COVID-19 infection
17. Mrs A complains her father contracted COVID-19 while admitted to The Royal Wolverhampton NHS Trust in March 2020. She complains he died as a result.
18. We considered how likely it is Mr A contracted COVID-19 in hospital.
19. Mr A was admitted initially on 12 March 2020 and was discharged home on 26 March. Our adviser confirmed that during these 14 days as a hospital inpatient, he did not have clinical features suggestive of COVID-19. This suggests it is unlikely Mr A had COVID-19 prior to this admission.
20. The Trust did not test Mr A for COVID-19 during the admission. This was in line with government guidance in place at the time on infection control and prevention in healthcare settings. This said only patients with symptoms needed to have the diagnosis confirmed by testing.
21. Mr A was readmitted on 27 March and tested for COVID-19 on 28 March. The result was positive. The incubation period of COVID-19 is between 2-14 days. With this in mind, we think it is highly likely Mr A contracted COVID-19 during his first hospital admission.
22. We considered if Mr A’s likely infection with COVID-19 indicates a failing in the Trust’s infection control measures.
23. At the point of Mr A’s admission, there was little official guidance available to hospitals. During the early phase of the pandemic in March 2020, information about Personal Protective Equipment (PPE) and infection control measures were continually being re-evaluated throughout the NHS. Formal guidance regarding the spread of the virus in healthcare settings was only issued by Public Health England on 4 April 2020, after this was recognised to be an issue.
24. The Trust developed its own protocol for the movement of patients in hospital, based on their risk of COVID-19. This came into effect from 2 April 2020.
25. Although infection control measures reduce the risk of transmission, they cannot completely stop transmission. This is due to the personal nature of healthcare and the fact that staff and patients can be asymptomatic during the early phase of COVID-19, and therefore unknowingly transmit the virus.
26. It is not possible to conclude there was a failing in the Trust’s infection control procedures that led to Mr A being infected with COVID-19.
27. Mrs A says after the Trust discharged her father on 26 March, a member of the district nursing team told her Mr A had come into contact with a COVID-19 positive patient in hospital. She says she spoke to a doctor on the ward, who confirmed this. Mrs A questions why the Trust did not inform her of this.
28. We have found no information in the hospital records to suggest the nursing or medical staff suspected he had been in contact with a COVID-19 positive patient.
29. There is a mention on 25 March 2020 of a community nurse asking that the doctor provide Mr A’s warfarin dose for the next 14 days, in order to reduce the risk of COVID-19 exposure to the community phlebotomist. It is unclear if this was intended as a general precaution, rather than a specific risk relating to Mr A.
30. A doctor recorded on 31 March ‘likely exposed to COVID-19 during admission as per note on Portal’. The Trust has advised this is an electronic system the Trust’s medical team uses to record communication about a patient. We have obtained a copy of the notes. There is nothing recorded there to show Mr A came into contact with a COVID-19 positive patient.
31. The doctor Mrs A spoke to, after her father was discharged from hospital, has recorded details of the conversation. This includes: ‘His daughter was also worried that why (sic) we discharged him if he was exposed, I explained that his chances of being infected are higher if he stayed in the hospital so we discharged him as he was otherwise stable’.
32. This entry suggests the concern was about possible future risk of exposure in hospital, rather than any definite exposure having taken place.
33. We cannot reconcile what ward staff told Mrs A or the community nurse about her father having been exposed to a patient with COVID-19, as there is nothing in the records to clarify what happened.
34. Irrespective of this, we think it is likely Mr A contracted COVID-19 while in hospital, as already explained. We have identified no failings in how the Trust acted and do not uphold this part of the complaint.
Discharge from hospital on 26 March 2020
35. Mrs A says her father was too unwell to be discharged from hospital, putting him at risk. She complains the Trust did not test her father for COVID-19 prior to discharge and questions if the Trust could have treated him if a test had been positive. She says the decision to discharge her father also put the family at risk because the Trust did not tell them he had been exposed to COVID-19.
36. On 19 March 2020, the government and NHS England wrote to NHS Trusts to advise of the need for faster rates of appropriate discharge from hospital. It said the default position would be ‘discharge home today’. This supported COVID-19 guidance from Public Health England, which said patients could be discharged from hospital if this was clinically appropriate. It is a clinical judgement whether a patient needs to be in hospital.
