Mid Yorkshire Hospitals NHS Trust

7. Miss U complains about aspects of care her father, Mr U, received while an inpatient at Hospital A, part of The Mid Yorkshire Hospitals NHS Trust (the Trust).

8. Specifically, she complains during his admission between 9 January and 27 January 2021:

- staff did not provide Mr U with any nutritional intake between 9 January 2021 and 14 January. Staff inserted a PICC line on 14 January to begin total parenteral nutrition (TPN) feeding. Miss U says her father was complaining about being very hungry during this time - staff did not provide Mr U with any nutritional intake between 17 and 19 January - staff did not give Mr U IV fluids on 13 January and 16 January - after the PICC line was inserted on 19 January, staff did not give Mr U a feeding bag until nine hours later on 20 January.

9. Miss U explains these events led to her father’s worsening clinical condition and his death on 27 January. She says staff’s lack of care, specifically in relation to not providing him with the necessary nutrition, caused his clinical condition to deteriorate. She says due to this he was left unable to fight COVID-19.

10. She says the way her father was treated during this time has caused her and her family severe distress. She says her father’s death would have been avoidable if he were given the care he should have received.

11. She says her mother has been left with no financial support, which her father had provided for many years. This is because Mr U’s pension payments have been stopped and she no longer gets Carer’s Allowance for looking after him.

12. She would like an acknowledgement of the failings and for the Trust to make service improvements. She would also like a financial remedy for her mother to reflect the impact this has had on her.

13. Mr U was diagnosed with progressive supranuclear palsy in May 2020. This is a degenerative disease which causes problems with speech, mobility, swallowing, vision, and memory.

14. As Mr U’s ability to swallow declined, his risk of choking increased. Mr U’s neurologist suggested an insertion of a percutaneous endoscopic gastrostomy (PEG) tube to help with Mr U’s feeding and reduce the risk of him choking. Mr U agreed to this.

15. Mr U attended the Trust on 4 January 2021 for the elective PEG tube insertion. This procedure took place on 5 January. He remained under the Trust’s care until 8 January when he was discharged home.

16. On the morning of 9 January, Miss U found Mr U had removed his PEG tube. She called the nurses and they advised her to take Mr U to the emergency department.

17. Miss U took Mr U to the emergency department. A gastroenterologist attempted to reinsert the PEG tube through the existing track. They then attempted to draw out stomach fluid to confirm the position of the tube, however this was not successful.

18. As the gastroenterologist could not confirm the positioning of the PEG tube, they planned to carry out a tubogram of the PEG tube to confirm its position. This is where dye is inserted down the tube and into the part of the body where the tube ends. The results from an X-ray then show the positioning of the tube.

19. Staff carried out a tubogram on 11 January. This showed the PEG tube was not in the stomach where it needed to be for PEG feeding, because of this, staff suggested referring Mr U for a nasojejunal feeding tube to be inserted. This would have enabled staff to feed Mr U through his intestine. Mr U also tested positive for COVID-19 on this date.

20. Staff carried out a computerised tomography (CT) scan on 13 January to determine if it was safe to provide Mr U with nasojejunal feeding. The CT scan showed the stomach was perforated with some signs of a collection of fluid within the abdominal cavity. This suggested a leakage through his perforated stomach, which meant it was unsafe to feed Mr U into his intestine.

21. On 13 January, the doctor was delayed in prescribing Mr U with IV fluids. Mr U’s cannula had also fallen out so once the doctor had prescribed IV fluids, staff were unable to give them to him until they reinserted the cannula. This meant he was left without IV fluids for some time that day.

22. On 14 January staff assessed Mr U’s CT scan results. They decided to begin TPN feeding. This means providing nutrition through the vein. To do this, a PICC line was needed. The radiologist inserted the PICC line the same day.

23. On 16 January, Mr U’s cannula had come out again. Staff were unable to give him IV fluids until his cannula was reinserted. This meant he was left without IV fluids for some time that day.

24. On 17 January, Mr U removed his PICC line. The same day staff submitted a request to the radiologist to reinsert the PICC line.

