Issue 1 – complaint about the provision of an interpreter
20. Mrs G complains the Trust did not provide an interpreter for Mr G, who did not speak English, even though it knew he needed one. She also complains the Trust’s explanation in its complaint response, that one reason it did not provide an interpreter was because her son volunteered, is unacceptable.
21. We first considered what should have happened. NHS England’s interpreting guidance says if a patient is unable to understand their clinicians because of a language barrier, and therefore unable to take part in discussions and decisions about their care, they should be offered an interpreter.
22. The guidance is clear that ‘patients should always be offered a registered interpreter. Reliance on family, friends or unqualified interpreters is strongly discouraged and ‘would not be considered good practice’.
23. This is also stated in the Trust’s interpretation policy, which says: ‘relatives, carers and friends must not routinely be asked or expected to interpret. If used, there is an increased risk to patient safety, inaccuracy, compromised confidentiality’.
24. We accept that an interpreter cannot be with a patient all the time. We asked our advisers about how the guidance and policy should be applied in practice. Having done that, we think some of the more day-to-day aspects of care, such as drink or meal preferences, can rely on interpretation from family as these are not as significant to the care being provided.
25. An interpreter should be used, however, for all conversations about important assessments, investigations, and decisions. Examples relevant to Mr G’s care would be the conversations and decisions around blood transfusions and nutritional support.
26. Having established what should happen, we looked at what did happen. The records show some of the staff looking after Mr G said an interpreter would be beneficial. The acute pain team said on 22 February that an interpreter was needed for consent discussions. On 26 and 27 February the physiotherapists recognised that an interpreter would be beneficial, and the language barrier was making their assessment difficult.
27. Despite this, the Trust did not provide an interpreter for Mr G at any stage during the admission. In its complaint response the Trust accepted it did not provide an interpreter.
28. It said it did not provide one because Mr G’s delirium made communication difficult. It thought Mr F was happy to translate for his father, and noted that even then, Mr G could not communicate with his son. We think it was not appropriate for the Trust to expect Mr F to translate for his father, as relatives should only be used for day-to-day conversations.
29. We have considered the Trust’s explanation that Mr G’s delirium meant an interpreter was not needed. Our view is if the Trust thought delirium was preventing meaningful conversation (and therefore impacting Mr G’s capacity to be involved in conversations and decisions about his care) it should have done a capacity assessment to assess the extent of his delirium. The GMC consent guidelines say doctors must assess a patient’s capacity if they think it might be impaired. In line with the NHS England guidance, an interpreter would need to be present for that.
30. The Trust did not offer an interpreter for Mr G and relied on his son. This was not in line with the NHS England guidance, and we think this is a failing. We consider the impact of this separately, in paragraphs 41 to 46 of the report.
Issue 2 – complaint about the blood transfusion consent and communication with Mr G’s son
31. Mrs G is unhappy the Trust did two blood transfusions without getting Mr G’s consent, and it did not tell Mr F about the blood transfusions until after they happened.
32. GMC good medical practice says doctors must be satisfied that they have consent before carrying out any examination, investigation or providing treatment. GMC consent guidelines say that in cases where a patient may have a mental impairment (such as delirium) doctors should assess the person’s ability to consent and record the outcome of this in the notes.
33. If a patient can give consent, doctors must give patients options for treating or managing their condition, explain the purpose of any treatment and the potential benefits and risks associated with it.
34. If a patient lacks capacity to consent to their treatment, doctors and nurses can give treatments to a patient in their best interests, if that treatment is of overall benefit.
35. The GMC consent guidelines also say doctors should consider ‘the views of people close to the patient on the patient’s preferences, feelings, beliefs and values, and whether they consider the proposed treatment to be in the patient’s best interests’.
36. The records show us a doctor assessed Mr G at around 11.50am on 3 March, after a nurse noted he had melaena (black stools indicating a bleed has happened in the digestive tract). The doctor saw Mr G’s haemoglobin levels had dropped, which confirmed that a bleed had occurred that needed treatment.
37. The Trust decided Mr G needed a blood transfusion and this took place at around 5pm that day. The Trust did another blood test afterwards and Mr G’s haemoglobin was still low despite the blood transfusion. The Trust decided he needed another blood transfusion, and this took place from 1am to 6am on 4 March.
38. A doctor reviewed Mr G after this and wrote in their notes at 8.40am that staff needed to update Mr F. We do not know what time this happened, but it was done by 4pm according to the notes.
