COVID-19 status
20. Department of Health guidance on COVID-19 testing, in place at the time, said a swab test should be taken to confirm the diagnosis in patients presenting with symptoms of COVID-19. On admission, the Trust noted Mr A was generally unwell and had collapsed at home. The team assessing Mr A considered COVID-19 was one of several possible causes, as Mr A had gastrointestinal symptoms associated with COVID-19.
21. In line with the guidance, the Trust took a swab sample to test for COVID-19. However, the sample was not processed due to a labelling error. The Trust has said this was due to human error.
22. Mrs A says ward staff told her the swab was positive but then subsequently said it was inconclusive. We cannot explain how this happened as there is no record of staff having any conversations with Mrs A specifically about this.
23. The Trust identified, early in the morning of 17 April, the problem with the sample. The records show it took another swab that morning.
24. We considered if the sampling error affected how the Trust treated Mr A. The records show that despite the absence of a positive test result, the doctors treating him felt COVID-19 was the cause of Mr A’s acute symptoms. The Trust explained that as he was suspected of having COVID-19, he was cared for in a side room. This was in line with guidance.
25. We saw that Mr A had gastrointestinal symptoms of COVID-19, rather than respiratory. Our physician adviser explained that there was no specific treatment for this at the time.
26. Therefore, the absence of a confirmed diagnosis did not alter how the Trust treated Mr A.
27. We know Mrs A does not accept her husband had COVID-19, and thinks the Trust used this as an excuse to stop treating him. She says her husband told her he had not been retested.
28. As we have already shared with Mrs A, the evidence in the hospital records clearly shows the Trust retested Mr A on 17 April, and the result was positive. We cannot account for why Mr A believed he had not been retested.
29. The Trust also tested Mr A’s COVID-19 blood markers throughout his final admission. The results were consistent with a diagnosis of COVID-19. We have seen no reason to dispute the diagnosis.
30. The records show the Trust were actively trying to manage and treat Mr A’s condition. We have seen no evidence to support Mrs A’s concern the Trust used COVID-19 as an excuse to ‘give up’ on her husband. We hope this reassures her.
31. Mrs A also thinks the Trust put her at risk by discharging her husband when his COVID-19 status was unclear.
32. The guidance in place at the time does not stipulate if patients should remain in hospital pending a COVID-19 test result. The decision to discharge a patient is a matter of clinical judgement. We consider this in further detail under the section called ‘Discharge from hospital on 17 and 21 April’.
33. That said, it is important to note the Trust did not discharge Mr A on 17 April. The records show he self-discharged against medical advice.
34. Irrespective of this, we think it is unlikely the course of events would have changed had the test result been known. This is because there was no specific treatment for COVID-19 at the time. Mr A did not need any supplementary oxygen during this admission, which would have been a reason to remain in hospital. The guidance in place said patients could be discharged, even with a confirmed diagnosis of COVID-19, if they no longer needed to be in hospital. It is possible the Trust would have decided Mr A could be discharged in due course.
35. We know Mrs A is concerned that the Trust should have been particularly cautious with her husband because he was a transplant patient.
36. There is no specific COVID-19 guidance for this situation. The GMC tells doctors they must ‘adequately assess the patient’s conditions, taking account of their history…’ and must ‘consult with colleagues where appropriate’.
37. The records available show the Trust took account of Mr A’s history of heart transplantation and the fact his immune system was suppressed due to the anti-rejection drugs he was taking. The team treating Mr A asked the cardiology team for input. This is in line with GMC guidance.
38. The cardiology team reviewed Mr A, gave advice on medication and ongoing monitoring. They did not consider he needed to be transferred to the cardiology ward.
39. In summary, the only failing we have seen relating to Mr A’s COVID-19 testing is the error the Trust has already acknowledged. This meant the initial swab sample could not be processed. We have seen this did not make any difference to Mr A’s treatment, as the Trust was already managing him in line with COVID-19 guidance. We note the Trust has already apologised to Mrs A for the error. With this in mind, we do not uphold this part of the complaint.