25. The request was reviewed by a radiologist on 19 January. They wanted to have discussion with the medical team about the safety of reinsertion. The radiologist had concerns because Mr U had previously pulled out the PICC line.

26. Staff discussed this on 20 January and decided to insert the PICC line and bandage it so Mr U could not remove it easily. The radiologist reinserted the PICC line at 4pm on 20 January. A feeding bag was added at 12.19am on 21 January.

27. Mr U’s clinical condition deteriorated as he had developed COVID-19 pneumonia. Mr U sadly died on 27 January.

Nutritional intake between 9 January and 14 January

31. NICE guidelines say staff should consider nutritional support for patients who have, or are likely to have, eaten little or nothing for more than five days.

32. It also says the preferred route for nutritional support is through the gastrointestinal tract where possible. However, under certain circumstances, intravenous feeding is required.

33. GMC guidance says clinicians should promptly provide and arrange suitable investigations and treatment where necessary.

34. The records show staff screened Mr U for malnutrition on 9 January 2021. It is clear from the records (see paragraphs 17 to 22) that between 9 and 14 January, staff considered different ways of feeding Mr U.

35. To start with, staff attempted to feed Mr U through the gastrointestinal tract. Then, when it became clear Mr U had a perforated stomach (part of the gastrointestinal tract), focus changed to feeding him intravenously (by TPN feeding through a PICC line). Our adviser says feeding needs to happen intravenously when the stomach is perforated.

36. We can see staff acted in line with the NICE guidelines on nutritional support. They appropriately planned to feed Mr U through the gastrointestinal tract, but after further investigations made it clear they could not, they took steps to feed him intravenously.

37. We asked our adviser to consider the timeliness of the investigations to assess how best to provide nutritional support to Mr U. Our adviser said the investigations and treatment carried out here were prompt and in line with GMC guidance. We have not seen any unnecessary delays in investigating how best to provide Mr U with nutrition.

38. We do not underestimate how distressing it was for Miss U to hear Mr U say he was hungry. This was clearly a difficult situation, and we hope we have clearly explained why we are satisfied the Trust met the relevant standards in trying to provide nutritional support for Mr U. We do not uphold this part of the complaint.

Nutritional intake between 17 January and 20 January

39. As detailed in paragraphs 32 and 34, staff should consider if a patient needs nutritional support if they are left without nutrition for five days and are likely to be without nutrition for another five days. Clinicians should promptly arrange investigations which will help decide the treatment the patient receives.

40. Mr U removed the PICC line on 17 January. As nutrition support had to be provided intravenously due to his perforated stomach, later that day, staff submitted a request to the radiologist to reinsert the PICC line. We can see the radiologist did not reinsert the PICC line until 19 January. We have considered why they could not have inserted the PICC line sooner.

41. The radiologist said they did not have availability to consider Mr U’s case on 18 January. While we recognise this was not ideal for Mr U, the radiologist had other patients to treat during this day.

42. It is not possible for us to determine whether the radiologist should have prioritised Mr U’s PICC insertion on this day. This is because we do not know the condition of the other patients waiting for a PICC line to be inserted.

43. The radiologist reviewed Mr U’s case on 19 January. They had concerns about reinserting the PICC line as Mr U had previously removed it, because of this, the radiologist scheduled to discuss Mr U’s case with the medical team to ensure it was safe to reinsert the PICC line.

44. The radiologist discussed their concerns with the medical team on 20 January. They collaboratively decided to insert the PICC line and bandage it so Mr U could not remove it easily. The radiologist reinserted the PICC line at 4pm on 20 January.

45. GMC guidance say clinicians must work collaboratively with colleagues, taking on board their skills and contributions, which we can see the radiologist did. As they had concerns about reinserting Mr U’s PICC line, they scheduled to discuss his care with the medical team prior to carrying out any treatment. This is in line with the guidance.

46. We recognise it took the radiologist three days to reinsert the PICC line, but we cannot see the radiologist delayed this unnecessarily. We can see the radiologist had a plan in place (to discuss this with the medical team) and they did once they had availability. This works in line with GMC guidance. We have not found a failing here.