39. There is no evidence in the records the Trust thought about Mr G’s consent, or capacity to consent, to the blood transfusions. This was not in line with the GMC good medical practice or the GMC consent guidelines and is evidence of a failing.
40. The Trust did not contact Mr F before the blood transfusion, and this was not in line with the requirement in the GMC consent guidelines to get the views of people close to the patient. This was a further failing. We consider the impact of this separately, in paragraphs 41 to 46 of the report.
Impact of the failings we saw in issue 1 and 2 of the complaint
41. Mrs G says the failure to provide an interpreter for Mr G, and the failure to get consent for the blood transfusion meant she was worried the Trust were not taking Mr G’s wishes into account and this caused her and Mr F distress. Mrs G also says the failure to communicate about the bleed led to further distress and worry for them.
42. We understand why the Trust’s actions led to Mrs G and Mr F feeling this way. We can see the failings have left them thinking Mr G should have been more involved in his care when the Trust did not take his wishes into account. We also recognise that finding out about the bleed after it happened was difficult for them. We can see this caused them both avoidable distress.
43. Mrs G is concerned these failings were a factor in Mr G’s deteriorating health. We have seen no indication the communication problems here had any impact on his condition. As we set out in the remainder of the report, the care the Trust provided to Mr G was in line with the relevant standards.
44. In summary, we have seen the failings had no impact on Mr G but did cause avoidable worry and distress. We partly uphold parts 1 and 2 of the complaint and recommend the Trust takes action to put things right.
Issue 3 – complaint about Mr G’s food intake
45. Mrs G complains the Trust did not ensure Mr G was getting enough food. She says her husband was left to ‘starve’ because the Trust did not feed him anything from 28 February until his death on 8 March. She is unhappy that it only attempted NG tube feeding once, and that it did not try this again after 2 March.
46. NICE CG32 says patients are at risk of malnutrition if they ‘have eaten little or nothing for more than five days and/or are likely to eat little or nothing for the next five days or longer’.
47. NICE CG32 also says ‘healthcare professionals should consider using… nutrition support, alone or in combination, for people who are either malnourished or at risk of malnutrition’.
48. For someone who is not taking food orally, NICE CG32 recommends enteral feeding. This refers to the intake of food straight into the gastrointestinal tract. It involves using a nasogastric (NG) tube, which passes into the stomach from the nose.
49. The other option for feeding recommended in NICE CG32 is parenteral feeding. This involves using an intravenous drip and cannula to slowly pump liquid nutrients into the blood stream. It is not a permanent solution for feeding. It would be used where a patient is expected to return to oral or enteral nutrition at some point. That means it is not a suitable option for patients who are dying.
50. We next looked at what nutritional support the Trust provided for Mr G. The records show that after Mr G was admitted the Trust tried oral feeding, but Mr G refused to eat or drink because of his delirium and frail condition.
51. On 23 February the Trust considered NG feeding, and the following day it inserted an NG tube. Mr G unfortunately pulled this out several times over 24 and 25 February before it could be used for nutrition. He was not tolerating the tube and it was causing him agitation.
52. On 28 February the Trust inserted an NG tube again. Mrs G says NG feeding was attempted once but we have seen it was attempted a few times up to 28 February. The tube was ready to use on 1 March after a chest X-ray confirmed it was in the right place. Mr G received one lot of feeding on 1 March via the NG tube. The following day he pulled the NG tube out. At this point he was not tolerating a cannula either.
53. The Trust reconsidered an NG tube on 3 and 4 March but decided not to place one. At this stage Mr G was seriously unwell, and the Trust was moving the focus of his care towards end of life care (which we address in issue 4).
54. Our view is that the Trust followed the NICE guidance. It tried oral feeding first, and when that was not working it appropriately moved on to trying enteral feeding.
55. Mr G could not tolerate the NG tube despite several attempts to replace it, and the staff did what they could to try and get food into Mr G. As per the NICE guidance the next step after failed enteral feeding would be to try parenteral feeding, but this was not appropriate for Mr G. He was not tolerating a cannula and soon after the focus of his care moved to end of life care.
56. For these reasons we think the Trust’s attempt to feed Mr G were in line with what should happen and there are no failings here. We therefore do not uphold this part of the complaint.
57. We appreciate how distressing it must have been for Mrs G and Mr F to see Mr G go without food. We hope our explanation has shown that this was not because the Trust got something wrong, but because Mr G sadly could not tolerate any of the appropriate ways of feeding him.