Discharge from hospital on 17 and 21 April
40. Mrs A says the Trust should not have discharged her husband as he still unwell and had not completed treatment for pneumonia. She says this meant he did not have the best chance to recover.
41. The decision to discharge a patient is ultimately a clinical decision. However, the government produced COVID-19 discharge guidance to aid decision making. This includes a list of criteria that would indicate a patient needed to remain in hospital. The guidance is clear, patients who do not meet the criteria should be considered for discharge (this might mean to a different care setting, not just for home). The guidance notes there will be exceptions but said these needed to be justified.
42. In general, patients are discharged if their clinical condition is stable and if any ongoing treatment can be given at home.
43. The Trust did not discharge Mr A on 17 April. The Trust wanted Mr A to remain in hospital for more blood tests, but he was not willing to stay.
44. On 21 April Mr A was clinically stable. His observations, in particular his oxygen saturations, were normal and his blood test results were stable. Our physician adviser said Mr A did not need any inpatient treatment. There was no specific treatment that could have been given to prevent his subsequent deterioration. Mr A’s condition did not meet any of the criteria that meant he needed to remain in hospital.
45. Before the Trust discharged Mr A it carried out a therapy assessment, which identified the need for equipment at home. This was supplied prior to discharge.
46. The Trust’s decision to discharge Mr A on 21 April was in line with the relevant guidance.
47. Mrs A questions why the Trust discharged her husband without him having completed treatment for pneumonia.
48. The records show the Trust did not diagnose Mr A with bacterial pneumonia during this admission. Our physician adviser confirmed neither Mr A’s clinical presentation nor his chest X-ray results were in keeping with a picture of bacterial pneumonia.
49. The Trust did give Mr A a five-day course of antibiotics while he was in hospital, as a precaution, to cover the possibility of bacterial infection. Our physician adviser confirmed no further treatment was required and there was no indication to discharge him on pneumonia treatment.
50. In summary, based on the evidence we have seen, we have identified no failings in the Trust’s decision to discharge Mr A on 21 April. The Trust acted in line with relevant guidance. We do not uphold this part of the complaint.
Antibiotics
51. Mrs A complains the Trust discharged her husband without antibiotics to continue at home. The Trust says Mr A refused antibiotics to take home with him. Mrs A says he would not have done this in view of his medical history.
52. GMC guidance tells doctors to ‘prescribe drugs or treatment, including repeat prescriptions, only when you have adequate knowledge of the patient’s health and are satisfied that the drugs or treatment serve the patient’s needs.’
53. Mr A did not have symptoms requiring antibiotics during either of his first two admissions. Mr A initially presented with diarrhoea and was generally unwell. Antibiotics are not indicated for this.
54. The doctor who assessed Mr A on admission thought it likely he had an atypical presentation of COVID-19 but started the sepsis pathway as a precaution. Accordingly, they started treating him with IV antibiotics. We appreciate why the Trust took a cautious approach given Mr A’s medical history.
55. The consultant has recorded, on 17 April, the antibiotics are to be stopped as Mr A was refusing them. They discussed with Mr A his preference to leave hospital and there is no mention he needed to continue antibiotics at home.
56. As previously stated, antibiotics were not indicated and therefore did not need to be given for Mr A to continue at home.
57. As explained, Mr A’s condition did not need antibiotics during his second admission, but the Trust gave them again as a precaution. They were stopped on 20 April.
58. We have identified no failings in the Trust’s use of antibiotics. We do not uphold this part of the complaint.
Toileting and personal care
59. Mrs A says the Trust failed to provide her husband help with toileting and personal care during his first two admissions. She says the Trust left him in soiled clothing and each time he was discharged, he was still in the same clothing he was admitted in. She told us this was wet and soiled as he had been too unwell to go to the toilet. We acknowledge how upsetting it was for Mrs A to see her husband in this condition.
