Lancashire Teaching Hospitals NHS Foundation Trust

9. Mrs I complains about the care and treatment the Trust provided to her mother, Mrs A, in May 2020. Specifically, she complains that:

· staff at hospital A, part of the Trust, placed her mother on a ward with other patients who had COVID-19. She says her mother, who had been isolating prior to her stay, caught COVID-19, and died. Mrs I is also concerned the hospital did not keep hygiene records for the month of May · a member of staff initially advised that the hospital would discharge her mother after a couple of days, but this did not happen. She feels the Trust could have discharged her mother sooner · doctors at hospital A transferred her mother to Hospital B prior to her death. She says they told her this was for dialysis, but she feels it was because they had given up hope and were sending her there to die · doctors enrolled her mother on a COVID-19 trial despite her not having capacity to consent to this. She feels the doctors should have encouraged her mother to speak to her family first

10. Mrs I feels due to failures by the Trust, her mother caught COVID-19 and died. She feels if the hospital discharged her mother earlier, she would not have caught COVID-19. She says the Trust robbed her of time with her mother, causing her hurt and upset.

11. Mrs I says the Trust not following protocols has undermined her faith and confidence, leaving her terrified of going to hospital. She says the poor communication was frustrating and exacerbated her grief.

12. As an outcome to the complaint, Mrs I would like an apology, service improvements, and financial compensation.

13. On 11 May, Mrs I took Mrs A to A&E at hospital B (part of the Trust) as she had pains in her left leg. She lived with her husband, was housebound, and unable to walk. There were no beds available at hospital B, so the Trust transferred her to hospital A (also part of the Trust).

14. The Trust admitted Mrs A to the Medical Assessment Unit (MAU) where she was treated for suspected Deep Vein Thrombosis (DVT). Mrs A had a COVID-19 test on 12 May, which came back negative. The Trust were considering discharging Mrs A to her cousins, as the family had raised safeguarding concerns around Mrs A returning home.

15. On 14 May, the clinical team performed a CT scan to assess if there was any underlying malignancy for the DVT. The CT scan showed the clot had extended into the major vein within Mrs A's abdomen, there was a mass associated with her right ovary, fluid around her heart, and an abnormality in the lining of her stomach. The clinical team arranged further tests to investigate these findings.

16. On 15 May, the Trust transferred Mrs A to an elderly medicine ward. The clinical staff on this ward diagnosed her with a urinary tract infection (UTI) and some possible neoplastic lesions (an abnormal growth of cells) on her face.

17. On 17 and 18 May, three other patients that had stayed on the same wards as Mrs A tested positive for COVID-19. The clinical team isolated Mrs A in a bay on 17 May and monitored her for symptoms. On 18 May, her condition appeared to be improving but she was still awaiting a gastroscopy in relation to the abnormality the CT scan showed in her stomach lining.

18. On 19 May, Mrs A became unwell and had a temperature. The clinical team retested her for COVID-19. The test returned positive, and the Trust moved her to a dedicated COVID-19 ward. Mrs A subsequently developed an Acute Kidney Injury (AKI) on 28 May.

19. On 3 June, doctors arranged to transfer Mrs A back to hospital B as they felt she may be suitable for Continuous Positive Airway Pressure (CPAP) treatment for her COVID-19 infection. CPAP is a machine which delivers air into the airways and is a recognised treatment for COVID-19. The Trust also thought Mrs A may benefit from dialysis for her AKI.

20. On arrival at hospital B, the clinical staff there decided Mrs A was not suitable for either CPAP or dialysis. Mrs A sadly died on 5 June.

COVID-19 infection

Placement on a ward with other COVID-19 infected patients

24. Mrs I complains staff at Hospital A placed her mother on wards with other patients who had COVID-19. She says her mother, who had been isolating prior to her stay, caught COVID-19, and died.

25. Mrs A presented at Hospital A on 11 May 2020 and tested positive for COVID-19 on 19 May (eight days later). During this time, she spent time on MAU and the elderly medicine ward.

26. In its complaint response, the Trust said that Mrs A likely did catch COVID-19 in Hospital A. It explained that a study funded by Public Health England had looked at whether COVID-19 infections were hospital acquired. The study considered the length of stay prior to catching COVID-19. It considered that a positive test result eight to 14 days after admission meant the likelihood of the infection being hospital acquired was ‘probable’.

