E. Mr R told us he asked for Mrs R to have a CT scan. We can also see from the records that Mrs R was seen by an oncology doctor on 22 July, who asked for an ultrasound scan to be done, and for her to be moved to a bed on ward B. The Trust told Mr R in a complaints meeting that a cancer consultant and a specialist nurse met Mr and Mrs R to discuss that an ultrasound scan would not have helped Mrs R's overall condition. It said an ultrasound might have shown fluid that could be drained, but Mrs R would need to leave the ward for a drain to be inserted. The Trust said this would not have helped her prognosis or have been appropriate. The Trust said Mr R agreed with this decision at the time.
37. The Physician Adviser told us that the need for tests such as CT or ultrasound scans will depend on what is not known about a patient, and what knowledge the scan result may help achieve. He said the presence of widespread cancer, including in the liver, was already known to Mrs R’s doctors and she had also been diagnosed with fluid in the abdominal cavity. The Physician Adviser said investigations (such as a CT scan or ultrasound) to look for cancer and fluid would not have added to the possible treatment options for Mrs R while she was in A&E and then on the ward A. Good Medical Practice says that doctors should promptly provide or arrange suitable advice, investigations, or treatment where necessary. The CT and ultrasound scans were not necessary in Mrs R’s situation. Therefore, we find that A&E and ward A doctors acted in line with Good Medical Practice.
38. The Oncology Adviser agreed with this. He said that at the time of Mrs R’s admission to hospital on 19 July 2019, she was extremely unwell. The Oncology Adviser said that doctors on ward B quickly recognised that Mrs R was approaching the end of her life, and a CT scan and ultrasound would have been inappropriate because of this. NICE End of Life Guidelines recommends that doctors should not undertake unnecessary interventions when a patient is approaching the end of their life. We find that doctors on ward B acted in line with this.
Complaint D – the complaint that nurses did not support Mrs R to use the commode on 21 July 2019, and the Trust inaccurately told him that it had a ‘no lift’ policy
39. At a complaints meeting with the Trust, Mr R said his wife wanted to use the commode on Sunday 21st July 2019. He said Mrs R could not get up from her bed and there was only one nurse to help. Mr R said the nurse could not lift his wife on her own.
40. The Trust said the records show that Mrs R was offered a catheter on 20th July, but she refused it at that point. It said the ward has a 'no lift' policy and Mrs R was offered a bed pan for when she needed to urinate. The Trust said Mrs R used bed pans quite successfully for a while. It said on 21st July at 05.20hrs, Mrs R managed to get out of bed and onto the commode. However, she then had problems passing urine.
41. We can see from the records that Mrs R had a moving and handling risk assessment completed on admission to hospital. The Nurse Adviser told us that these mandatory assessments (required by Health and Safety Executive Manual Handling Regulations 1992 – amended in 2002) help identify where injuries could occur and what to do to prevent them. The risk assessment noted that Mrs R would need assistance from one to two members of staff when using the commode.
42. The records show that Mrs R was assisted by two members of staff to use the commode twice overnight on 21 July. This was noted at 05.20hrs, and was in line in with the moving and handling risk assessment. We acknowledge that Mr R has a different version of events, and we do not doubt he is sincere in his recollections. However, we have not found sufficient evidence to suggest the Trust acted inappropriately in assisting Mrs R to use the commode.
43. Moreover, the Nurse Adviser told us that Royal College of Nursing – Moving and Handling/Advice Guides say that: ‘No-one should routinely manually lift patients’. She said the records show Mrs R was able at times to transfer to the commode with the assistance of two members of staff, but there were occasions when she could not mobilise and then she was nursed in bed. We find that this supports the view that the Trust had a ‘no-lift’ policy.
Complaint E – the complaint that doctors put pressure on Mr R to complete the DNAR (do not attempt resuscitation form), and signed this ‘behind his back’
44. To consider what doctors should have done in relation to the DNAR process, we assess whether they acted in line with GMC Ethical Guidance: Treatment and Care Toward the End of Life – Cardiopulmonary Resuscitation (GMC Ethical Guidance). In doing so, we have taken account of what the Physician Adviser has told us.
45. GMC Ethical Guidance says that decisions about whether to resuscitate a patient:
‘must be based on the circumstances and wishes of the individual patient. This may involve discussions with the patient or with those close to them, or both, as well as members of the healthcare team. [Doctors] must approach discussions sensitively…’
46. The records show doctors discussed and explained the DNAR process with Mr and Mrs R on 20 July 2019. They note that: ‘Husband had been explained that CPR would be futile given how frail his wife is’ and ‘DNAR discussed and agreed’.
47. At the complaints meeting on 13 September 2019, the Trust told Mr R that the DNAR was completed by a doctor before Mrs R was transferred to the ward B. It told him it was completed because giving Mrs R cardiopulmonary resuscitation (CPR) in the event of her heart stopping would not have resuscitated her. The Trust said this was because her cancer had spread too much and caused her to be too weak for the rest of her body and her heart to start again. It said Mrs R’s doctors took this decision in her best interests as CPR would have caused unnecessary distress to her.
48. It is clear from the records that doctors did discuss the DNAR decision with Mr and Mrs R in line with GMC Ethical Guidance. The Physician Adviser agrees with this. However, we are unable to reach a definite view on whether Mr R was pressured by doctors, or whether they were not transparent about the process as he believes. This is because there is very little recorded detail about the content of the discussion with Mr R.
49. We recognise this must have been a highly emotive and difficult conversation for Mr R to have had with his wife’s doctors. We also see how this might have led him to feel he was being pressured into agreeing to the DNAR decision. However, we cannot say that this was the deliberate intention of Mrs R’s doctors. We hope that Mr R will be reassured that we have seen no evidence to suggest that the DNAR decision was inappropriate at that stage of Mrs R’s illness.
Complaint F – the complaint that doctors on the ward B did not let Mr R take Mrs R home, in line with her wishes.
50. Mr R told us Mrs R wanted to die at home, and he asked if he could take her home. He said clinicians told him could not take her home because she might die in the ambulance. Mr R later clarified that a nurse on ward B told him that: ‘If you brought your wife home that would kill her’. To consider whether doctors acted appropriately when deciding that Mrs R should not go home, we assess whether they acted in line with NICE End of Life Guidelines. We have also taken account of what the Oncology Adviser told us.
51. NICE End of Life Guidelines say that a discussion should be had with the patient and the people close to them and the multidisciplinary team to create an individual care plan. The plan should include (amongst other things) the patient’s preferred care setting and preferences for symptom management.
52. We can see from the records that a palliative care nurse spoke to Mr and Mrs R on 22 July 2019 about where they would like her to receive care during her last days. The records note that a hospice or oncology ward was their preference. The following day the palliative care nurse noted that Mrs R’s condition had significantly deteriorated overnight, and that the hospice would need to be updated to see if it would take Mrs R as an emergency. Later that morning a clinical nurse specialist noted that Mr R had been made aware of Mrs R’s worsening situation and wanted Mrs R to stay on the ward B.
53. We do not doubt that Mrs R would have preferred to have been discharged home during the last days of her admission. However, the records show that both Mr and Mrs R felt that a hospice or ward-based care was best for her at that point of her illness. The Oncology Adviser told us that the palliative treatment of fluids and intravenous antibiotics was appropriate given the progression of Mrs R’s condition at that point. We have also seen that appropriate discussions with Mr and Mrs R about her preferred place of care took place on both the 22 and 23 July. This was in line with NICE End of Life Guidelines. The Oncology Adviser also told us that, in his view, Mrs R’s care during her final admission was of a very high standard. We hope Mr R will take some comfort from this.