37. We considered if the Trust’s decision to discharge Mr A was in line with the guidance.
38. Mr A had an occupational therapy assessment on 19 March and again on 23 March. The occupational therapy staff considered Mr A was able to mobilise independently. They noted he had oxygen at home and did not require additional equipment for discharge.
39. Ward staff noted on 23 March, he was waiting for a physiotherapy review, but we could not see a record that this had taken place.
40. Our adviser said Mr A’s clinical condition was stable between 23 and 26 March, when his National Early Warning Score (NEW2) generally ranged between two and four. NEWS2 is a nationally used tool for identifying if a patient is at risk of acute deterioration. A score of zero to four means the patient is at low risk of deteriorating.
41. On 23 March, Mr A’s temperature spiked once but returned to normal after this. On 24 March, the medical team requested a chest X-ray. This was performed that afternoon and reported on in the evening of the 26 March. The report said, ‘appearances may be suggestive of infective changes on the background of pulmonary oedema’. The radiographer reported no concerns about COVID-19.
42. Our adviser said these changes, although subtle, may have represented early features of COVID-19. They noted that during Mr A’s admission, his blood tests showed a normal white cell count but a slightly low lymphocyte count. Lymphocytes are a type of white blood cell, which the body uses to fight infection. COVID-19 has been found to lower the lymphocyte count. This may also have raised the suspicion of COVID-19.
43. However, this is with the benefit of hindsight, knowing that Mr A subsequently went on to develop COVID-19 symptoms. We do not consider it a failing that Mr A’s chest X-ray and lymphocyte count did not lead the Trust to suspect he had COVID-19, as he was asymptomatic at the time.
44. On the day of discharge, Mr A’s temperature, pulse rate, blood pressure, respiratory rate, and oxygen saturation were all within an acceptable range for him. Medically, Mr A was well enough to be discharged. There were also no concerns from a nursing perspective that would have prevented his discharge. The Trust acted in line with the relevant guidance when deciding if Mr A could be discharged.
45. Our clinical adviser confirmed Mr A’s clinical presentation had changed by the time he was readmitted, with signs consistent with COVID-19.
46. At the time of discharge on 26 March, it was not routine to test patients before discharge if they did not have symptoms suggestive of COVID-19. This guidance was not issued until 4 April 2020. Additionally, government guidance at the time said that patients who had been exposed to a confirmed COVID-19 patient did not need to be tested, unless they developed symptoms within 14 days of exposure. However, they would have been expected to isolate on returning home.
47. GMC guidance tells doctors to be considerate to those close to the patient. Therefore, if Mr A was known to have been in contact with a COVID-19 positive patient, it would have been good practice to let his family know, in line with this guidance.
48. Even if the Trust had tested Mr A for COVID-19 prior to discharge, and if the result had been positive, this does not mean the hospital would not have discharged him. This would depend on his clinical need to stay in hospital, in line with the guidance in place at the time.
49. There was no specific treatment for COVID-19 during Mr A’s admission to hospital. Symptoms were managed using supportive oxygen. Our adviser confirmed that even if the Trust had decided to keep Mr A in hospital, given his multiple co-morbidities, it is unlikely an earlier diagnosis of COVID-19 would have increased his chances of survival.
50. We think the Trust acted in line with guidance in place at the time by discharging Mr A when clinically appropriate, and without confirming his COVID-19 status. We do not uphold this part of the complaint.
DNAR decision
51. Mrs A complains doctors pressured her father into agreeing a DNAR decision. She says her father would not have understood what he was agreeing to and would not have agreed. She believes the DNAR decision meant the Trust gave up on her father and stopped treating him.
52. Resuscitation guidance from the GMC is clear that cardiopulmonary resuscitation (CPR) generally has a very low success rate and often results in adverse outcomes for the patient, such as brain injury caused by lack of oxygen, organ damage, and increased disability.
53. The guidance states: ‘If cardiac or respiratory arrest is an expected part of the dying process and CPR will not be successful, making and recording an advance decision not to attempt CPR will help to ensure that the patient dies in a dignified and peaceful manner.’
54. The GMC also tells doctors: ‘In cases in which CPR might be successful, it might still not be seen as clinically appropriate because of the likely clinical outcomes. When considering whether to attempt CPR, you should consider the benefits, burdens and risks of treatment that the patient may need if CPR is successful. In cases where you assess that such treatment is unlikely to be clinically appropriate, you may conclude that CPR should not be attempted.’
