Issue 1 - Oxygen tube becoming disconnected
15. Miss I complains on 17 July, nursing staff accidentally disconnected but failed to notice and reconnect the tube to Mr O’s oxygen machine for around an hour, causing him to struggle to breathe. Miss I explained she was distressed and concerned as a result of finding the oxygen tube disconnected and witnessing her brother struggling to breathe.
16. Miss I explained she remembers Nurse 1 and a Health Care Assistant (HCA) being in the room when she realised the oxygen tube was disconnected. Miss I told us she thought the tube became disconnected when the HCA had been repositioning Mr O between 12.30am and 1am on 17 July. She then says it was not until 2am that she realised the tube had become disconnected, stating it was up to an hour that Mr O had been without oxygen.
17. In its response to our investigation proposal, the Care Home explained it confirmed in its initial investigation, of 11 April 2020, that the oxygen tube became disconnected on 17 July. The Care Home went on to explain it was difficult to ascertain who did this, when this occurred, and for how long. The Practice Manager at the Care Home responded to us saying the nurse had stated Mr O was recently repositioned by the care staff and he was alerted to this incident by his sister within approximately five minutes of the staff leaving the room. The nurse stated that when they reconnected the tubing, Mr O did not appear distressed, and his oxygen saturations were within normal limits. They state that Miss I was visibly distressed by the tubing being disconnected and they tried to reassure her that this had not caused Mr O any further harm or distress. The nurse goes on to state they are unsure why Miss I omitted to notify staff for over an hour if she was aware that the oxygen tubing had been disconnected.
18. The Care Home produced a care plan for Mr O on 19 July, two days after the oxygen tube became disconnected. The care plan includes the requirement to ensure that tubing is always patent (unobstructed), no occlusion (blockage), or trapped within the bed or furniture. The nursing record entries for the 16 and 17 July note that oxygen was in place.
19. Mr O’s nursing records show a retrospective entry was added by Nurse 1 on 22 July. The entry states that on 17 July, while a care worker was undertaking two hourly turns on Mr O (repositioning him on his bed), they knocked the oxygen tube out resulting in a break in the connection and supply of oxygen. The entry goes on to say Mr O went without oxygen for less than five minutes, and his oxygen saturation remained within parameters set out in his hospital records.
20. We reviewed Mr O’s hospital notes which details Mr O’s target oxygen saturation levels as being 94 – 98%, and an oxygen flow of 2L/m (two litres per minute). Nurse 1’s entry on 22 July does not say what Mr O’s oxygen saturation was at the time, only that it was ‘within his parameters’. As the saturation levels are not recorded, it is difficult to ascertain what level they were after the oxygen tube became disconnected. Miss I told us she recalled asking staff to check Mr O’s oxygen saturation machine once she became aware the tube was disconnected, around 2am, and it showed the oxygen saturation level to be at 78%. From review of the repositioning charts, we can see Mr O was repositioned at 9.30pm and 11.30pm on 16 July, and 12.39am and 1.39am on 17 July.
21. We asked the Care Home whether Nurse 1 could provide information about their recollection of the events. Nurse 1 no longer works at the Care Home and has worked as an agency nurse for the last two years. Nurse 1 said they became aware the oxygen tube had disconnected at 10.30pm on 16 July 2019 (not 17 July as Miss I recalls), which they took from the accident form they had completed. Nurse 1 explained that due to the passage of time, their recollection of the events was sparse, but they remembered reconnecting Mr O’s oxygen tube as they were the nurse on duty.
22. Nurse 1 explained they could not remember how Mr O’s oxygen tube became disconnected but that it was likely due to repositioning of the bed, which can stretch the tubing or cause it to become disconnected. Nurse 1 explained that because of this, nurses routinely conduct checks to ensure the oxygen tube is still connected, that there is oxygen in the cylinders, and that the patient is receiving the correct oxygen per litre.