58. Our physician adviser explained Mr G’s health did not get worse because of his poor intake, but rather the poor intake was sadly a consequence of his overall deteriorating health. It is often the case that as a person’s health deteriorates, so does their intake of food. We know this was a serious concern for Mrs G, and we hope this gives her some reassurance about what happened.
Issue 4 – complaint about the decision to not resuscitate
59. Mrs G complains the Trust decided it would not resuscitate Mr G. She says the decision was a ‘death sentence’. She also complains the Trust made the decision without involving or getting consent from her or Mr F.
60. The resuscitation guidelines explain decisions to not attempt resuscitation (DNAR decisions) are needed in cases when there is a ‘good reason to believe’ that a person is going to die from an advanced or irreversible disease, and that CPR would not re-start the heart and breathing for a sustained period. The guidance is clear that resuscitation should not be offered in cases where there is no realistic prospect of a successful outcome.
61. This is because resuscitation is a very invasive intervention, and it can cause traumatic injuries. Inappropriate attempts at CPR can mean a person dies in an undignified manner, or they experience prolonged suffering before they die, receiving treatments that cannot reverse the cause of their illness.
62. The resuscitation guidelines say clinicians do not need consent from a relative to make a DNAR decision but should explain the decision to them. In cases where the decision needs to be made urgently, it should not be delayed if those close to the patient are not immediately contactable.
63. The records show there were some conversations about resuscitation between the doctors and Mr F early on in Mr G’s stay. Doctors discussed resuscitation with Mr F on 22 and 23 February and considered his and Mrs G’s views that they wanted Mr G to receive resuscitation if he needed it. The doctors felt at that time that resuscitation was appropriate.
64. Mr G’s condition got worse as time went on. When the consultant reviewed him on 5 March, after his health deteriorated further, they noted he was ‘gravely unwell’. They said if Mr G deteriorated further, or did not respond to treatment, the emphasis of his care should be ‘comfort and dignity’.
65. The notes say Mr G would not be suitable for care in the intensive care unit and should receive ward-based care only. The consultant tried to contact Mr F at this stage but could not reach him.
66. The consultant completed a treatment escalation plan (TEP) at 12.30pm. The TEP confirmed that Mr G should not receive CPR and was for ward-based care only. The form says Mr G did not have capacity to discuss the decision, and the Trust made the decision in his best interests.
67. The records show the Trust was able to reach Mr F and discuss Mr G’s deterioration and the TEP around two hours later at 2.30pm. Mr F came into hospital to see Mr G and spoke with the consultant at 5pm who confirmed the plan.
68. Having considered what should have happened, and what did happen, we think the Trust acted in line with the resuscitation guidance. The evidence shows Mr G sadly had multiple health problems and the combined impact of these meant the chance of resuscitation being successful was extremely low. The guidance says resuscitation should not be offered if there is no realistic prospect of success, so the decision to not offer it was appropriate.
69. The Trust did not need to get consent from Mrs G or Mr F. It acted in line with the resuscitation guidance when it discussed the DNAR decision, and the reasons for it, with Mr F. It could not discuss the decision with Mrs G because she was abroad, but it considered her views when Mr F expressed them.
70. We therefore think there are no failings in the Trust’s DNAR decision or its involvement of Mrs G and Mr F. We do not uphold this part of the complaint. We understand the DNAR decision is something Mrs G is very concerned about, and we hope we have helped her understand that what happened here was appropriate.
Issue 5 – complaint about medication and oxygen on 8 March
71. Mrs G complains the Trust stopped Mr G’s oxygen and medication on 8 March, and it did not involve her or Mr F in this decision. Mrs G had just arrived back from abroad and was visiting her husband in hospital for the first time on 8 March.
72. Mrs G left the hospital with Mr F at 9.30am so that she could make Mr G some food in the hope to try and encourage him to eat something. Mrs G says when she and Mr F got back to the hospital at 12.50pm they found all Mr G’s medication and oxygen had been stopped. She says this was done without involving her or Mr F and was without their consent. Mr G died around 1pm.
73. The GMC end of life guidance says doctors should use their specialist knowledge, experience, and clinical judgement to decide if a treatment is of overall benefit to a patient.
74. To do this, the end of life guidance says doctors should weigh up the benefits of a treatment that may prolong life or improve symptoms, against the burdens of that same treatment, such as discomfort and distress. There may be no benefit in providing life-prolonging but burdensome treatment in the last days of a patient’s life, when the focus of care is on managing their symptoms and keeping them comfortable.
