Royal Free London NHS Foundation Trust

6. Mrs G and Mr G complain the Royal Free London NHS Foundation Trust (the Trust) provided inadequate care and treatment for their late mother and grandmother, Mrs S. They are concerned about the assessment of her general condition throughout her admission. They are also concerned about her low blood pressure and level of confusion after the first operation until her death, and the delays in addressing this. In addition, they say:

A. Mrs S’s fitness for surgery was not fully evaluated, including assessment of blood tests and blood pressure, by a consultant geriatrician/consultant anaesthetist before either of the operations she had to undergo. They are also concerned whether her confusion meant she could give consent to the blood transfusion and second operation when she was still under the influence of anaesthesia

B. Mrs S's first operation went wrong, necessitating a second operation. Mrs G and Mr G are concerned a registrar carried out the first operation without the lead consultant being present until the end of the operation

C. they are concerned about the timing of the second operation. They consider this should either have happened as soon as the Trust realised something had gone wrong or the Trust should have waited until after the weekend as fewer specialist staff were available over the weekend. They have concerns the second operation was carried out too soon after the first and this may have led to Mrs S’s death as she was unable to take the strain of the second operation considering the potential risk of having a second operation when her vital signs were low

D. regional anaesthesia was used for the first operation. The second operation was carried out under general anaesthetic after an attempt to use regional anaesthesia did not work. Mrs G and Mr G are concerned about why the regional anaesthesia did not work in the second operation and would like to understand specifically why a general anaesthetic was required

E. no X-rays were taken after the second operation despite the request by the surgeon. They are concerned this makes it unclear as to whether the second operation addressed the problems from the first operation

F. Mrs S was given a blood transfusion after the first operation. They are concerned at the delay in providing the transfusion. Mrs G and Mr G would like to understand what was done to establish if the transfusion had improved Mrs S’s condition, so she was fit for surgery, as this is not documented anywhere

G. the Trust did not act on Mrs S’s deterioration appropriately and should have transferred her to a high dependency unit (HDU) after her first operation

H. the Trust did not thoroughly investigate Mrs S’s stroke-like symptoms and instead focused on opiate medication as the cause of these symptoms. They would like to understand what discussion doctors had with the hyper acute stroke unit (HASU) as well as the tests they considered to conclude too much opiate medication had been provided and whether this was an appropriate conclusion. They also question if it was appropriate for Mrs S to be given a strong drug that is used to counteract the effects of opiate drugs, and how this was administered

I. admittance to the HASU should not have been delayed as Mrs S was continually drowsy and had stroke-like symptoms following a collapse, after a seizure

J. Mrs S’s fluids and nutrition were not managed appropriately because fluid balance charts were not accurately or timely documented, which led to her dehydration and deterioration

K. Mrs S’s urine was extremely dark in colour, and this was not investigated. Mrs G and Mr G question why urine tests were not taken and analysed daily due to the risk of haematuria

L. medication to prevent deep vein thrombosis (DVT)/pulmonary embolism (PE) was stopped without any alternative preventative measures being undertaken

M. nurses never applied the anti-fungal cream Mrs S had with her when she was admitted, which could have resulted in an infection

N. the Trust did not take appropriate and timely action to investigate whether Mrs S had: o an infection, including sepsis o metabolic acidosis o urinary problems and what was causing them o an electrolyte imbalance

O. not enough specialist consultation was documented to explain why a diuretic was stopped after the first operation

P. it took the doctor a considerable amount of time to obtain the death certificate after Mrs S died as it appears this doctor had to go to various departments. Mrs G and Mr G are questioning why the Trust did not consider performing a post-mortem considering the uncertainty of what caused her stroke-like symptoms/opiate overdose. They are also concerned at the accuracy of the full recording of the cause of death and contributory factors.

Q. most record keeping was inaccurate. Mrs G and Mr G are concerned the CQC identified failings in record keeping at the Trust in the months before Mrs S’s admission. They say Mrs S’s case demonstrates the Trust had not taken appropriate action in response to this

R. communication was poor as the Trust did not make Mrs G or Mr G aware of the need for a second operation, Mrs S’s deterioration or how ill she was on 13 April. In addition, it did not discuss the ‘do not attempt to resuscitate’ (DNAR) decision with them. They are concerned the actions proposed by the Trust to improve communication with families are inadequate.

7. Mrs G and Mr G believe the true cause of Mrs S’s condition could have been diagnosed sooner to avoid hastening her death if the Trust had taken other action. They explain they have suffered significant distress.

8. Mrs G and Mr G would like a complete, truthful and honest explanation of how and why all these flaws and failings could happen in such a short period of time. They want the Trust to acknowledge its mistakes, explain how and why these happened, and to make service improvements.

9. On 9 April 2014 Mrs S was admitted to the emergency department at the Trust, following a fall in the care home where she lived. Mrs S fractured her right hip. Specifically, she fractured the top (known as the neck) of her thigh bone (known as the femur).

10. Mrs S had a right hip replacement carried out on 9 April 2014.

11. During a physiotherapy review the following day, a physiotherapist found her right leg was abnormally rotated. An X-ray showed Mrs S’s hip prosthesis had penetrated her thigh bone.

12. On 10 April 2014, a consultant orthopaedic surgeon scheduled Mrs S for revision surgery the following morning (11 April). Mrs S had a blood transfusion before her surgery.

13. Mrs S had revision surgery in the morning on 11 April 2014. Mr G visited his grandmother at 5.00pm. It was at that point he learned his grandmother had undergone revision surgery. Mrs G visited her mother later that evening and Mr G updated her. This was the first time Mrs G knew about her mother’s revision surgery.

14. The following day, Mrs G witnessed an improvement in her mother’s condition. A doctor reviewed Mrs S that afternoon and noted her observations were stable and she appeared well.

15. A physiotherapist reviewed Mrs S on Sunday 13 April 2014. During the review, Mrs S became unresponsive and the left side of her face drooped. A middle grade orthopaedic doctor reviewed Mrs S. The doctor noted Mrs S was unable to move the limbs on her left side. Shortly afterwards the same middle grade orthopaedic doctor discussed Mrs S’s condition with a doctor in a HASU at another trust. The HASU doctor advised Mrs S should be treated medically and not transferred to the HASU. The same middle grade orthopaedic doctor reassessed Mrs S an hour later. They arranged a CT head scan. The scan showed no acute changes in her brain.

16. A different middle grade doctor reviewed Mrs S that afternoon the same day and diagnosed opiate toxicity. The doctor gave her a drug known as naloxone to rapidly reverse the effects of opioid overdose. Mrs S’s level of consciousness immediately improved, albeit briefly.

17. A medical specialist registrar reviewed Mrs S that evening. They noted Mrs S’s face was still drooping on the left. They prescribed Mrs S aspirin and arranged an MRI scan for the following day. A middle grade doctor discussed Mrs S’s condition with a HASU registrar to see if she should be transferred. The other trust was not able to admit Mrs S as it had no beds available.

18. In the early hours of 14 April 2014, Mrs S’s condition deteriorated. That morning a registrar completed a DNAR form for Mrs S. Mrs S’s blood test indicated she had severe sepsis (a condition where the body’s immune system overreacts to an infection and starts to damage the body’s own tissue and organs). Near midday, a consultant orthogeriatrician and another doctor met Mrs S’s family and told them she had experienced a massive stroke (clinically known as a cerebrovascular accident or CVA) and was unlikely to survive.

19. Mrs S’s family say she died on 14 April 2014. Her main cause of death was recorded as massive stroke.

23. Based on the evidence we have seen, our findings about Mrs G and Mr G’s complaints are set out below.

Issue A – Mrs S’s fitness for surgery and consent to a blood transfusion and second operation

24. Good Medical Practice says doctors must adequately assess the patient’s conditions, taking account of the history (including the symptoms, and psychological, spiritual, social and cultural factors), their views and values, and where necessary, examine the patient. They must also promptly provide or arrange suitable advice, investigations, or treatment where necessary and refer a patient to another practitioner, when this serves the patient's needs. The hip fracture guidance says from admission patients should be offered continued, coordinated orthogeriatric and multidisciplinary review.

25. Nurses took Mrs S’s blood pressure when she was admitted on 9 April 2014. This raised no concerns. Nurses also took a sample of blood and sent it for testing. An orthogeriatrician reviewed Mrs S on 9 April 2014. They took Mrs S’s blood pressure and reviewed her blood test results, which showed low sodium and potassium. The orthogeriatrician had no concerns about Mrs S’s blood pressure. The Orthogeriatrician Adviser said the doctor took appropriate action to manage these issues by giving Mrs S intravenous potassium and stopping her regular blood pressure medication.

26. An anaesthetist also reviewed Mrs S before her first surgery. The anaesthetist completed a preoperative assessment. This included a review of Mrs S’s blood pressure and blood test results. The Anaesthetist Adviser said the preoperative anaesthetic assessment is documented in the anaesthetic records, and includes all relevant clinical information to enable an anaesthetist to plan appropriate anaesthesia for Mrs S. The anaesthetist who reviewed Mrs S concluded she was fit for surgery. The Anaesthetist Adviser said the information recorded was comprehensive and in line with Good Medical Practice.

27. Doctors sent another sample of Mrs S’s blood for testing on 10 April 2014. The results came back that day. They showed Mrs S had low haemoglobin. Nurses checked Mrs S’s blood pressure throughout the day. Her systolic blood pressure dropped from around 115 in the early hours of 10 April 2014 to 102 by the afternoon which for Mrs S was considered low. In the afternoon nurses gave Mrs S intravenous fluids, which improved Mrs S’s blood pressure. This was checked again twice. A consultant orthopaedic surgeon arranged a blood transfusion for Mrs S before her revision surgery to improve her haemoglobin level. An anaesthetist reviewed Mrs S before her revision surgery and concluded she was fit for surgery. The anaesthetist’s pre-operative assessment included a review of Mrs S’s blood pressure and blood test results. The Anaesthetist Adviser said the review in Mrs S’s records on 11 April was comprehensive and in line with Good Medical Practice.