60. According to the ward manager's investigation, Mr A was ‘well looked after with no lapses in care’. They said nursing staff carried out intentional rounding every two hours. This included offering him assistance in going to the toilet and checking the call bell was in reach. They also said Mr A was offered clean pyjamas, but he refused, preferring to stay in his own clothes. They said Mr A was continent and mobile.
61. Mrs A disputes the Trust's response and says staff never asked her husband if he had been able to get to the toilet or needed assistance.
62. In line with basic nursing practice, supported by NMC standards, nurses are expected to assess the capabilities of their patients and their ability to attend to their activities of daily living. They are also expected to encourage patients to do as much for themselves as possible, to maintain their independence.
63. Our nursing adviser said it is important to remember the COVID-19 pandemic meant changes to the way care was delivered. Infection control procedures meant healthcare staff should not touch or interact with patients unless essential care was being provided.
64. The nursing records for the first admission show ward staff completed continence, and moving and handling assessments, noting Mr A was independent or needed minimal assistance. During two-hourly care rounding checks, staff documented Mr A was either independent with toileting, or they offered support.
65. On 15 April staff noted ‘minimal assistance required with personal hygiene/care’ and ‘able to walk independently’. On 16 April staff noted ‘patient is independent and self-caring’. On 17 April they noted Mr A had ‘been up to toilet independently, independently mobile’.
66. During the second admission, nursing staff recorded Mr A was self-caring on 19 April. On 20 April staff recorded at several points that Mr A was able to meet his own personal and hygiene needs or needed minimal assistance. Also on that day, a physiotherapist noted Mr A had showered and was independently mobile to toilet.
67. The records available show nursing staff assessed Mr A as being independent and regularly checked if he needed assistance, in line with guidance. The records show Mr A declined assistance with personal care. Mr A had capacity to make decisions about his care so staff would not have been able to force him to wash or change. This may account for Mr A’s appearance when he left hospital.
68. We have identified no failings in this area and do not uphold this part of the complaint.
Decision making about limit of treatment
69. Mrs A complains doctors did not involve her in decisions about her husband not being for ventilation or resuscitation. She disputes the Trust’s account that her husband agreed to the decisions. She says he would not have been able to hear or understand what was said to him because of his condition, lack of hearing aids and use of a CPAP hood.
70. NICE COVID-19 guidance in place at the time says decisions about escalation of treatment 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.
71. 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.’
72. GMC guidance tells doctors they must make decisions about cardiopulmonary resuscitation (CPR): ‘based on the circumstances and wishes of the individual patient. This may involve discussions with the patient or with those close to them, or both, as well as members of the healthcare team.’
73. The GMC also says healthcare professionals should acknowledge the role of people close to the patient and respect their feelings, although the patient must remain the focus.
74. Resuscitation guidance from the GMC is clear that CPR generally has a very low success rate. It often results in adverse outcomes for the patient, such as brain injury caused by lack of oxygen, organ damage, and increased disability.
75. 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.’
76. The guidance is also clear that decisions about treatment ultimately rest with the doctor concerned. They are not expected to provide treatment they consider is not in the patient’s best interests.
77. The GMC tells doctors they ‘must make a record of the decisions made about a patient’s treatment and care, and who was consulted in relation to those decisions.’
78. The GMC guidance tells doctors, where there is disagreement with the patient and/or their loved ones about what is in the patient’s best interests, they should attempt to reach a consensus. This would mean explaining the benefits, burdens and risks with a view to the patient and family accepting the doctor’s professional opinion.
79. The GMC also tells doctors they should support patients to die with dignity and to act if they think patient safety is being compromised.
80. The Trust uses a ‘Recommended Summary Plan for Emergency Care and Treatment’ (RESPECT) form to record patient preferences about treatment limits and CPR, and the decisions reached by clinicians. On the form, clinicians are asked to record the date, names and roles of those involved in the decision making, and where discussions can be found.
81. We looked to see if the Trust made its decisions in line with guidance.
82. According to the hospital records, the doctor who assessed Mr A in the emergency department on 21 April recorded they had discussed with him (and Mrs A) that he may not be suitable for the Intensive Therapy Unit (ITU). They noted Mr and Mrs A both wanted him to be considered for the ITU and CPR.