23. When we asked Nurse 1 how they determined Mr O had been without oxygen for less than five minutes, as per their nursing record entry, they explained they could not recall exactly how they calculated it. They said they remembered Mr O needing a lot of support and monitoring and so they would have been in the room frequently and would have checked the oxygen tube connection, and the position of the bed.
24. When we asked Nurse 1 whether they recalled any conversation they had with Miss I, after the oxygen tube was reconnected, they said they had tried to reassure her that Mr O was breathing suitably. Nurse 1 explained they recall only being able to reassure Miss I by showing her the oxygen saturation on the machine.
25. We sought clinical advice from our nursing adviser who referred to clinical guidelines and standards in providing their advice. The Royal Marsden Manual of Clinical Nursing Procedures (Dougherty and Lister 2015), a well-respected publication which provides advice on procedures for nursing care, advises that nurses should check the patient regularly to ensure they are still attached to oxygen, but the guideline does not specify how frequently this should be done.
26. Our adviser explained while there are no national clinical guidelines which insist that oxygen apparatus is intact for patients prescribed oxygen therapy, there was a medical prescription in place for Mr O to be provided with oxygen 24 hours a day. This written prescription on Mr O’s drug chart meant that Mr O’s oxygen concentrator machine should be providing continuous oxygen through tubing into a nasal cannula (short tubes placed in Mr O’s nostrils) at all times, and this did not happen.
27. Our adviser explained Mr O’s nasal cannula should have been in place, and connected to the oxygen concentrator machine, at all times. However, to provide nursing care, there are occasions where it is necessary for the nasal oxygen tubing to be disconnected for a few minutes. Providing continuous oxygen through a nasal cannula can dry out the fluids in the nose and this can result in the patient having painful nasal passages.
28. To reduce the drying effect of the oxygen, sometimes the nasal cannula is temporarily removed to insert water-based gel into the nose. When patients are having their face washed, clothes changed, or they are having their position altered in bed, it might also be necessary to disconnect the oxygen tubing for a short period of time.
29. We asked our adviser whether they could determine Mr O’s oxygen parameters for the 17 July. They said from reviewing Mr O’s notes from 22 July 2019, regarding the night of the 17 July, it mentions Mr O’s oxygen levels remained within his parameters. However, there is no precise oxygen saturation measure recorded in the notes from when his oxygen was reconnected.
30. Based on the evidence, we think the oxygen tube became disconnected between 10pm on 16 July and 2am on 17 July after the HCA repositioned Mr O, as we can see from the nursing chart. We are unable to identify specifically when the oxygen tube became disconnected based on the evidence we have. This is because the medical records entry, and the accident form concerning the event, were entered retrospectively. We note Nurse 1’s accident form entry on 16 July conflicts with their later retrospective entry of 22 July, which said the oxygen tube became disconnected on 17 July. We do not consider this to change our decision and consider the impact to Mr O below.
31. Miss I’s recollection of the time the oxygen tube became disconnected also differs to that of Nurse 1, and we do not have evidence which corroborates either account. We know the oxygen tube had become unnecessarily disconnected for a period of time. We think the fact this was not identified by a nurse immediately, following Mr O being repositioned, is a failing as it is not in line with the Royal Marsden guidance.
Impact
32. We asked our adviser what the impact would have been of the oxygen tube becoming disconnected for five minutes (as stated by Nurse 1) and for one hour (as stated by Miss I), as these are the two conflicting accounts for how long the oxygen tube was disconnected for. If disconnected for five minutes, our adviser said the Care Home’s care plan for the provision of continuous oxygen for Mr O advises that he was able to tolerate not having oxygen through his nasal cannula during the time his personal hygiene was being carried out. It is unlikely therefore there was any significant impact had his oxygen tube been disconnected for up to five minutes, as it is likely the oxygen tube would have been disconnected for this duration while washing and dressing Mr O.