28. Mrs S had a multidisciplinary review involving input from an orthogeriatrician, an orthopaedic surgeon, and an anaesthetist, before each operation. This was in line with the hip fracture guidance. These reviews included an assessment of her blood pressure and blood test results. Treatment was provided to correct any health issues before each procedure and an appropriate preoperative anaesthetic assessment was completed. These actions were in line with Good Medical Practice, and we are satisfied Mrs S’s fitness for surgery was appropriately evaluated before each of her operations.

29. The MCA says a person must be assumed to have capacity unless it is established that they lack capacity. It also says a person is not to be treated as unable to make a decision unless all practicable steps to help them to do so have been taken without success.

30. Mrs S experienced an episode of confusion during her physiotherapy review on 10 April 2014. She was unable to say where she was. She thought she was still in the care home where she lived. Mrs G said when she visited her mother in the early afternoon, her mother was confused about where she was but not as severely as the previous day. The Orthogeriatrician Adviser said Mrs S’s episode of confusion should not necessarily have triggered any follow-up action or a full capacity assessment. They said such tests are not indicated for a single episode of confusion or even fluctuating confusion. They said ongoing confusion would require further investigation.

31. An orthogeriatrician reviewed Mrs S later on 10 April 2014. They noted Mrs S ‘remains well’ and did not raise concerns about Mrs S being confused. A consultant orthopaedic surgeon then reviewed Mrs S shortly after and scheduled Mrs S for surgery. The consultant orthopaedic surgeon did not record any concerns either. In the local resolution meeting on 17 July 2014, they said Mrs S was ‘completely compos mentis’. They said they discussed the procedure with Mrs S, including why the procedure was needed, the risks and benefits of the revision surgery and what they planned to do. They did not document the full details of this discussion in the records.

32. An orthopaedic doctor and a specialist registrar completed two consent forms. Both forms explained the proposed procedure and set out the risk and benefits of the operation. Mrs S signed both forms. Neither doctor recorded a concern about Mrs S’s capacity to make the decision to consent to the revision surgery. The Orthogeriatrician Adviser said a patient’s capacity to consent to treatment is assessed at the time of making a decision. They said even with intermittent episodes of confusion, if a patient is lucid at the time, they can appropriately be deemed to have capacity to consent to the specific care decision being discussed.

33. The Orthogeriatrician Adviser said the MCA sets out a four-point process for consent to treatment. The clinician tells the patient about the treatment; assesses their ability to understand the procedure by asking the patient to explain it back to them; sets out the risks and benefits of the procedure and allows the patient to weigh up the pros and cons of proceeding, and then the final stage is to document their consent. This is what happened. They said this is documented in ‘Consent form 1’ for patients who are considered to have capacity. ‘Consent form 4’ is for patients who are deemed not have capacity. For both surgeries Mrs S signed Consent form 1. This indicates clinicians were satisfied she had capacity to provide consent.

34. Late that evening, Mrs S started her blood transfusion. The Orthogeriatrician Adviser said formal consent forms are not required for blood transfusions. They said a blood transfusion was given as part of preparing Mrs S for the revision operation and to prevent her from becoming anaemic after the operation due to loss of blood. They said ‘bleeding’ is listed as a risk on the consent forms Mrs S signed. Therefore, consent to the blood transfusion was provided by signing the consent form for the surgery. There is no evidence we have seen to suggest Mrs S did not consent to the blood transfusion.

35. Finally, to address Mrs and Mr G’s concern Mrs S remained under the influence of anaesthesia, the Anaesthetist Adviser said the spinal anaesthetic for Mrs S’s first operation wears off after two to four hours. Therefore, we cannot see Mrs S’s confusion on 10 April 2014 was a result of the anaesthesia from the operation.

36. We conclude the doctors at the Trust’s actions were in line with the MCA and the appropriate standards. We therefore find no failings in relation to this aspect of Mrs S’s care.

Issue B – Why Mrs S’s first operation went wrong and how it was supervised

37. The hip fracture guidance says: · ‘Consultants or senior staff should supervise trainee and junior members of the anaesthesia, surgical and theatre teams when they carry out hip fracture procedures; · The level of supervision required for a trainee or junior staff member for a particular case depends on two main factors: the junior’s ability and the complexity of the case; and · Use cemented implants in patients undergoing surgery with arthroplasty [the surgical reconstruction or replacement of a joint]’.

38. A specialist registrar carried out Mrs S’s right hip replacement. The Trust told us the registrar was a senior trainee working on a team of hip surgeon trainees led by a consultant orthopaedic surgeon. The registrar had four to five years’ experience as a specialist surgeon. They were assisted by a post-fellowship trainee. A post-fellowship trainee is more experienced than a specialist registrar. The supervising consultant was not present for the whole procedure. During a local resolution meeting on 17 July 2014, they said they ‘popped in’ at the end of the procedure to ensure everything was ok, which they said it was.

39. The Surgeon Adviser said it is acceptable for a surgical trainee to perform this type of operation as long as the responsible consultant is satisfied the registrar is competent to do so, and adequate supervision is in place. They said the post-fellowship trainee was appropriately qualified to carry out the hemiarthroplasty operation on their own, without supervision. We are satisfied Mrs S’s surgery on 9 April 2014 was carried out by an appropriately qualified surgeon with adequate supervision and assistance from a more senior surgeon. We find the Trust acted in accordance with the hip fracture guidance in the way it supervised Mrs S’s first operation.

40. Mrs S’s operation involved inserting a prosthesis into the central canal in her femur. This comprised a metal stem that sat inside the central femur canal with a ball joint at the top which inserted into Mrs S’s hip joint. The Surgeon Adviser noted an uncemented hip hemiarthroplasty was used in Mrs S’s case. This was not in line with the hip fracture guidance. The Surgeon Adviser said no concerns about intraoperative events or complications were documented in the operation notes.

41. The Surgeon Adviser said an X-ray taken on 10 April 2014 showed most of the prosthesis was lying outside the canal of the femur. The Surgeon Adviser said this meant either the prothesis had not been inserted correctly, or there was an intraoperative periprosthetic fracture (a bone fracture around an artificial joint) that was not detected during the operation. They said this would need urgent revision surgery as it would be impossible for Mrs S to be able to walk.

42. The Trust said this was a known complication, but one which does not happen often. The Surgeon Adviser agreed. They said periprosthetic fractures do occur in the type of surgery Mrs S had, and sometimes the prothesis pierces the bone.

43. The hip fracture guidance says a cemented prosthesis should have been used for Mrs S’s surgery. There is no explanation in the records about why doctors used an uncemented prosthesis. The Surgeon Adviser said uncemented prostheses are usually only used for patients who are immobile prior to breaking their hip, or for patients who might have an adverse reaction to the cement. There is no evidence Mrs S fitted these criteria. The Surgeon Adviser said using an uncemented prosthesis increases the risk of the prosthesis piercing the femur. This is what happened in Mrs S’s case.

44. The Surgeon Adviser said the stem of a prothesis piercing the femur would usually be noticed during an operation because the angle of the prothesis would not be correct. He could not say why this did not happen. However, the Surgeon Adviser said during such a procedure, only the upper hip area is visible to the surgeon. The surgeon would not have been able to see lower down the femur where the prothesis had pierced Mrs S’s bone. This may explain why the fact that Mrs S’s hip replacement had gone wrong was not identified until after the operation.

45. Based on the evidence we have seen; the Trust inappropriately used an uncemented prothesis for Mrs S’s first surgery. This was not in line with the hip fracture guidance. We find this fell so far below the relevant standard that it was service failure.

Issue C – The timing of Mrs S’s second operation

46. A physiotherapist identified a problem with Mrs S’s hip replacement in the morning of Thursday 10 April 2014. Mrs S had a check X-ray later the same afternoon. The orthopaedic and orthogeriatric teams reviewed Mrs S, and later that day, she was scheduled for revision surgery the following morning (Friday).

47. The hip fracture guidance says: ‘recommendations emphasise the importance of early surgery and coordinating care through a multidisciplinary hip fracture program to help people recover faster and regain their mobility’. The Surgeon Adviser said there is no specific guidance for how soon revision surgery should take place after a problem is identified. Taking account of the events which took place between the problem with Mrs S’s hip being identified and her revision surgery taking place, we are satisfied there was no delay in arranging this. The Trust did so as soon as it realised something had gone wrong. This was in line with the hip fracture guidance.

48. Before Mrs S’s revision surgery, her low blood pressure was managed by giving her intravenous fluids. As a result, Mrs S’s blood pressure improved. She was also given a blood transfusion. Mrs S’s observation chart indicates nurses monitored her breathing, oxygen saturation, temperature, blood pressure, and heart rate (also known as her vital signs) throughout the day on 10 April 2014, and in the morning of 11 April before she went for surgery. As we explain in paragraph 28, we are satisfied Mrs S’s fitness for revision surgery was appropriately assessed before her second operation.

49. The Surgeon Adviser said it was clinically necessary to do the second surgery as soon as possible to ensure early mobilisation, which is the goal of early surgery for a fractured neck of femur. They said waiting would have caused difficulty in mobilisation. The Surgeon Adviser said on balance, if Mrs S was reasonably fit for surgery there would be no benefit in delaying her operation, as long as adequate surgical expertise and aftercare were available.

50. Taking account of the evidence and the clinical advice we received, we cannot see there was any reason to delay Mrs S’s revision surgery. We consider the Trust arranged Mrs S’s revision surgery in an appropriate timeframe with a view to helping her regain her mobility. This was line with the hip fracture guidance.

Issue D – The anaesthesia used for the second operation

51. Regional anaesthesia was used for the first operation. The second operation was carried out under general anaesthetic, after an attempt to use regional anaesthetic did not work. Mrs G and Mr G are concerned why the regional anaesthesia did not work and would like to understand why general anaesthetic was required.

52. The hip fracture guidance says patients should be offered a choice of spinal (regional), or general anaesthesia. It also says intraoperative nerve blocks should be considered for all patients undergoing surgery.

53. The Anaesthetist Adviser said Mrs S received a spinal anaesthetic with a supplementary lumbar plexus nerve block (this is a regional anaesthetic which would have acted on Mrs S’s lower extremities) for the first operation. This was in line with the hip fracture guidance. The anaesthetic record for the first operation contains an entry which says ‘bony ++’. The Anaesthetist Adviser said this means there was a bony obstruction to the passage of the spinal needle. This indicated it was technically difficult to place the spinal anaesthetic. They said the entry served as a warning for other anaesthetists.