55. NICE COVID-19 guidance tells doctor to, ‘sensitively discuss a possible ‘do not attempt cardiopulmonary resuscitation’ decision with all adults with capacity and an assessment suggestive of increased frailty.
56. We have seen evidence from the medical records that a doctor discussed CPR with Mr A. They documented Mr A initially expressed a preference for resuscitation. After the doctor explained why they thought this would not be in his best interests, they documented Mr A understood and agreed to the DNAR form being completed. This evidence suggests the doctor followed the GMC and NICE guidelines in discussing and making this decision with Mr A.
57. The doctor also recorded they were satisfied Mr A had capacity to make this decision. We know Mrs A disputes this.
58. The GMC tells doctors to work on a presumption of capacity. It says doctors: ‘must work on the presumption that every adult patient has the capacity to make decisions about their care and treatment. You must not assume that a patient lacks capacity to make a decision solely because of their age, disability, appearance, behaviour, medical condition (including mental illness), beliefs, apparent inability to communicate or because they make a decision that others disagree with or consider unwise.’
59. Mr A was clearly unwell, but this does not mean he was unable to be involved in his own decision making. We have seen no evidence to suggest Mr A lacked capacity to discuss the DNAR decision. We are satisfied the Trust approached this in line with the GMC guidelines.
60. Mrs A told us she is concerned the Trust stopped trying to treat her father once the DNAR decision had been made. We can reassure Mrs A that the DNAR decision did not mean the Trust stopped treating her father. Our adviser confirmed the Trust gave all the supportive treatment available including oxygen, diuretics, and antibiotics following the DNAR decision.
61. Doctors determined Mr A was not a candidate for more intensive treatment. NICE COVID-19 guidance in place at the time said decisions about escalation of treatment to high dependency and intensive care should be based on the patient’s likelihood of recovery. It recommended taking the patient’s frailty, along with the impact of pre-existing health conditions, into account to determine those less likely to benefit from an escalation of treatment. It advised clinicians to discuss care preferences with patients.
62. Mr A’s significant co-morbidities and frailty meant escalation of treatment to non-invasive or invasive mechanical ventilation (which would be the reason to transfer him to a high dependency or intensive care unit) was unlikely to improve his chance of survival. The doctors decided not to escalate his treatment, as this was in his best interests. This is irrespective of the DNAR decision. The Trust acted in line with NICE guidance when determining how to treat Mr A’s condition.
63. The only concern we have is that an on-call doctor refused to review Mr A when the nursing staff requested this. They asked the doctor to review him on 31 March as his oxygen saturation level had dropped. Nursing staff documented the doctor refused to attend ‘because according to them there is no point due to his other co-morbidities’. Their advice was to keep Mr A comfortable ‘because he has a DNAR in place’.
64. GMC ‘Good medical practice’ tells doctors they must make patients their first concern. It also tells them their behaviour must maintain trust in the profession. The doctor did not follow these principles when they refused to review Mr A. Their refusal was not in line with the guidance, and they should have responded to the nurse’s request.
65. We can see that when another doctor became aware of what happened the following day, they reported it through the Trust’s incident reporting process. The Trust told us feedback was given to the nursing and medical staff about the need for clear communication of the reasons for requesting a medical review, the outcome of the discussion, and the rationale for any decisions made.
66. We considered if the doctor’s refusal was detrimental to Mr A and have seen it was not. This is because the nursing staff increased his oxygen when his saturation level dropped, and he was already receiving intravenous antibiotics and diuretics. Our adviser confirmed no other treatment could have been given.
67. Mr A’s condition remained stable and when a doctor reviewed him in the morning, they continued the same treatment plan. We can therefore assure Mrs A the lack of review did not prevent Mr A from receiving appropriate treatment. Nevertheless, we realise this incident would have been upsetting for her.
68. In summary, we have seen no indications of failings in how the Trust approached the DNAR decision. We saw one incident where a doctor documented they would not review Mr A, due to him having a DNAR decision in place, which is a failing. But we have seen no evidence Mr A would have been treated differently if this had not happened. Fortunately, this failing did not adversely affect Mr A, and the Trust has taken action to address the problem. We therefore do not uphold this part of the complaint.
69. This concludes our investigation of Mrs A’s complaint. We hope we have been able to provide some reassurance that we do not think her father’s death could have been prevented. We thank Mrs A for bringing her complaint to us.