IV fluids on 13 January and 16 January

47. NICE guidelines on intravenous fluid therapy say IV fluid requirements for patients are during a 24-hour period. This suggests if a patient needs IV fluids but is left without them for longer than this 24-hour period, this may not be appropriate.

48. We have been able to consider Mr U’s IV fluid charts. On 13 January, Mr U was due to be given some IV fluids at 1.35pm. These IV fluids were not given until early morning on 14 January. On 16 January, Mr U was given IV fluids in the morning. He was then given further IV fluids that evening.

49. We recognise Mr U remained without IV fluids for a period when he should have had them. However, we can see staff did provide Mr U with the required IV fluids within a 24-hour period.

50. Although staff’s actions fell, to some extent, short of what was expected, we can see they still acted in line with NICE guidelines on IV fluid therapy. Because of this, we do not think this is a failing.

51. We recognise Miss U was understandably concerned about her father not receiving IV fluids for a period during these days.

52. We would like to provide some reassurance to Miss U that these periods would not have had a significant effect on Mr U’s clinical condition at the time. As Mr U was elderly, at an advanced stage of his condition and had contracted COVID-19, he was sadly at an increased risk of dying. Short delays in providing him with IV fluids would not have contributed to this.

Delay in providing Mr U with a feeding bag after the PICC line was reinserted

53. From the records we have seen, we can see staff provided Mr U with a TPN feed at 12.19am on 21 January. This was just over eight hours after the PICC line was inserted.

54. NICE guidelines on nutrition support say TPN feeding should be introduced progressively and closely monitored, usually starting at no more than 50% of the estimated needs for the first 24-48 hours. It does not state at what point after the PICC line is inserted staff should begin TPN feeding.

55. Our adviser said the NICE guidelines on nutrition support suggests it is appropriate for staff to begin TPN feeding at any point during this timeframe. However, the Trust recognises staff left Mr U waiting for a feeding bag for eight hours, which it says was not appropriate.

56. We have considered the reasons for this delay to see if staff at the Trust could have done more to provide Mr U with a TPN feed sooner.

57. The Trust say this delay occurred because of unforeseen staff sickness at the ward. This meant there were no staff on the ward trained in putting up a TPN feed. To resolve this, staff asked a nurse from the surgical ward to provide Mr U with a TPN feed. Due to pressures on the surgical ward that day, they could not get to him sooner.

58. Our nurse adviser explains TPN feeds must be put up by staff who are trained. NMC guidance says nurses must ask for help from a suitably qualified and experienced professional to carry out any action or procedure which is beyond the limits of their competence.

59. We can see that due to unforeseen sickness, there were no qualified and experienced nurses who could give Mr U a TPN feed on the ward. In line with NMC guidance, it was appropriate for staff to ask someone who was qualified and experienced to do this.

60. We recognise leaving Mr U without a TPN feed during this time was not ideal, especially as he had been without nutrition for three days prior and had COVID-19. But we can see staff acted in line with what we would expect in providing Mr U with a TPN feed. We cannot see there were any unnecessary delays here. We do not identify this as a failing.

1. We have carefully considered Miss U’s complaint and recognise the difficult circumstances she experienced.

2. We hope this report can provide Miss U some reassurance the Trust’s actions did not contribute to, or cause, her father’s (Mr U's) death.

3. During our investigation, we found staff at the Trust appropriately put plans in place to provide Mr U with nutritional support during his admission. We have not seen any unnecessary delays in providing Mr U with nutritional support.

4. We have found there were delays in providing Mr U with intravenous (IV) fluids on two occasions. While the staff’s actions fell, to some extent, short of what was expected, we can see they still acted in line with guidelines. We cannot say the delays in providing Mr U with IV fluids were service failings, nor that they would have had a serious impact on Mr U’s clinical condition.

5. We have also seen staff could not provide Mr U with a feed soon after his peripherally inserted central catheter (PICC) line was reinserted on 20 January. We recognise the delay in providing Mr U with a feed was not ideal, however we can see staff acted in accordance with guidelines. We have not seen any evidence staff could have done more in this situation.

6. We have therefore not upheld this complaint.