54. The anaesthetic plan for Mrs S’s revision surgery was to use a combined spinal epidural anaesthetic (CSE), as with the first surgery on 9 April. The Anaesthetist Adviser said a CSE was attempted three times but was unsuccessful due to ‘bone obstruction’. The attempt was abandoned, and Mrs S was given a general anaesthetic plus a fascia iliaca (FIB) block (a local anaesthetic). The Anaesthetist Adviser said in the circumstances, this choice was entirely appropriate. Given that attempts to obtain anaesthesia with a CSE were unsuccessful, there was no alternative but to give Mrs S a general anaesthetic if the operation was to proceed at that time.

55. We hope the Anaesthetist Adviser’s explanation provides Mrs G and Mr G with the explanation they are seeking. When faced with difficult circumstances that would have prevented the operation going ahead at that time, the anaesthetist used a combination of a general anaesthetic with a local anaesthetic block. This was in line with the NICE guidelines.

Issue E - Whether the second operation addressed the problems from the first

56. Good Medical Practice says doctors must promptly provide or arrange suitable advice, investigations, or treatment where necessary. The Surgeon Adviser confirmed the surgeon’s postoperative instructions, following Mrs S’s revision surgery, included carrying out an X-ray within 24 hours. There are no X-rays in the records after Mrs S’s revision surgery on 11 April 2014. In light of this, the Surgeon Adviser could not say if the revision surgery was successful at addressing the problems from the first surgery. The surgeon who carried out the revision surgery did not raise any concerns in the records about the outcome of the operation or mention any specific problems encountered during the procedure.

57. Mrs S’s revision surgery was carried out on a Friday. According to the surgeon’s postoperative instructions, Mrs S should have had an X-ray to check her prosthesis, on Saturday 12 April 2014. We know this did not happen. The Trust subsequently told the family there was no capacity in the X-ray department over the weekend to undertake routine imaging. The Surgeon Adviser said X-rays can usually be arranged over weekends in most hospitals, but often fewer staff are available. They said urgent X-ray requests are prioritised. The Surgeon Adviser said most orthopaedic surgeons would request a check X-ray within 24 hours of hip replacement surgery, even if it fell over a weekend. This is so the X-ray can be done as soon as possible if weekend staff levels mean it cannot be completed in 24 hours. The Surgeon Adviser said, regardless of when a check X-ray took place, the most important thing in the circumstances was to get Mrs S moving.

58. A doctor reviewed Mrs S on 12 April 2014. They referred to arranging a check X-ray in the care plan set out in the notes. The orthopaedic team saw Mrs S that afternoon. The orthopaedic consultant’s plan included arranging a ‘check x-ray [on] Monday’. The plan also noted ‘can get her up’, which suggests Mrs S was able to mobilise to some degree. This suggests Mrs S’s revision surgery was successful. There is further evidence to support this. A physiotherapist reviewed Mrs S in the morning of 13 April 2014. Mrs S was able to sit on the edge of the bed quite well, only needing minimal assistance.

59. It is likely the deterioration in Mrs S’s condition, on 13 April 2014, meant she became too unwell to have the check X-ray that was planned for 14 April. A check X-ray would have confirmed if the second operation addressed the problems from the first. Without it, we cannot definitively say if the revision surgery was successful. We acknowledge the surgeon who carried out the revision surgery asked for a check X-ray to be carried out in 24 hours. This was not possible. Based on the Trust’s comments, it is more likely than not this was due to a combination of relevant staff not being available over the weekend and emergency X-rays being prioritised over Mrs S’s check X-ray.

Issue F – Mrs S’s blood transfusion

60. A consultant orthogeriatrician reviewed Mrs S on 10 April 2014. He scheduled her for revision surgery for the following morning (11 April). The consultant orthogeriatrician noted in the records that Mrs S should have a blood transfusion before her surgery. He wrote ‘will need topping up pre surgery’.

61. The Orthogeriatrician Adviser said Mrs S’s haemoglobin level following her first operation was 90g/L. Haemoglobin is a protein in red blood cells that carries oxygen around the body. The Orthogeriatrician Adviser said medically Mrs S did not need a blood transfusion. They said transfusion should be considered in patients with haemoglobin below 80g/L. They said in Mrs S’s case, the transfusion was preventative, and was given to ensure she did not become anaemic following her second operation. If this had happened, it may have adversely impacted on her congestive heart failure. The Orthogeriatrician Adviser said Mrs S’s transfusion was to help her cope better with the second operation.

62. A nurse started the blood transfusion for Mrs S in the evening of 10 April 2014 and gave a second unit (meaning 525ml) in the early hours of 11 April. Given Mrs S’s haemoglobin level was above 80g/L, we cannot see there was any significant delay in arranging this for Mrs S. As the transfusion was to top up Mrs S’s haemoglobin level, we do not consider it was necessary to review her haemoglobin again before the surgery. As mentioned, we have concluded Mrs S’s fitness for revision surgery was appropriately assessed.

63. The consultant orthogeriatrician who requested Mrs S’s blood transfusion assessed her condition, took account of her medical history, and arranged appropriate treatment for her. These actions were in line with Good Medical Practice.

Issue G – Transfer to HDU after the first operation

64. The Orthogeriatrician Adviser said Mrs S’s anaesthetic chart during her first operation, and her observations following the procedure showed her condition was stable. They said Mrs S’s oxygen saturation, respiratory rate and blood pressure were normal. The Orthogeriatrician Adviser said there was no indication Mrs S needed to be on an HDU. Nurses monitored Mrs S’s condition throughout the night between 9 April and 10 April. They completed Mrs S’s observations charts, which noted her condition remained stable.

65. Mrs S experienced an episode of confusion during her physiotherapy review on 10 April 2014. However, aside from her abnormally rotated right leg, the physiotherapist did not record any other concerns about her overall physical condition. An orthogeriatrician reviewed Mrs S that afternoon. The orthogeriatrician noted Mrs S’s blood pressure was low but she was stable. A consultant orthopaedic surgeon reviewed Mrs S around an hour later. They did not record any concerns about a deterioration in Mrs S’s condition and there is nothing in the nursing notes to suggest this either. This is supported by the fact they scheduled Mrs S for revision surgery the following morning (11 April).

66. The Orthogeriatrician Adviser said Mrs S was appropriately reviewed between her first operation on 9 April 2014 and her revision surgery on 11 April. They said given Mrs S had had a single episode of confusion and the fact there is nothing in the notes indicating it continued, there was no action staff should have taken but did not.

67. We have seen no evidence there was a deterioration in Mrs S’s condition following her first operation, and no reason the Trust should have transferred her to a high dependency unit.

Issues H and I – Investigation of Mrs S’s stroke, discussions with the HASU and her treatment with opioid medication

68. The stroke guidance says doctors should have used a tool, such as ‘FAST’ (Face Arm Speech Test), to assess Mrs S’s sudden onset of neurological symptoms for a diagnosis of stroke. They should also have referred her for specialist assessment and investigation and arranged an urgent CT scan. The stroke guidance says everyone with suspected stroke should be admitted directly to a specialist acute stroke unit after an initial assessment. It also says Mrs S should have been given high-dose aspirin, specifically 300mg, within 24 hours. If she had no problems swallowing, aspirin should have been given orally. If she had problems swallowing, it should have been given rectally.

69. When Mrs S collapsed on the morning of 13 April 2014, she was promptly reviewed by a middle grade orthopaedic doctor and appropriately assessed for stroke. This was in line with the stroke guidance. Shortly after the same doctor sought specialist input by contacting an HASU at another trust. The HASU doctor advised Mrs S should not be transferred to HASU at that point. The Orthogeriatrician Adviser said it is unclear why Mrs S was not transferred to HASU. They explained a possible reason was Mrs S’s recent surgery. The Orthogeriatrician Adviser said treatment with drugs that break down blood clots was not an option for Mrs S as this could have resulted in severe bleeding from her surgical site.

70. Doctors arranged an urgent CT head scan to investigate Mrs S’s symptoms. This did not show acute changes in Mrs S’s brain. The Orthogeriatrician Adviser said the scan took place promptly and in an appropriate timeframe. In the afternoon of 13 April 2014, a middle grade doctor reviewed Mrs S and diagnosed opiate toxicity.

71. The Orthogeriatrician Adviser said this assessment was not as thorough as it should have been. They said the doctor did not record anything about Mrs S’s neurological status apart from her level of consciousness. The Orthogeriatrician Adviser said the doctor should have checked Mrs S’s neurological status by conducting a FAST assessment (Face, Arm, Speech, Test). They said this should have involved assessing: Mrs S’s facial asymmetry, the power and tone of her upper limbs, her speech and her reflex reaction to stimulus. There is no evidence that this type of assessment was undertaken. The Orthogeriatrician Adviser said the fact the doctor did not do so did not have had any impact for Mrs S at that point as she was already being treated for stroke.

72. We acknowledge it would have been better if the middle grade doctor who assessed Mrs S on 13 April had done an appropriate neurological assessment. However, we are satisfied the possibility of stroke was already recognised at that point in Mrs S’s care. This is shown by the fact doctors promptly assessed Mrs S for stroke after she collapsed, sought specialist input from an HASU and arranged a CT head scan to investigate the cause of Mrs S’s symptoms. These actions were in line with the stroke guidance.

73. A medical specialist registrar reviewed Mrs S that evening. The medical specialist registrar prescribed Mrs S a 300mg oral dose of aspirin and arranged for an MRI scan the following day. The medical specialist discussed Mrs S’s condition with an HASU registrar at another trust with a view to transferring her. The doctor was informed the HASU had no beds available. The HASU registrar agreed with the doctor’s proposed plan to treat Mrs S with high-dose aspirin and to arrange an MRI.

74. Given Mrs S was unable to swallow at that point, in line with the stroke guidance the medical specialist who saw her that evening should have prescribed rectal aspirin for Mrs S. There is no indication they did so. It is more likely than not had nurses tried to give Mrs S aspirin orally within that 24-hour period they would have identified the error. However, there is no indication they tried to administer aspirin or identified the error.