27. We understand why Mrs I is so concerned about Mrs A catching COVID-19 while in hospital. We have checked to see whether the Trust were following the national guidance in place at the time to help reduce the spread of infection.

28. Public Health England’s COVID-19 infection prevention and control guidance says, wherever possible, hospitals should place patients with possible or confirmed COVID-19 in single rooms. It says if a single room is not available, the clinical team should place possible or confirmed respiratory infected patients together. It states that where possible, the hospital should use a self-contained area or wing for the treatment and care of such patients.

29. At the time, the Trust was placing patients who had a positive COVID-19 test, or significant changes on chest X-rays or CT, scans into ‘red’ zones. The clinical team were caring for patients who had symptoms of COVID-19 separately while awaiting their test results.

30. The Trust placed patients who had a negative test result, or did not have COVID-19 symptoms, into ‘green’ zones. As Mrs A did not have symptoms of COVID-19 on admission, and her test was negative, the Trust placed her in a green zone. This was in line with the COVID-19 infection prevention and control guidance.

31. The Trust carried out a review of every confirmed COVID-19 patient to determine how they became infected. The Trust’s review of Mrs A’s infection showed that she had been in proximity to three other patients who also tested positive for COVID-19 while on MAU and the elderly medicine ward. All three patients had tested negative for COVID-19 on admission to the wards, and so the Trust placed them in green zones too.

32. In summary, we have not seen any failings in the Trust’s placement of Mrs A on a green ward following admission. The other patients on this ward had also tested negative on admission. This was in line with COVID-19 infection prevention guidance.

Hygiene records

33. Mrs I is also concerned the hospital did not keep adequate hygiene records for the month of May.

34. The NHS England and NHS improvement guidance for standard infection control precautions says that organisations must implement infection control measures and monitor compliance of this.

35. In line with this guidance, the Trust has its own policy to ensure compliance with infection control measures. Its policies for hand hygiene and environmental cleaning both state the hospital should complete audits monthly. The Trust explained that during the month of May, there was no data collected for the elderly medicine ward in relation to hand hygiene and environment. The Trust said that this was because of reduced staffing levels within the team and pressures due to the pandemic.

36. The Trust have acknowledged this was unsatisfactory. The Trust were under a period of immense pressure at the time, and we accept this has likely contributed to it not completing the audits. However, we agree this was a failing as this was not in line with the Trust’s own policies for monitoring compliance of infection control measures.

37. The lack of audit records for the time that Mrs A was in hospital means Mrs I lacks confidence that the Trust were correctly following infection control measures. However, our adviser explained it is not possible, on the balance of probabilities, to link the lack of audits that month to Mrs A catching the virus.

38. While the Trust did not complete the audits as they should have done, this does not mean that hospital staff were not taking the correct measures, in relation to hand hygiene and environment. Staff may still have been following the correct procedures despite the audits not taking place. The Trust explained in the complaint response that all staff have regular training and assessment of hand hygiene as part of their training.

39. We also know that Mrs A was in proximity to at least three other patients who also had the infection. COVID-19 is an airborne infection and so it is possible she could have caught the infection through droplets or small airborne particles too.

40. As such, although we have identified a failing in relation to monitoring infection control measures, we cannot link this failing to Mrs A catching COVID-19.

Delayed discharge

41. Mrs I complains a member of staff initially advised her the hospital would discharge Mrs A after a couple of days, but this did not happen. She feels the Trust could have discharged her mother sooner.

42. The Department of Health ‘Ready to Go?’ guidance says that ‘home care arrangements can usually be set up quickly once the patient is clinically well enough and safe for transfer’. It also says the ‘estimated date of discharge is based on the expected time required for tests and interventions to be completed, the integrated care pathway and the time it is likely to take for the patient to be clinically stable and fit for discharge’.

43. There seem to have been three issues that complicated Mrs A’s discharge from hospital. One of these was her clinical condition, and the abnormalities shown on her CT scan. The second issue was the opinion of therapists that she was not yet safe for discharge due to her poor mobility. The third issue complicating her discharge were the safeguarding concerns and the decision on where to discharge her to.

44. The physiotherapists documented on 12 May that Mrs A was not safe for discharge due to her poor mobility. On 13 May, a doctor documented that Mrs A was not well enough for discharge. On 18 May, a member of staff documented that the safeguarding issues were still ongoing. This meant that Mrs A remained in hospital.