75. The end of life guidance also says doctors should involve those close to the patient when making decisions about end of life care.
76. Having established what should happen, we looked at what did happen. As set out in our findings on issue 4, the consultant decided on 5 March that the emphasis of care should be to maintain Mr G’s dignity and keep him comfortable. The consultant that saw Mr G on 7 March agreed with this plan and explained it to Mr F.
77. The record from 7 March shows the consultant noted Mr F’s view that Mr G would want to be kept alive until his wife arrived to see him from abroad. They agreed they would continue to treat Mr G with intravenous medication whilst the cannula was in place, but that a new cannula should not be inserted. This was because antibiotics were going to have a limited benefit, and Mr G was not tolerating interventions.
78. The consultant also said that staff should ‘gently’ reapply nasal oxygen as tolerated, but Mr G should not have oxygen via a face mask as he was struggling to cope with this.
79. The records show Mr G had intravenous medications and nasal oxygen overnight. A doctor saw him at around 10.45am on 8 March and saw he did not have a cannula in. In accordance with the consultant’s plan the day before, they decided to not replace this.
80. There were no instructions to remove the cannula, and no record that staff took it out. We think, on balance, Mr G pulled the cannula out as he could not tolerate it.
81. The doctor also noted Mr G was on oxygen. There is no specific record of oxygen being removed, but according to Mrs G’s account it was not in place when she got back to the hospital. We think, on balance, the staff left Mr G’s oxygen off as he was not tolerating it, in accordance with the consultant’s plan to only give oxygen as tolerated.
82. Our view is that the Trust acted in line with the GMC end of life guidance. The doctors used their specialist knowledge and experience to make a clinical judgement about Mr G’s condition and identified that he was sadly dying as there was no realistic prospect of recovery from his illness. We think the evidence supports this. The doctors considered the benefits and burdens of further treatment for Mr G and used this information to reach an appropriate decision about the focus of his care.
83. We also think the Trust acted in line with the recommendation in the end of life guidance to involve those close to the patient when it spoke to Mr F on 7 March.
84. For these reasons, we think the Trust’s decision making and communication around Mr G’s medication and oxygen on 7 March were appropriate. We have seen no evidence that his medication was ‘stopped’ on 8 March, rather the Trust followed the treatment plan to maintain Mr G’s comfort.
85. We have seen no failings here, and do not uphold this part of the complaint.
Issue 6 – complaint about the medication error
86. Mrs G complained the Trust incorrectly prescribed tranexamic acid. Having reviewed the evidence, we understand Mrs G actually complains the Trust gave tranexamic acid in the wrong way on 8 March. She also complains the Trust did not tell her about the mistake when it discovered it.
87. The NMC guidance says nurses have a responsibility to correctly administer medications, as they are prescribed. They should be administered in keeping with the prescribed dose and route.
88. The NMC guidance and GMC good medical practice say clinicians should tell people, or those close to them, if something goes wrong in their care.
89. Mr G had a further GI bleed on 7 March, and the Trust decided he was too unwell to have any treatment for it. It prescribed him 1g oral tranexamic acid to try and control the bleeding. A nurse gave Mr G a 1g dose of the drug intravenously on 8 March, rather than orally as prescribed.
90. The records say a doctor spoke to Mrs G and Mr F after Mr G died, and explained what care he had received and the circumstances of his death. The doctor wrote that they reviewed Mr G’s notes and saw tranexamic acid had been given incorrectly. The record says the doctor told Mrs G and her son about this.
91. In terms of the administration of the medication, it is clear that there was a mistake and it was not given as prescribed. This was not in line with the NMC guidance and is evidence of a failing.
92. We considered whether this had any impact on Mr G. The BNF says a 1g dose of tranexamic acid can be given both orally and intravenously. Our physician adviser said Mr G had the right dose and did not come to any harm by having the medication a different way. This means there was fortunately no impact on Mr G.
93. In terms of Mrs G not being told about the error, it is not clear whether her concern is the error was realised earlier and kept from her, or whether her concern is she was not told about the error in that conversation on 8 March.
94. Looking at the evidence, we are satisfied the Trust only realised the error on 8 March. We do not doubt her recollection of the events of 8 March. But we also have to take into account what is said in the record of the conversation made at the time. We appreciate this was a very distressing time for Mrs G and we recognise this may explain the difference between her recollection and what is in the notes. However, we think, on balance, Mrs G was told about the mistake. There is no failing here.