75. Doctors assessed Mrs S and discussed Mrs S’s case with HASU as soon as a stroke was suspected. The Trust was advised to continue treating her. When doctors contacted HASU again to enquire about transferring Mrs S, there were no beds available, meaning she could not be transferred. The Trust followed the advice provided by the HASU doctors. Doctors appropriately treated Mrs S for a stroke and arranged a CT head scan to investigate her symptoms of stroke further. These actions were in line with the stroke guidance. However, Mrs S was not given high-dose aspirin within 24 hours of her stroke. This was not in line with the guidance. We find this fell so far below the relevant standard that it was service failure.

76. Mrs S was prescribed 30mg of codeine phosphate four times a day for pain relief following her second operation. Mrs S’s prescription chart said opioid drugs, which would include codeine phosphate, made her drowsy. There is no indication Mrs S experienced any significant drowsiness on 11 or 12 April. The Anaesthetist Adviser said a 30mg dose is considered a low dose of codeine phosphate. They said this drug is a weak opioid drug. They said Mrs S was only given codeine phosphate and was not given anything stronger.

77. Opiate toxicity was diagnosed that afternoon. The doctor based this conclusion on Mrs S’s medication and altered conscious state at the time.

78. The Anaesthetist Adviser said they could see no objective evidence of opioid toxicity. They said for there to be opioid toxicity, the patient must have received an excessive dose of opioid medication, and there should be a recognised clinical progression of symptoms and signs. These would include depression of respiration and decreased conscious level. The Anaesthetist Adviser said according to Mrs S’s observation chart, on 13 April 2014, her respiration rate was normal. This was inconsistent with opioid toxicity.

79. The Anaesthetist Adviser said the low dosage of codeine phosphate doctors prescribed Mrs S could not cause opioid toxicity. They said the diagnosis appears to have been made on the basis of changes in Mrs S’s Glasgow Coma Scale (GCS). This a scoring system used to describe a person’s level of consciousness. A score of 3 would indicate someone is unconscious and a score of 15 would indicate a person is fully conscious. The Anaesthetist Adviser said the GCS is made up of the sum of three measurements: E meaning eye opening (from 1 to 4), M meaning movement (from 1 to 6), and V meaning vocalisation (from 1 to 5) (can someone speak or make sounds).

80. The Anaesthetist Adviser said immediately following Mrs S’s collapse, her GCS was calculated incorrectly. The records say her GCS was E3 V2 M6, which is 11 out of 15. The Anaesthetist Adviser said Mrs S was mumbling words, which would increase her V score by one point. They said her GCS should have been recorded at 12 out of 15. The Anaesthetist Adviser said when a middle grade orthopaedic doctor reviewed Mrs S that morning, her GCS was again recorded as 11 out of 15. The Anaesthetist Adviser said the breakdown of the scores noted in the records, specifically 4, 2 and 6, total 12 out of 15.

81. During the afternoon of 13 April 2014, a middle grade doctor gave Mrs S an injection of naloxone which, according to the records, immediately improved her level of consciousness. The notes say ‘rapid rise in GCS to 13’. They prescribed further naloxone for Mrs S in the form of an intravenous infusion around two hours later. The doctor also stopped Mrs S’s codeine phosphate. The Orthogeriatrician Adviser said the improvement in Mrs S’s level of consciousness after the naloxone injection suggests she had at least some degree of opiate toxicity. They said it was therefore appropriate to prescribe a naloxone infusion. The Anaesthetist Adviser disagreed with this conclusion. They said given Mrs S’s GCS was calculated incorrectly, her GCS only went up from 12 to 13. The Anaesthetist Adviser said this was a not a clinically significant increase and did not indicate opioid toxicity in Mrs S’s case.

82. Weighing up the evidence and the advice from the Orthogeriatrician and Anaesthetist Advisers, we cannot say the Trust’s conclusion Mrs S was experiencing opioid toxicity was wholly inaccurate. We acknowledge the Anaesthetist Adviser’s view that based on the overall picture, opioid toxicity was unlikely and the Trust reached this conclusion based on GCS scores that were calculated incorrectly. This meant the change in Mrs S’s GCS when she was given naloxone was less significant than implied in the records. We also acknowledge the Anaesthetist Adviser’s view that the dosage of codeine phosphate doctors prescribed Mrs S was too low to cause opioid toxicity and that Mrs S had no symptoms of drowsiness or depressed breathing associated with opioid toxicity. However, we have weighed this against information in the records which says when a middle grade doctor gave Mrs S an injection of naloxone her conscious level improved immediately. The Orthogeriatrician Adviser confirmed that this improvement suggests Mrs S had at least some degree of opiate toxicity. Although we have not seen any clear evidence Mrs S was given too much opioid medication, taking account of her symptoms at the time and the improvement in her level of consciousness, after she was given naloxone, we can understand why doctors at the Trust felt she might be experiencing opioid toxicity and treated her with this drug. Good Medical Practice says doctors should have assessed Mrs S’s condition, taken account of her symptoms, and promptly provided suitable treatment. This is what happened. Doctors at the Trust assessed Mrs S’s condition, identified she could be experiencing opioid toxicity, and gave her an appropriate drug to counteract the effects of opiate medication. This was in line with Good Medical Practice.

Issue J – Fluids and nutrition

83. Nurses should act in accordance with the food and fluids guidance and the NMC Code. The food and fluids guidance says: · screening for malnutrition should be carried out by healthcare professionals with appropriate skills and training · all hospital in-patients should be screened on admission and screening should be repeated weekly or when there is cause for clinical concern (for example unintentional weight loss, fragile skin and poor wound healing); and · nutrition support should be considered for people who 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

84. The NMC Code says nutrition and hydration are fundamental aspects of nursing care. It says nurses should keep clear and accurate records of their practice. The Nurse Adviser said when a person is admitted to hospital, an episode of illness may result in an increase or reduction of fluid intake. It is therefore important for nursing staff to accurately record fluid intake and output and ensure any plan of care concerning fluid intake and output is followed.

85. When Mrs S was admitted on 9 April 2014, in line with the food and fluids guidance, nurses appropriately carried out an initial nutritional risk assessment. The Nurse Adviser said the risk score in the assessment was calculated correctly. The assessment concluded Mrs S had a low risk of malnutrition. The assessment noted a plan to weigh Mrs S weekly with the aim of preventing weight loss. The Nurse Adviser said no specific actions relevant to Mrs S’s nutritional care were highlighted in the assessment. This means it is unclear how nurses intended to prevent Mrs S losing weight.

86. Doctors scheduled Mrs S for surgery shortly after she was admitted. In light of this, she was not given anything to eat before her first operation. According to an entry on her fluid chart, Mrs S returned to the ward at approximately 2.00pm. There is nothing in the records to indicate nurses gave Mrs S anything to eat that afternoon. Mrs G told us that when she visited her mother, she found no record that staff had given her mother anything to eat since her admission. Mrs S’s records reflect this. There is no reference to Mrs S being given anything to eat on 10 April 2014 on the food chart, or in the nursing notes. As she was scheduled for revision surgery, Mrs S was made nil by mouth again from midnight. Taking account of this evidence, it is more likely than not, Mrs S was not given any food on 10 April.

87. On 11 April 2014, Mrs S had revision surgery on her right hip. Mr G said when he visited his grandmother that evening other patients were receiving their evening meal, but his grandmother was not. They said the ward sister said there was no reason Mrs S could not eat, and she then got his grandmother mother half a cup of soup.

88. The Nurse Adviser said no food chart was completed on 11 April. There is a nursing entry at 8.00pm which noted Mrs G raised concerns with a nurse about her mother not being given any food since her admission. The nurse highlighted the fact Mrs S had some soup but had declined anything else. Mrs G told the nurse an unopened bottle of Ensure (a nutritional supplement drink) was left on her mother’s table and said her mother needed help to open it. According to the nursing records, the nurse reassured Mrs G her mother would be given assistance to help her eat and drink by using a ‘red tray’. This is used to identify patients who may require assistance with eating and drinking. The Nurse Adviser said there is no indication Mrs S’s care plan was updated to include this intervention. They said there is nothing in the records that confirms the required assistance was provided.

89. The Nurse Adviser said Mrs S’s limited food intake since her admission, the fact she had undergone two major operations in a short space of time, and her identified need for assistance with eating and drinking, meant her nutritional risk (this refers to her risk of malnutrition) had increased by 11 April 2014. They said nurses should have reassessed Mrs S’s nutritional risk at that point, but this did not happen.

90. Had nurses assessed Mrs S’s risk of malnutrition, the Nurse Adviser said her risk score calculation would have been seven. The Nurse Adviser said based on this score, in line with the instruction in the Trust’s nutritional risk assessment document, nurses should have referred Mrs S to a dietician. There is no evidence they did so at that point or at any other point in her admission. This was not in line with the food and fluids guidance.

91. Mrs S’s food was documented on 12 April 2014. According to the records, she ate three quarters of a bowl of cereal for breakfast. At lunchtime she had a whole bowl of fortified soup and three quarters of her main meal. She also ate half of her pudding. That evening, Mrs S ate a quarter of a sandwich. Mrs G told us her mother struggled to eat and drink without her assistance. There is no information in the records that nurses helped Mrs G eat and drink that day. This is further evidence nurses did not provide the ‘red tray’ support they said they would.

92. On 13 April, Mrs S had a bowl of cereal for breakfast. She was made nil by mouth at midday due to difficulty swallowing. Due to her deteriorating condition, Mrs S had no further food from that point until she sadly died.

93. Intravenous fluids were in progress when Mrs S was transferred from the emergency department to a ward in the early hours of 9 April 2014. The amount of fluids nurses gave Mrs S was not recorded nor was the time the fluids were completed. Mrs S was given a litre of intravenous fluids during her surgery. No intravenous fluids were given when Mrs S returned to the ward. A nurse gave her a 50ml cup of tea on her return to the ward after surgery. A nurse also gave Mrs S water to drink but the amount has not been documented in her fluid balance chart. No other oral fluid intake is recorded in the notes. Based on this evidence, we cannot see Mrs S’s total fluid intake was accurately recorded on 9 April 2014.