33. With respect to the oxygen tube being disconnected for an hour, our adviser said when the Respiratory Support Nurse visited the Care Home on 18 July 2019, she found that Mr O’s oxygenation levels were acceptable on one litre of oxygen per minute through his nasal cannula. There was a discussion with Miss I present about carrying out a trial without any oxygen at all, but Miss I felt Mr O needed time to recover from a recent blocked catheter and a course of antibiotics. While this trial without oxygen was not carried out, Mr O was on a low dose of oxygen through his nasal cannula, and it is unlikely that there was any significant impact had his oxygen tube been disconnected for up to one hour.
34. We think Miss I finding the oxygen tube disconnected caused her some distress and concern as she was unsure of how long the tube had been disconnected for, and told us she observed her brother struggling for breath. We consider the impact Miss I experienced, of distress and concern, to be linked to the failing that the oxygen tube was disconnected. We think her observing this could have reasonably caused her concern and distress. We cannot say Miss I’s distress was linked to her brother struggling to breathe, as we did not, on balance, consider this impact to have occurred to Mr O.
35. We next go on to consider whether the Care Home has done enough to acknowledge the failing when it handled Miss I’s complaint. To do this we have referred to our Principles of Remedy which says where maladministration (fault) leads to an injustice, an organisation should try to put the complainant in a position they would have been in had the maladministration not occurred. It says suitable remedies include apologies, explanations, improvements to services, or paying a financial remedy.
36. In its initial complaint response letter dated 11 April 2020, the Care Home said: In relation to Mr O’s oxygen tube being disconnected on the 17.7.19, this should not have happened, but it was reported to the Manager by the night nurse in the morning. The most likely cause was that it became dislodged when staff were supporting him. Regular checks are in place for this. The Practice Manager assures me they apologised at the time to you. Mr O was also seen by the respiratory nurse soon afterwards who also spoke with you to reassure you that this short time without the tube inserted would not have any detrimental long-term effect on your brother.
37. We note the Care Home did recognise the oxygen tube becoming disconnected should not have happened. Miss I told us she did not recall the Practice Manager apologising to her at the time of events. We did not see evidence that the Care Home apologised to Miss I for the distress she experienced when finding the oxygen tube disconnected, and so we consider this impact remains unremedied.
38. We think the Care Home should apologise to Miss I, acknowledging the failing we found, and the impact to her. We consider this would be in line with our Principles for Remedy. We have provided further detail about this in our recommendations section at the end of this report.
Issue 2 – Pressure mattress collapsing
39. Miss I complains on 19 July, Mr O’s pressure mattress collapsed, and the Care Home failed to provide him with an adequate replacement until two days later. Miss I says this led to Mr O experiencing additional discomfort and it affected his breathing.
40. Miss I told us that Mr O was on an air (pressure) mattress due to his high risk of developing pressure ulcers. She said his mattress started to collapse following his being repositioned, but that it appeared to be a slow leak so was not identified at the time by the nursing staff. She explained the mattress eventually ended up in a ‘U’ shape as it began to lose air. Miss I says she reported this to a nurse on 19 July.
41. She says nurses ‘went hunting around’ the Care Home for another mattress. She says a nurse attempted to call the off-duty manager at the Care Home, who confirmed they did not have any pressure mattresses in stock. Miss I confirmed that nursing staff decided to replace Mr O’s pressure mattress with a foam (static) mattress which was unsuitable for his needs. Miss I told us the Care Home eventually replaced the static mattress on 22 July.
42. The Care Home said in its final response letter that it was unable to find documentation showing the mattress Mr O was using had collapsed. It went on to explain there is documentation on the 21 July saying Mr O had a red left buttock but there was no evidence to suggest the skin had broken down. The Care Home said a dressing had been applied by the nursing team for protection and this was checked daily. The records show the dressing was to be checked every three to five days, as per the wound chart care plan. We saw the dressing was checked on 24 July by a nurse who noted it as being intact.