95. Overall, we think there was a failing to give medication properly, but this had no impact on Mr G, and the communication about the mistake was appropriate. We partly uphold this part of the complaint. Although Mr G was not adversely affected, the mistake could have had serious consequences if another medication was incorrectly given. We will recommend the Trust takes action to improve its services, as it has not addressed this yet.
Issue 7 – Complaint handling
96. Mrs G says the Trust’s responses to her complaint lacked detail and were not transparent. She also says the Trust did not address all of her complaint and it did not provide an explanation for the GI bleed and tranexamic acid error.
97. Our principles of good complaint handling (our Principles) set out what we expect to see from an organisation’s complaint investigation and response. They say organisations should ensure ‘complaints are investigated thoroughly and fairly to establish the facts of the case’. They also say organisations should provide ‘honest, evidence-based’ explanations, give reasons for decisions and say when they have got something wrong.
98. We have considered the Trust’s complaint responses to see if it provided a transparent explanation for what happened or if its responses lacked detail. The six areas of complaint that we have looked at formed part of Mrs G’s complaint to the Trust. We have considered each in turn.
99. The Trust addressed the interpreter issue in its complaint responses, and explained in detail why it did not provide one. This was in line with our Principles. However, despite its explanation it failed to recognise that it made a mistake, which it should have.
100. The Trust did not address Mrs G’s concerns about consent for the blood transfusion and the delayed contact with Mr F in its complaint responses. This was despite Mrs G raising these concerns twice. She also specifically asked it to explain the GI bleed and it did not do this. This was not in line with our Principles.
101. In terms of Mrs G’s concerns about Mr G’s intake of food, the Trust also failed to properly address this in its complaint response. Its first response lacked detail as it only referred to the impact of Mr G’s condition on his ability to eat, rather than giving any assurances about the care it provided to him, and whether that care was adequate.
102. Its second response only addressed what happened after 5 March, and was not transparent about what went on before then. Although we found no failings in the care itself, the Trust’s complaint responses to these points were poor and not in line with our Principles.
103. Next, we considered the Trust’s response to the complaint about the DNAR decision. The Trust addressed this in its first response to the complaint. We think its explanation was detailed enough and honest, and our investigation has shown its actions were in line with the relevant clinical standards. It appears there is nothing additional the Trust needed to do to address this issue.
104. Regarding Mrs G’s concerns that the Trust stopped treatment on 8 March, it very briefly said in its first response that it moved to a ‘comfort and dignity’ approach. It also said it did not stop Mr G’s medication, but ‘a cannula was not resited’ and it removed the oxygen to help Mr G’s comfort and dignity.
105. We can understand why Mrs G felt this part of the response lacked detail, because the explanations did not go into detail about why important decisions were made. However, the Trust did address these points and give an explanation, albeit a brief one. Although the response was not ideal, it did not fall far enough below the standard to amount to a failing.
106. Lastly, we considered the Trust’s response to Mrs G’s complaint about the tranexamic acid. Mrs G asked the Trust what the mistake was, why it happened and whether this had an impact on Mr G. She raised this with the Trust twice, and on both occasions, it failed to address the issue, apart from a brief explanation that tranexamic acid was needed to help control bleeding. It did not address the points Mrs G raised with it, and this was not in line with our Principles.
107. Overall, we think parts of the Trust’s complaint responses were not in line with our Principles and they fell so far below what we expect to see that we think there is evidence of a failing here.
108. Mrs G says the poor complaint responses added to her distress, and we understand why she feels this. It is evident the poor responses from the Trust made a difficult time even more difficult for her, and her son Mr F. We therefore uphold this part of the complaint.
Summary of findings
109. The Trust failed to provide an interpreter at any stage during Mr G’s admission, and there were occasions where one was essential. It failed to consider Mr G’s consent, or capacity to consent, for the blood transfusion. It also failed to contact Mr F at the right time.
110. These failings did not have an impact on Mr G or the care provided, but they understandably caused distress and worry for Mrs G and Mr F when they were left thinking more could have been done for him.
111. We found the Trust provided nutritional support for Mr G in line with the relevant standard. We also found its DNAR decision and end of life treatment plans were in line with the relevant standard.
112. The Trust failed to give tranexamic acid by the method it was prescribed, but this fortunately had no impact on Mr G.
113. We also saw failings in the Trust’s complaint handling. Its responses did not address some of the concerns raised, and in places lacked detail and were not transparent. This added to Mrs G’s and Mr F’s distress.