94. There is no oral fluid intake recorded on the morning of 10 April 2014. At 10.35am, a doctor noted in the records Mrs S’s fluid input needed to be monitored. At 11.20pm a different doctor noted ‘fluid Balance not up to date’ and advised a plan to manage Mrs S’s fluid balance. This indicates Mrs S’s fluid balance was not appropriately monitored by nurses during this period.

95. The Nurse Adviser said nurses gave Mrs S 250ml of intravenous gelofusin, which is a liquid given intravenously to replace blood and fluid lost as the result of an operation, at 1.00pm and a further 250ml at 4.00pm. The Nurse Adviser said a 258ml blood transfusion was started late that evening. They said Mrs S had a total oral fluid intake of 250ml between 2.00pm and 6.00pm. This evidence shows Mrs S’s fluid balance was monitored appropriately from 1.00pm onwards. However, prior to this point, it was not accurately monitored and recorded.

96. According to Mrs S’s fluid prescription chart on 11 April 2014, nurses gave her a second blood transfusion of one unit (meaning 525ml) in the early hours of the morning. The Nurse Adviser said this is also recorded in Mrs S’s clinical notes but not on her fluid balance chart. According to Mrs S’s fluid prescription chart, a nurse gave Mrs S one litre of an intravenous fluid known as Hartmann’s solution, used to replace low fluids and electrolytes such as sodium and potassium, in the morning. Nurses did not note when this finished in Mrs S’s records. The Nurse Adviser said a further litre of intravenous Hartmann’s solution was started that evening. This was appropriately documented in Mrs S’s records.

97. The Nurse Adviser said Mrs S’s fluid balance chart on 12 April 2014 appropriately recorded that her oral fluid intake between 8.00am and midday was 570ml. However, no oral intake is recorded before or after this period. We know from Mrs S’s intravenous fluid prescription chart that she was given a litre of intravenous saline which started early in the morning, with a plan for it to be infused by Mrs S over a period of 10 hours. The fluid balance chart notes Mrs S was given this saline. However, nurses did not record the starting amount, how long it was given for or details of how much was actually infused by Mrs S. The Nurse Adviser said the saline that nurses gave Mrs S is not included in their calculation of Mrs S’s total fluid intake that day. The Nurse Adviser also said Mrs S’s total recorded urine output was incorrectly calculated as 795ml. They said it should have been 835ml. Taking account of this evidence, it is clear nurses did not keep accurate records of Mrs S’s fluid balance on 12 April 2014.

98. The Nurse Adviser said Mrs S’s fluid balance charts for 13 and 14 April 2014 were appropriately completed and accurately included her full fluid intake.

99. In summary, we have identified that nurses at the Trust did not:

· record any specific actions they intended to take to prevent weight loss in Mrs S’s assessment on 9 April 2014 · give Mrs S any food between her admission and the evening of 11 April · include a ‘red tray’ requirement in Mrs S’s nutritional care plan and did not help Mrs S to eat and drink, despite her finding it difficult to do this on her own · reassess Mrs S’s risk of malnutrition on 11 April or refer her to a dietician as they should have done; and · keep full and accurate records of Mrs S’s fluid balance on 9, 10, 11 or 12 April

100. Taking account of the evidence set out above, it is clear nurses at the Trust did not keep clear and accurate records of Mrs S’s food and fluid intake. Nurses did not deliver these fundamental aspects of Mrs S’s care effectively. We find this fell so far below the NMC Code it was service failure.

Issue K – Urine monitoring

101. The NMC Code says nurses should ‘treat people as individuals and uphold their dignity’. To achieve this, nurses must make sure they deliver the fundamentals of care effectively. The fundamentals of care include nutrition, hydration and bladder care. The Royal Marsden guidance says when monitoring fluid output, it is important for nursing staff to observe urine for colour, clarity/debris and any evidence of odour. Urine is a clear, straw-coloured fluid. The more concentrated urine is, the deeper yellow it becomes. An abnormal colour such as pink may be due to the presence of blood. If urine is cloudy, this may be an indication of infection in the urinary tract.

102. Mrs G told us the urine in her mother’s catheter bag on 12 April 2014 was extremely dark in colour. Mrs G was concerned this indicated there might be blood in her mother’s urine. The records support Mrs G’s recollection about the colour of her mother’s urine.

103. On the afternoon of 12 April 2014, a nurse noted that Mrs S’s urine output was tailing off and it was concentrated. Doctors reviewed Mrs S an hour later during a ward round. It is unclear if they reviewed Mrs S’s fluid balance chart but they noted Mrs S was well and her observations were stable. Doctors did not record any concerns about blood in Mrs S’s urine. That evening a nurse noted in the records they had encouraged Mrs S to drink fluids as her urine was concentrated. Mrs S’s urine output was measured an hour later. Another entry in the records by a different nurse also noted Mrs S’s urine was concentrated. A nurse recorded Mrs S’s urine output again at midnight.

104. On 13 April 2014, nursing staff appropriately escalated concerns to medical staff about Mrs S’s diminishing urine output. At midday Mrs S was made nil by mouth as she had difficulty swallowing. Nurses continued to monitor Mrs S’s urine output every two hours and gave her intravenous fluids at 4.00pm and 8.00pm. Mrs S’s urine output monitoring was increased to every hour on 14 April. The first time blood was found in Mrs S’s urine was on 14 April. A urine dipstick analysis confirmed the presence of blood and excess protein. The Orthogeriatrician Adviser said this indicated Mrs S’s kidneys were inflamed. This is known as nephritis. The Orthogeriatrician Adviser said this was because Mrs S’s kidneys were under significant stress by that point as a consequence of sepsis. They said it was not due to mismanagement of her medications. They said there were no concerns about a urinary tract infection or a problem with her kidneys. Therefore, there was no clear reason to do a urine dipstick test at any point in her care until 14 April.

105. Taking account of the above, the Nurse Adviser said it is evident Mrs S’s urine output was being monitored by nursing staff and they were alert to changes in the concentration and colour of her urine. There is no evidence in the records indicating blood in Mrs S’s urine before 14 April 2014. We acknowledge Mrs G’s view that since her mother’s urine was concentrated on 12 April, and given her risk of experiencing haematuria, Mrs S should have had her urine analysed daily. The Nurse Adviser said there is no national guidance which recommends routine daily testing for the presence of blood in a patient’s urine.

106. Based on the evidence we have seen so far, we are satisfied nurses appropriately monitored changes in the concentration of Mrs S’s urine and escalated their concerns to doctors when required. We are satisfied there was no clear indication of blood in Mrs S’s urine before 14 April 2014 and no requirement for nurses to test Mrs S’s urine daily for the presence of blood. In light of this, we are satisfied nurses at the Trust managed this aspect of Mrs S’s care in line with the Royal Marsden guidance.

Issue L – DVT/PE medication

107. DVT is where a blood clot forms in a deep vein in the body, usually the leg. A PE is where a blood clot blocks an artery supplying blood to the lungs, usually after it breaks loose from another part of the body.

108. Good Medical Practice says doctors must ‘prescribe drugs or treatment, including repeat prescriptions, only when [they] are satisfied the drugs or treatment serve the patient’s needs’. The hip fracture guidance recommends patients are given low molecular weight heparin (a blood-thinning drug which prevents blood clots from forming. It is known as an anticoagulant) for DVT/PE prophylaxis (meaning treatment) for 28 days after surgery.

109. Following her first operation, Mrs S was prescribed 40mg of Clexane via injection directly below the surface of her skin. This is a drug used to prevent blood clots in the deep veins in the legs and in the lungs. Doctors gave Mrs S one dose on 9 April 2014. It was then stopped because of the risk of internal bleeding.

110. One of the side effects of Clexane is an increased risk of bleeding, including in the renal (meaning, relating to the kidneys) tract and as a result of this, the patient may have blood in their urine. The Nurse Adviser said, although treatment with Clexane was stopped, the use of graduated compression stockings (known as mechanical prophylaxis) was continued. Mrs S was also prescribed 75mg of oral aspirin (this is a lower-strength blood thinning drug). This started on 10 April.

111. The Orthogeriatrician Adviser said the discontinuation of Clexane was entirely appropriate. The combination of aspirin and Clexane would have significantly increased Mrs S’s risk of internal bleeding. They said it was appropriate to continue treatment with aspirin as a means of trying to reduce Mrs S’s risk of stroke.

112. The Orthogeriatrician Adviser said Mrs S received appropriate treatment for DVT/PE. In light of this advice and taking account of the evidence set out above, we are satisfied doctors acted appropriately when they stopped Mrs S’s treatment with Clexane. They reviewed Mrs S’s blood thinning medication when it became apparent it would not serve her needs. This was in line with Good Medical Practice.

Issue M – Anti-fungal cream

113. The care home passed a copy of Mrs S’s medicine administration record sheet (MARS) to the Trust when she was admitted on 9 April 2014. It said Mrs S was being treated with two anti-fungal creams. These were miconazole 2% (used for either oral or skin fungal infections) and timodine cream (used to treat inflamed skin conditions).

114. Mrs G said her mother had miconazole with her when she was admitted. Doctors at the Trust prescribed both miconazole and timodine for Mrs S. There was a delay by the pharmacy in providing them. In line with the NMC Code, nurses should have recognised Mrs S’s needs in relation to her treatment with anti-fungal cream and taken appropriate steps to address that need. Nurses should initially have used the miconazole cream Mrs S had with her when she was admitted until more became available. There is no indication this happened.

115. According to the records, Mrs S should have had miconazole 2% applied to the relevant area of her body twice a day and timodine three times a day. Neither prescription said what part of Mrs S’s body the cream should be applied to. In light of this, nurses should have sought this information from the care home. There is no indication in the records that any action was taken to obtain this information.

116. The Nurse Adviser said according to the Trust’s MARS, nurses applied timodine six times out of a possible fifteen occasions when it should have been applied between 9 and 12 April 2014. Miconazole was not applied at any point. The Trust’s MARS said this was because there was no miconazole available. This is contradicted by an entry in the nursing records which said a nurse collected both anti-fungal creams from the pharmacy after midday on 10 April. Despite having the two necessary anti-fungal treatments available, nurses did not apply one as frequently as they should have done and did not apply the other at all. They also did not take any action to clarify where Mrs S’s prescribed anti-fungal treatments needed to be applied.