43. On 11 April 2020, the Care Home wrote to Miss I stating: We reviewed the pressure ulcer risk assessment in Mr O’s nursing records. The records show that on 20 July, a dynamic support mattress was in use and that Mr O had no pressure ulcers. There is no evidence in the records showing Mr O’s pressure mattress had collapsed and a temporary foam mattress was used. We do not doubt Miss I’s recollection of the events but cannot see evidence which supports her complaint about the pressure mattress collapsing.
44. We reviewed the medical records to establish the facts on which mattresses were in place, and when. We also asked the Care Home which type of mattress was in place prior to the 21 July, as there is a conflicting account from Miss I. Miss I said up until 20 July, Mr O was on a high specification foam mattress and on 21 July, it was replaced with a static foam mattress but the replacement high specification foam mattress did not arrive until 22 July. The Care Home told us Mr O developed a category one pressure ulcer on his left buttock and so decided to move him from a high specification static foam mattress to a dynamic support mattress on 21 July.
45. While we recognise the conflicting accounts between Miss I and the Care Home on the type of mattress, how and when this changed, our fundamental consideration is on the appropriateness of the mattresses in place for Mr O, given his condition.
46. The Care Home confirmed with us that Mr O was using a high specification foam mattress before 21 July. What we saw from the records was that on 21 July, Mr O was on a Bi-wave dynamic support mattress. This type of mattress relieves pressure from different areas of the body, or that moves air or fluid.
47. NICE guidance on the prevention and management of pressure ulcers states that a high specification foam mattress should be used for adults assessed as being at high risk of developing a pressure ulcer, in primary and community care settings. The guidance goes on to state that for those patients with a pressure ulcer, if a high specification foam mattress is not sufficient to redistribute pressure, a dynamic support surface should be considered.
48. National Pressure Ulcer Advisory Council guidance describes a category one pressure ulcer as intact skin with non-blanchable redness of a localised area, usually over a bony prominence. NICE guidance on the prevention and management of pressure ulcers says nursing staff should encourage adults, who have been assessed as being at high risk of developing a pressure ulcer, to change their position frequently and at least every four hours. If patients are unable to reposition themselves, staff should offer help and use appropriate equipment if needed.
49. NICE guidance goes on to say nursing staff should also consider using a barrier preparation (a cream product applied directly to the skin surface to help maintain the skin's physical barrier) to prevent skin damage in adults who are at high risk of developing a moisture lesion or incontinence-associated dermatitis, as identified by skin assessment (such as those with incontinence, oedema, dry or inflamed skin).
50. We reviewed the nursing notes and saw that on 21 July Mr O developed a category one pressure ulcer on his left buttock and was using a dynamic support mattress. The records show the pressure ulcer was small, red and dry, and showed no sign of infection. There is no indication that Mr O’s pressure ulcer presented as skin damage, a moister lesion, or incontinence-associated dermatitis requiring barrier preparation. The records also demonstrate Mr O was repositioned every two to three hours, except when Miss I declined this intervention, and there is no indication of any deterioration of the pressure ulcer.
51. Mr O was at high risk of developing pressure ulcers due to his condition. This was recognised and monitored by the Care Home. Mr O was given a high specification foam mattress upon admission to the Care Home on 27 June, which was in line with NICE guidelines. The evidence shows that despite having that mattress, Mr O developed a pressure ulcer on his left buttock on 21 July, and so the Care Home decided to move him to dynamic support mattress that same day. NICE guidance says a dynamic support mattress should be used where a high specification foam mattress is not sufficient to redistribute pressure.
52. On the balance of probabilities, and from our reviewing of the wound charts, Mr O developed the pressure ulcer on 21 July, despite the correct precautions (such as repositioning) being undertaken. We saw when the Care Home became aware of the pressure ulcer, it changed Mr O’s mattress to a dynamic support type, in line with NICE guidelines, as well as treating the ulcer itself by originally applying a dressing on it.
53. Miss I told us how she was Mr O’s full-time carer and that they both had a very close relationship. We were sorry to hear of Miss I’s loss of her brother and the worry and upset she said she experienced as a result of his care. We did not find a failing with respect to the mattress Mr O was provided with.