45. Mrs I says the discharge facilitator initially told her that her mother would be ready for discharge within a few days. We cannot see any specific documentation within the medical records which evidences the discharge facilitator told Mrs I this. That is not to say this did not occur, as we acknowledge the discharge facilitator may not have documented this conversation.

46. What we can see is that the discharge facilitator started enquiries regarding discharge with the family as early as 12 May. This is in line with the national guidance to try and avoid delays in discharges. We also acknowledge it can be difficult to predict when a patient will be ready for discharge, as this depends on multiple factors and can change depending on the patient’s changing clinical condition and circumstances.

47. Overall, we have found no failings in relation to this area of the complaint. This is because the Department of Health guidance is clear that a patient needs to be clinically well enough to be discharged. Sadly, Mrs A was not well enough.

Transfer to Hospital B

48. Mrs I complains doctors at Hospital A transferred her mother to Hospital B prior to her death. She says they told her this was for dialysis, but she feels it was because they had given up hope and were sending her there to die.

49. GMC Good Medical Practice says doctor should:

· promptly provide or arrange suitable advice, investigations, or treatment where necessary · refer a patient to another practitioner when this serves the patient’s needs.

50. The COVID-19 infection control guidance also says that healthcare providers can transfer a patient to another healthcare facility if medically necessary. This can include for specialist care arising out of complications or other medical events (such as for cardiac angioplasty or renal dialysis).

51. Mrs A’s lung and kidney functions deteriorated on 2 June. The treatment options available to the clinical team included CPAP treatment for her respiratory deterioration, and dialysis for her kidney failure. Hospital A did not have those treatment options available, so the Trust transferred Mrs A to Hospital B instead.

52. We have found the Trust acted in line with the GMC and COVID-19 infection prevention guidance by transferring Mrs A to Hospital B. This gave her the option to have treatments which might have been beneficial to her. Sadly, on arrival she was too unwell to have the treatments.

COVID-19 trial

53. Mrs I complains a doctor at the hospital enrolled her mother on a COVID-19 trial, despite Mrs A not having capacity to consent to this. She feels the doctor should have encouraged her mother to speak to her family first. We understand why Mrs I has concerns about her mother consenting to this new treatment.

54. The Mental Capacity Act 2005 protects and empowers people who may lack the mental capacity to make decisions about their care and treatment. This states that health care professionals should assume a patient has capacity to make decisions themselves unless proved otherwise.

55. There are multiple entries in Mrs A’s medical records which show she was holding rational conversations and demonstrating capacity from 13 May onwards. A registered nurse documented completion of a Mental Capacity Assessment on 18 May and found her to have capacity. Another registered nurse documented she had capacity on 19 May. The doctors who saw her on 27 May also documented she had capacity to consent to the trial.

56. In summary, the evidence suggests that Mrs A did have capacity to make her own decisions about her care and treatment. As Mrs A had capacity, there were no requirement for the doctors to encourage Mrs A to speak to her family first about any treatment she received. We have not found any failings in relation to this part of the complaint.

1. We have considered Mrs I’s complaint about the care the Trust provided to her mother, Mrs A.

2. We were very sorry to hear that Mrs A caught COVID-19 while in hospital. We can see that her mother’s death from this illness has had a devastating impact on Mrs I.

3. We have not found any failings in the Trust placing Mrs A on a ward where other patients tested positive for COVID-19. We have found the Trust acted in line with national guidance by placing patients with known or suspected COVID-19 in the same area of the hospital. The Trust placed Mrs A in an area where there were no known COVID-19 patients at the time.

4. We have found the Trust failed to complete hygiene audits in the month of May. However, this does not mean that staff were not following infection prevention protocols and we cannot link this failing to Mrs A catching COVID-19.

5. We have found Mrs A was not well enough for the Trust to discharge her. We understand why Mrs I feels an earlier discharge could have prevented her mother catching COVID-19 though.

6. We found the Trust acted in accordance with national guidance by transferring Mrs A to another hospital for treatment.

7. We also found that Mrs A had capacity to make decisions about her own treatment. We would not have expected the clinical team to have encouraged her to speak to her family about the COVID-19 trial.

8. We have decided to partly uphold this complaint. This is because we have not identified any failings in relation to most of the issues complained about. Where we have identified a failing, we cannot see any link between this and Mrs A catching COVID-19.