117. We can see why Mrs G and Mr G are concerned this could have resulted in an infection. Nurses did not adequately recognise Mrs S’s needs in relation to her treatment with anti-fungal cream or take appropriate steps to address that need. This was not in line with the NMC Code. We find this aspect of the care provided for Mrs S fell so far below the relevant standard it was service failure.

Issue N – Action taken in relation to sepsis, metabolic acidosis, urinary problems and electrolyte imbalance

118. The Orthogeriatrician Adviser said Mrs S was managed as having had an acute stroke on 13 April 2014, and it is clear from Mrs S’s fluid balance charts she was made nil by mouth at around midday on 13 April. In the early hours of 14 April, Mrs S’s urine output dropped and a medical review was requested. She was seen by a medical registrar when Mrs S’s blood tests showed a C-reactive protein (CRP) of 252. CRP is produced by the liver in response to inflammation. A high CRP is an indication of inflammation possibly due to infection somewhere in the body. A CRP test result of more than 200 milligrams per litre (mg/l) is an indication of severe inflammation or infection.

119. Mrs S had a white cell count (WCC) of 6.3 k/uL. A normal range for white blood cells is 5 to 10 thousand per cubic millilitre (k/uL). Mrs S had a very fast heart rate of 120 beats per minute. The registrar prescribed Mrs S digoxin, which is a drug used to treat irregular heart rate. The registrar requested a chest X-ray to exclude lung infection known as aspiration pneumonia, which is caused by material from the mouth or stomach entering the lungs, as a possible cause of her symptoms. The registrar noted Mrs S was already on a broad-spectrum antibiotic called teicoplanin.

120. The Orthogeriatrician Adviser said blood cultures (this is where a person’s blood is tested for the presence of foreign material such as bacteria or fungus) and a venous/arterial blood gas test (these are tests to establish the level of carbon dioxide in the person arterial blood and venous blood) done at that stage may have suggested a metabolic acidosis. This is a condition where there is too much acid in the body’s fluids. They explained that metabolic acidosis can be due to a variety of causes. However, where a person has a high lactic acid level and normal kidney function, the cause is most commonly due to sepsis. The Orthogeriatrician Adviser said metabolic acidosis is treated with broad spectrum antibiotics and intravenous fluids. They said the absence of the above tests (meaning blood cultures and venous/arterial blood gas tests) did not affect Mrs S’s management as she was started on broad spectrum antibiotics on the 12 April 2014 and intravenous fluids were also ongoing.

121. The Orthogeriatrician said Mrs S’s urine output was adequate for the whole of the 13 April at 35 to 40ml per hour and a total output of 1029ml in 24 hr. The Orthogeriatrician Adviser said there is no suggestion Mrs S had any urinary problems apart from her declining urine output in the early hours of 14 April, which was as a consequence of her progressive sepsis.

122. The Orthogeriatrician Adviser said Mrs S’s electrolytes were marginally deranged (meaning not within the normal range). They said her sodium and calcium levels were a little low. The Orthogeriatrician Adviser said this level of derangement is commonly seen in frail older patients and was unlikely to have had any impact on her overall condition.

123. The Orthogeriatrician Adviser said Mrs S’s condition continued to deteriorate and she did not respond to her treatment. Mrs S was reviewed in the morning of 14 April 2014 when she was noted to have severe metabolic acidosis. The Orthogeriatrician Adviser said the blood test results indicated severe sepsis. Doctors requested a urine dip stick test and repeat blood tests. A venous blood gas test at midday showed Mrs S’s blood was even more acidic. This was a sign her condition had deteriorated further. The Orthogeriatrician Adviser said Mrs S’s condition was rapidly deteriorating at that point. They said Mrs S’s sepsis was managed appropriately in that broad spectrum antibiotics had been prescribed and fluid resuscitation was started on 13 April 2014.

124. We acknowledge Mrs G and Mr G’s concerns about these aspects of Mrs S’s care. Mrs S’s condition rapidly deteriorated on 14 April. Doctors did what they could to treat her deterioration and investigate the cause of her symptoms. The Orthogeriatrician Adviser said while investigations are useful in cases of sepsis, treatment has to be based on observation of the patient’s condition and guided by experience. This is what happened in Mrs S’s case.

125. Mrs S was assessed appropriately in the early hours of 14 April and adequate treatment was provided in response to her symptoms. Blood and urine cultures were not a viable option at that stage as the results would have taken days before they were available. Mrs S had no specific urinary problems apart from declining output and her slightly low electrolyte levels were a consequence of the overall deterioration in her condition. At the point metabolic acidosis and sepsis were diagnosed, Mrs S was already receiving the relevant treatment for both conditions in that she had been prescribed antibiotics and intravenous fluids. In light of this, we are satisfied the conditions referred to by Mrs G and Mr G were appropriately investigated and treated where possible. This was in line with Good Medical Practice.

Issue O – Diuretic medication

126. Good Medical Practice says doctors must ‘prescribe drugs or treatment, including repeat prescriptions, only when [they] are satisfied the drugs or treatment serve the patient’s needs.’

127. An orthogeriatrician reviewed Mrs S in the Trust’s emergency department in the morning of 9 April 2014. The orthogeriatrician noted Mrs S’s blood test results showed she had low sodium and potassium. The orthogeriatrician wrote ‘hold co-amilofruse’ and ‘replace potassium’ in Mrs S’s records. Co-amilofruse is a type of drug known as a diuretic. Diuretic drugs help the body expel excess fluid. They are also used to treat high blood pressure, which was the case for Mrs S.

128. The Orthogeriatrician Adviser said low blood pressure is a common occurrence in patients with hip fracture and it is appropriate in such circumstances to discontinue blood pressure medication. He also said in Mrs S’s case, her low sodium could have been due to her treatment with co-amilofruse. In light of this, they said it was entirely appropriate for the orthogeriatrician to stop treatment with this medication at her preoperative review on 9 April. Mrs G and Mr G told us they believe nurses kept giving Mrs S this drug despite the orthogeriatrician’s instruction to stop it. Mrs S’s ‘as required’ prescription chart includes co-amilofruse. However, the chart says it was never given to Mrs S by nurses. The Orthogeriatrician Adviser said there is no evidence in the rest of the records that co-amilofruse was given to Mrs S at any point during her admission.

129. We consider the decision to stop Mrs S’s treatment with co-amilofruse was appropriate. We are satisfied the notes made by the orthogeriatrician, although brief, indicate why they stopped treatment with this drug. We can see this decision was taken before Mrs S’s surgery and not after as Mrs G and Mr G initially thought. We hope Mrs G and Mr G take some reassurance from this. The orthogeriatrician stopped Mrs S’s treatment with co-amilofruse as it no longer served her needs. This was in line with Good Medical Practice.

Issue P – Mrs S’s death certificate

130. Mrs G and Mr G say it took the doctor a considerable amount of time to obtain the death certificate after Mrs S died as it appears this doctor had to go to various departments. Mrs G and Mr G are questioning why the Trust did not consider performing a post-mortem, considering the uncertainty of what caused her stroke like symptoms/opiate overdose. They are also concerned at the accuracy of the full recording of the cause of death and contributory factors.

131. Mr G told us he had to chase doctors for the relevant certificate so he could register her death. He said it was the beginning of a religious festival for him and his family and if he did not receive the certificate quickly, his grandmother’s funeral would be delayed. Mr G said despite him chasing this several times, it took an hour for doctors to provide the certificate by which time it was too late and the funeral was delayed.

132. The Orthogeriatrician Adviser said in line with the hip fracture guidance, the Trust provided multidisciplinary care for Mrs S involving orthopaedic, orthogeriatrician and anaesthetist teams. They said in order to ensure Mrs S’s death certificate was as accurate as possible, discussions needed to take place between these various teams. They said the coroner also needed to be informed before the cause of death certificate could be issued as Mrs S had undergone surgery. They said this was a legal requirement.

133. The Orthogeriatrician Adviser said a post-mortem is generally requested either by the doctor responsible for the patient if the cause of death is uncertain or by the coroner for specific reasons. They said as mentioned above, Mrs S’s case was discussed with the coroner as she had had surgery within the previous 28 days. They said the coroner has to be satisfied with the cause of death and they may suggest the information to be put on the death certificate.

134. Mrs G and Mr G say the death certificate is inaccurate because it does not reflect a full recording of the cause of death and contributory factors. Mrs G is concerned massive stroke was included on her mother’s death certificate when this was never confirmed and both Mrs G and Mr G consider that Mrs S’s revision surgery should have been included on the death certificate. We acknowledge it was unclear initially whether Mrs S had definitely had a stroke especially as her CT head scan showed no clear changes. However, towards the end of Mrs S’s life, doctors considered stroke to be the most likely cause of her deterioration. A consultant orthogeriatrician met Mrs S’s family in the afternoon on 14 April 2014 and explained she had experienced a massive stroke. Mrs S’s records confirm a doctor spoke to the coroner and discussed Mrs S’s history, recent operations including the revision surgery and clinical stroke. During this conversation, the information to be recorded on the death certificate was discussed and agreed. This included a primary cause of death of ‘massive cerebrovascular accident (CVA)’. CVA is the medical term for a stroke. We are persuaded the doctor who completed the death certificate was guided by what the coroner’s office told them. This conclusion is based on the fact that the Trust’s doctor referred to ‘massive CVA’ and the ‘revision surgery’ when noting Mrs S’s cause of death in the records. The same doctor also mentioned ‘clinical stroke’ and ‘operation and revision’ in the summary of the call with the coroner’s office. However, this was changed to ‘massive CVA’ as the primary cause of death and ‘Right neck of femur fracture 9 April 2014’ as a contributory factor in the clinical records and in the death certificate. This change implies the coroner’s office agreed the cause of death but decided not to include a reference to the revision surgery as contributory factors in the death certificate. Taking account of this, we cannot see the death certificate was inaccurate.

135. In line with the Principles, we would expect the Trust to have behaved helpfully in relation to providing Mrs S’s death certificate and dealt with this promptly. The doctor who provided the death certificate had to discuss Mrs S’s cause of death with various teams and the coroner. He passed the certificate to Mr G an hour after Mrs S died. We are satisfied the doctor did so as promptly as possible in the circumstances. We note the coroner agreed Mrs S’s cause of death and contributory factors as set out in her death certificate. That said, we acknowledge the impact the time taken to provide the death certificate had for Mrs S’s family. Given the fact Mrs S’s funeral was delayed we can understand why this was upsetting for Mrs G and Mr G.

Issue Q – Record keeping

136. On 1 March 2014, the CQC published a report of its inspection of hospital A, where Mrs S was treated in April 2014. At the time, hospital A was part of a different Trust. It became part of the Trust on 1 July 2014. The CQC’s report: ‘identified some shortfalls in record keeping in different areas of the hospital. Some of these related to incomplete records of checks of key equipment used in the care and treatment of patients. In addition, some patient records were not accurately maintained in respect of checks carried out during and after surgery to ensure surgical procedures were conducted safely.’

137. In relation to record keeping, Good Medical Practice says doctors should have ensured the documents they made (including clinical records) to formally record their work were clear, accurate and legible. They should have made records at the same time as the events they were recording or as soon as possible afterwards. It also says clinical records should include:

· relevant clinical findings · the decisions made and actions agreed, and who is making the decisions and agreeing the actions · the information given to patients · any drugs prescribed or other investigation or treatment; and · who is making the record and when

138. The NMC Code says nurses must ‘must keep clear and accurate records of the discussions you have, the assessments you make, the treatments and medicines you give, and how effective these have been'.

139. Our clinical advisers reviewed Mrs S’s records and commented on their accuracy. The Anaesthetist Adviser explained anaesthetic record charts are designed by individual local anaesthetic departments with reference to the minimum standards set out in Good Medical Practice. They said the anaesthetic record charts used by the Trust to record the care provided for Mrs S were completed appropriately in accordance with Good Medical Practice.

140. The Surgeon Adviser said in general the Trust’s record keeping in relation to Mrs S’s operations was poor. They said there was no detailed documentation on what the post-operative X-ray after the first surgery showed, no clear information about the need for urgent revision surgery and no detailed record of the discussion with Mrs S about the risks and complications of the revision surgery. The Surgeon Adviser also noted the documentation about the level of supervision for first operation was poor. Surgical staff at the Trust did not record all relevant clinical findings or full details of the decisions they made and the actions agreed. This was not in line with Good Medical Practice.

141. The Orthogeriatrician Adviser said all but one entry in the records had the date, time, name and grade of doctor recorded. The entry missing this information relates to a review by a middle grade doctor on 13 April 2014. We know from Mrs G the review took place that day. Given there was only one poorly recorded entry we are satisfied overall, the record keeping by medical staff was in line with Good Medial Practice.

142. As already mentioned, we identified failings in the nutrition and fluids care nurses provided for Mrs S. Nurses did not keep full and accurate records of Mrs S’s fluid balance, record their intended actions to prevent weight loss and did not update Mrs S’s nutritional care plan appropriately. The Nurse Adviser said considering Mrs S’s records overall, there is evidence of nursing assessment, including risk assessments (such as pressure ulcer assessments and falls, moving and handling assessments). They said nursing entries in the multidisciplinary health record sheet are appropriate and indicate what care was implemented, the impact of interventions and the interactions which took place with Mrs S, her family and other members of the multidisciplinary team.

143. However, the Nurse Adviser said Mrs S’s care plans are generic and specific actions are not highlighted on those care plans. They said this does not demonstrate any consideration of a person-centred approach to care delivery. The evidence above shows nurses at the Trust did not keep clear and accurate records of the assessments they made or the treatments they gave Mrs S. This was not in line with the NMC Code.

144. Taking account of the evidence in Mrs S’s records and our clinical adviser’s advice, we can see parts of Mrs S’s records were completed appropriately in line with relevant standards. That said, we have identified significant failings in the record keeping by surgical staff and nurses at the Trust. We find their record keeping fell so far below the relevant standard it was service failure.

Issue R – Communication

145. Good Medical Practice says doctors must ‘be considerate to those close to the patient and be sensitive and responsive in giving them information and support’ It also says doctors ‘should accommodate a patient’s wishes if they want another person, such as a relative, partner, friend, carer or advocate, to be involved in discussions or to help them make decisions’.

146. A consultant orthogeriatrician reviewed Mrs S in the evening of 10 April 2014. They scheduled her for revision surgery the following morning (11 April). Given the serious nature of Mrs S’s revision surgery and the risks involved, doctors at the Trust should have sought Mrs S’s consent to contact her family to tell them about the operation. There is no evidence that clinical staff took steps to try and inform Mrs S’s family that she required a second operation. Mrs G was only informed about the revision surgery when she visited her mother on 11 April. This was not in line with Good Medical Practice.

147. During local resolution, the Trust said it accepted Mrs G and Mr G should have been informed Mrs S required a second operation. The Trust told them in future it would find out if families wanted to be informed if further operations were required. We can see why Mrs G and Mr G remained unhappy at this explanation. The Trust did not set out how it intended to do what it said it would. The Trust provided us with a further response about this issue. The Trust told us it understands the worry a patient’s family experiences, and their wish to be informed of any procedures. As such, the Trust said ward staff will now ensure if a patient has been informed of the need for impending surgery, they will ask the patient if he or she would like their next of kin to be contacted. We are satisfied the action proposed by the Trust is in line with the standards set out in Good Medical Practice.

148. A physiotherapist reviewed Mrs S on Sunday 13 April 2014. During the review, Mrs S became unresponsive. A doctor reviewed Mrs S and contacted an HASU for advice. Mrs G and Mr G told us the Trust contacted them shortly afterwards to say Mrs S had collapsed and become unresponsive about half an hour before. They were told Mrs S was going in for a CT scan because of a suspected stroke. Based on this, we are satisfied doctors at the Trust appropriately contacted the family to inform them about Mrs S’s deterioration and this was done without any delay.

149. Mrs G told us when she arrived to see her mother on 13 April 2014, she was told her mother’s CT scan did not indicate she had suffered a stroke. Mr G told us a doctor met his mother that evening and confirmed his grandmother had experienced a stroke. Mr G said at no point did doctors indicate how bad the stroke was.

150. It is clear from the records that when Mrs S collapsed, doctors suspected the cause was a stroke. This was communicated to Mrs S’s family when the Trust called them. Mrs S’s CT head scan showed no acute changes in her brain. This was explained to Mrs S’s family when they arrived to see Mrs S. This did not mean Mrs S did not suffer stroke. It meant that, based on the CT scan results, doctors could not say how severe the stroke was or what part of Mrs S’s brain was affected. In the circumstances, it would have been helpful if doctors had been clearer about this in the discussion with Mrs S’s family. Based on the information available to them at the time, doctors could not definitively say how ill Mrs S was on 13 April 2014. The severity of Mrs S’s stroke only became clear when her condition deteriorated further on 14 April. At that point, doctors confirmed Mrs S had experienced a massive stroke. Taking account of the evidence, even though they could not say how ill Mrs S was until the evening, we are satisfied doctors were sensitive and responsive in providing the information they could about Mrs S’s condition on 13 April. This was in line with Good Medical Practice.

151. When Mrs S was admitted on 9 April 2014, a senior house officer completed a ‘neck of femur fracture admission checklist’. The section of the form which should record resuscitation status, meaning DNAR or full resuscitation, was not completed. A DNAR form was completed for Mrs S on 14 April after her condition rapidly deteriorated in the early hours of the morning. The Orthogeriatrician Adviser said they were not aware of any guidance in place at the time about when DNAR forms should be completed. However, they said due to the high mortality of hip fracture patients, it is appropriate to discuss patients’ and or carer’s views on resuscitation at the time of admission. They said this is why it is part of the neck of femur fracture admission checklist. We have seen no evidence the DNAR decision was discussed with Mrs S or her family at any point during her admission. This was not in line with Good Medical Practice.

152. We have found failings in the Trust’s communication with Mrs G and Mr G in relation to informing them about Mrs S’s revision surgery and discussing the DNAR decision. We find these failings fell so far below the relevant standard it was service failure.

Summary

153. We found failings in the following aspects of the care provided for Mrs S:

· the way Mrs S’s first operation was carried out · Mrs S was not given high-dose aspirin within 24 hours of her stroke · the management of Mrs S’s food and fluid care and the way this was documented · the Trust’s record keeping · that nurses did not provide Mrs S with appropriate anti-fungal treatment; and · the decision not to resuscitate Mrs S was not discussed.

Impact of the failings identified and our decision

154. Mrs G and Mr G believe the true cause of Mrs S’s condition could have been diagnosed sooner to avoid hastening her death if the Trust had taken other action. This relates to the clinical aspects of the care and treatment provided so we will start by considering those.

155. We have found Mrs S’s first surgery was not carried out appropriately. Our investigation established that a cemented prosthesis should have been used. Had a cemented prothesis been used, it would have reduced the risk of further surgery. In its comments to us, the Trust said it believed a surgical accident caused a perforated femur which should have been recognised. The Trust said therefore neither cemented nor un-cemented prostheses would have made a difference as this was a surgical accident. The Trust said the operation was done by competent surgeons, however a mistake was made and unfortunately occasionally this happens. It said: ‘the gross operative abnormality on the balance of probability should have been recognised perioperatively and the Trust’s failure to do so fell below an acceptable standard of care’. The Surgeon Adviser said older patients such as Mrs S have weaker bones than younger patients. They said as their bones are softer, there is always a risk of periprosthetic fractures during a hemiarthroplasty procedure. They said the risk is increased by using an uncemented prosthesis. They said the risk is not increased by a great deal, but it is still higher than with a cemented prosthesis.

156. The Surgeon Adviser said with an uncemented prosthesis, the surgeon uses a tool called a rasp. This is used to scrape away bone in the canal of the femur. This is done to shape the canal appropriately to ensure a good fit for the prothesis. In Mrs S’s case, the Surgeon Adviser could not say whether the use of rasps caused her fracture or whether this was caused by the stem of the prosthesis when it was inserted. The Surgeon Adviser said the use of cement provides a degree of cushioning for the prosthesis when it is inserted. This means it is less likely to fracture the femur. The Surgeon Adviser said this is why the hip fracture guidance recommends the use of a cemented prosthesis for the type of surgery Mrs S had. In light of this advice, we consider it more likely than not a cemented prosthesis would have reduced the risk of fracture occurring and the need for revision surgery.

157. The Surgeon Adviser said surgery for a fractured neck of femur is associated with a risk of mortality which is increased with age and associated health conditions. These are known as comorbidities. The Surgeon Adviser said it is highly likely a second operation soon after the first surgery had a significant impact on Mrs S’s overall risk of dying.

158. The Orthogeriatrician Adviser said Mrs S was already at risk of stroke even before she was admitted because of her atrial fibrillation (irregular heartbeat), which they said in itself increased her risk of stroke. The Orthogeriatrician Adviser said Mrs S’s key factors for having a stroke were atrial fibrillation, her age and the fact she could not be given any anti-clotting medication. They said her risk of stroke was also slightly increased by her need to have two surgeries in quick succession. However, the Orthogeriatrician Adviser said there was no clear causal link between Mrs S’s revision surgery and her having a stroke, beyond the ongoing risk factors already mentioned (unable to have anti-clotting medication, atrial fibrillation and her age). The Orthogeriatrician Adviser said even if the first operation had been carried out appropriately and Mrs S had been given adequate food and fluids, her risk of stroke would have remained the same.

159. The Orthogeriatrician Adviser said the management of Mrs S’s nutrition had no bearing on her risk of stroke because a lack of nutrition and risk of stroke are not linked. The Orthogeriatrician Adviser also said the only thing that could have addressed Mrs S’s stroke was thrombolysis (drug treatment to dissolve clots in blood vessels) but this was not an option due to her risk of bleeding from her surgical site. They said given her significant health issues and deterioration on 14 April 2014, not giving her aspirin on 13 April did not affect the outcome for Mrs S.

160. Taking account of the advice we have received, the factors which contributed to Mrs S’s stroke and ultimately her death were her age, her atrial fibrillation, having to have hip fracture surgery, having to have revision surgery and not being able to have anti-clotting medication. In light of this, we cannot say that had the failing in Mrs S’s first surgery not occurred, she would not have had a stroke and died when she did. However, if not for the failing in Mrs S’s hip fracture surgery, she would not have required revision surgery. Further surgery placed her at increased risk of dying. We consider Mrs S was placed at increased risk of dying as a result of the failings in her first operation. This was an injustice to Mrs S which occurred as a result of the service failure we identified. In light of this, although we cannot say Mrs S’s death was avoidable, we agree with Mrs G and Mr G that there was a missed opportunity by the Trust to prevent Mrs S dying when she did. This was an injustice to Mrs S. We have no doubt the thought Mrs S was not given the best possible chance to recover will confirm Mrs G and Mr G’s worst fears. We acknowledge it will cause them significant distress beyond that they experienced at the loss of their mother and grandmother. This was an injustice to Mrs G and Mr G. In light of this, we uphold their complaint about the way Mrs S’s first operation was carried out.

161. We found failings in the way Mrs S’s food and fluids were managed, and the fact she was not given high-dose aspirin within 24 hours of her stroke. These failings did not affect the outcome for Mrs S. As mentioned, a lack of nutrition had no bearing on Mrs S’s stroke. Mrs S was already prescribed aspirin prior to her stroke, and we cannot say not being given high-dose aspirin within 24 hours of her stroke contributed to her death. This is because she did not have a further stroke as a result of not being given this drug. However, the failings in the management of Mrs S’s food and fluids and the lack of appropriate treatment with high-dose aspirin meant Mrs S was not given the best chance possible to recover. This was an injustice to Mrs S. We have no doubt this knowledge will cause Mrs G and Mr G distress. This was an injustice to them that occurred as a result of the service failure. In light of this, we uphold these aspects of their complaint.

162. Mrs S experienced pain as a result of the Trust’s failure to provide anti-fungal cream. Mrs G said by 12 April 2014, the sides of her mother’s mouth had been left to get so sore they bled. Mr G told us the following day, his grandmother pointed to the side of her mouth, which was extremely red, and indicated to him she was in pain. Nurses did not apply Mrs S’s prescribed miconazole cream at any point. This should have been used to relieve the soreness Mrs S was experiencing. Had nurses at the Trust treated Mrs S with miconazole from the point she was admitted, it is more likely than not that the soreness and bleeding at the side of her mouth would not have become as bad as they did. Mrs S experienced pain as a result of the Trust’s failure to provide appropriate anti-fungal treatment. This was an injustice to Mrs S. We have no doubt witnessing Mrs S’s unnecessary pain caused Mrs G and Mr G distress. This was an injustice to them that occurred as a result of the service failure. In light of this, we uphold this aspect of Mrs G and Mr G’s complaint.

163. Turning to the non-clinical issues we identified, there were failings in the Trust’s record keeping and communication with Mrs G and Mr G. Aspects of the nursing records were completed appropriately. There were also failings in record keeping by surgical staff. These inaccuracies and omissions were insensitive and unnecessary. Also, we cannot see the Trust has acknowledged the DNAR decision was not discussed with Mrs S or her family at any point. Mrs G and Mr G only found out about this after Mrs S died. We can see how poor record keeping by the Trust undermined Mrs G and Mr G’s confidence in the care provided for Mrs S and added to the distress they experienced. We have no doubt learning the DNAR decision was put in place without any discussion with Mrs S or themselves compounded the distress Mrs G and Mr G experienced at what was already a distressing time for them, given the loss of Mrs S. In light of this, we uphold these aspects of Mrs G and Mr G’s complaint.

164. In summary, Mrs S was placed at increased risk of dying as a result of the failings in her first operation, was not given the best chance possible to recover and experienced unnecessary pain as a result of not being provided with appropriate anti-fungal treatment. We cannot say Mrs S’s death was avoidable. However, it is clear the injustices to Mrs S caused Mrs G and Mr G to experience significant distress at what was already a distressing time. The Trust’s actions caused unremedied injustice to Mrs G and Mr G.

165. Weighing the failings against the aspects of care where we found no failings, overall we partly uphold the complaint.

1. The findings set out below provide our decision on this case.

2. We find there were failings in relation to:

· the way the Trust carried out Mrs S’s first operation · not giving Mrs S high dose aspirin within 24 hours of her stroke · the management and documentation of her food and fluids · the Trust’s record keeping · the failure to apply anti-fungal treatment; and · the lack of discussion with Mrs S’s family about a do not attempt to resuscitate decision.

These failings had a significant impact on Mrs S. They placed her at increased risk of dying as a result of unnecessary revision surgery. Her lack of nutrition did not give Mrs S the best chance to recover. She also experienced unnecessary pain as she was not being provided with appropriate anti-fungal treatment. We cannot say Mrs S’s death was avoidable. However, it is clear the injustices to Mrs S caused Mrs G and Mr G to experience significant distress at what was already a distressing time and will leave them believing the outcome may have been different if Mrs S’s treatment had been carried out as it should have been. The Trust’s actions caused unmediated injustice to Mrs G and Mr G.

3. We find there were no failings in relation to:

· supervising Mrs S’s first operation · handling Mrs S’s ability to consent to her revision surgery and blood transfusion · not transferring Mrs S to a high dependency unit (HDU) after her first operation · stopping her treatment with a diuretic medication · stopping her treatment with blood clotting medication · scheduling her second operation · managing Mrs S’s anaesthetic during her second operation · taking no X-ray after Mrs S’s second operation · investigating her symptoms after doctors suspected a stroke · diagnosing and treating opioid overdose · not transferring Mrs S to a hyper acute stroke unit (HASU) on 13 April 2014 · treating Mrs S for sepsis, metabolic acidosis, urinary problems, and electrolyte imbalance · monitoring Mrs S’s urine · providing Mrs S’s death certificate; and · deciding not to carry out a post-mortem.

4. We partly uphold Mrs G and Mr G’s complaint about the Trust. Our decision is based on our consideration of the evidence we have seen.

5. The Trust agreed to:

· write to Mrs G and Mr G to acknowledge the failings we found and apologise for the distress these caused · make a payment of £6,000 in recognition of the distress caused; and · write to explain what it has done or will do in future to minimise the chances of the failings we have identified happening again.

166. 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.

167. Our view is that a financial remedy for the injustices we identify is appropriate. In order to determine a level of financial remedy, we review similar cases where similar injustice has arisen. We also consider the impact on an affected person. When determining severity, we consider, among other things: how long the failures impacted on the person affected; what that impact was; any ongoing/long-term impact; and the extent this affected the person’s ability to live a normal life (that is, to go about life unhindered). We find the injustices set out are evidence of failures in care which caused Mrs S’s family distress and added to the bereavement they experienced following her death. We cannot remedy the injustice to Mrs S at this stage. Taking account of this, we recommend within a month of this report, the Trust:

· write to Mrs G and Mr G to acknowledge the impact of the failings identified and apologise; and · make a payment of £6,000 to compensate them for the impact.

Our Principles say public organisations should seek continuous improvement and should use the lessons learnt from complaints to ensure they do not repeat maladministration or poor service. In line with this, we recommend within three months of this report the Trust explains in writing what it has done or will do in future to ensure another patient does not have further surgery to correct poorly carried out hip fracture surgery. The Trust should also explain how it will ensure improved accuracy and thoroughness in future record keeping including the documentation of patients’ food and fluid care. The Trust should explain what it will do to ensure patients receive all necessary treatments and medications (including high-dose aspirin and anti-fungal treatments) and what it will do when these are unavailable from its pharmacy. The Trust should also explain what it will do to ensure DNAR decisions are appropriately discussed with family members. A copy of this should be shared with us and Mrs G and Mr G. The Trust should also forward a copy of our report and its action plan to NHS Improvement and the Care Quality Commission (CQC). It should confirm to us when this has been done.

168. In this report we have set out our decision. We have thoroughly and impartially investigated the complaint and drawn conclusions from careful consideration of the evidence. We partly uphold Mrs G and Mr G’s complaint.