83. On 23 April another doctor documented a discussion they had with Mr A about his wishes. They noted again Mr A wanted full escalation. They said the subject needed to be discussed again with Mr A after he had spoken to his family. We could not find record of a further discussion taking place.
84. Given Mr and Mrs A’s preferences differed from the view of the medical team, we would expect to see evidence of further discussion, in line with GMC guidance.
85. An ITU consultant reviewed Mr A on 24 April. They noted the anti-rejection drugs (also known as immunosuppressants) Mr A was on would severely impair his recovery from COVID-19 as the drugs impaired his immune system. They did not believe intubation (for ventilation) would help him.
86. Another ITU consultant completed a RESPECT form on 25 April. They ticked the box to say Mr A had mental capacity and had been fully involved in making the decision. We could find no record they had discussed this with Mr A. Additionally, we saw the form was only partially completed. They did not complete the date(s) of discussion, roles of those involved, or where the details were recorded.
87. Regarding the escalation of treatment, doctors determined Mr A was not a candidate for more intensive treatment. Mr A’s significant co-morbidities meant escalation of treatment to invasive mechanical ventilation was very unlikely to improve his chance of survival. The doctors decided it was not in his best interests to escalate his treatment. This is irrespective of the do not attempt resuscitation decision.
88. On 28 April a consultant documented a discussion with Mrs A. They said they explained the ITU staff and Mr A had decided intubation and ventilation would be futile as progression of COVID-19 at this level would lead to respiratory failure, meaning it would be fatal.
89. We think the Trust reached decisions about Mr A’s suitability for CPR and escalation of treatment that were in line with relevant guidance. CPR and invasive ventilation would not have been in his best interests.
90. There is evidence the Trust made some attempt to discuss Mr and Mrs A’s preference with them. However, we think the Trust failed to fully communicate what it had decided with Mr and Mrs A, and so failed to reach a consensus. It also did not document its decisions in line with the GMC guidance or the instructions on the RESPECT form.
91. We saw the Trust’s complaint response states it discussed the limit of treatment with the heart transplant team at hospital A (part of a different Trust). It stated the team from hospital A were also of the view that Mr A would not survive ITU or a cardiac arrest.
92. We could not find record of this conversation between the Trust and hospital A. There is a record of a conversation on 22 April, but the doctor has recorded only hospital A’s advice on immunosuppressants. This would suggest either the Trust’s response is wrong, or the Trust did not document hospital A’s view on the limit of treatment.
93. Mrs A says there are several factors that would have made communication with her husband difficult.
94. Our physician adviser said CPAP hoods present a physical barrier to communication, much in the same way that face masks do. They said most patients are fully conscious and able to communicate while using a CPAP hood.
95. Concerning Mr A’s hearing, on 27 April a speech and language therapist has documented his hearing had decreased, which they attributed to the noise from the oxygen. We could find no record of Mr A needing hearing aids or any other reference to his hearing during any of the admissions.
96. We appreciate why Mrs A is concerned her husband may not have fully understood what staff said to him, or that he may not have been able to fully participate in discussions. We have seen no evidence Mr A lacked capacity or was too unwell to be involved in discussions about his treatment.
97. The records show staff were able to obtain information from Mr A throughout and had conversations with him. Therefore, despite the CPAP hood and lack of hearing aids, there appears to have been no difficulty in communication.
98. Mrs A says the Trust should have recognised her husband was dying at this point and should have put palliative care in place so he could die at home, as he wished.
99. Our physician adviser said it was not until 2 May that Mr A could be considered approaching the end of life. This was on the basis that his oxygen requirements had been stable up until then, albeit he had needed a high level of supplementary oxygen. The ITU consultant phoned Mrs A on 2 May to explain that her husband had deteriorated, and the focus should be on keeping him comfortable. Sadly, Mr A died later that day.
100. Therefore, there was no point during the admission that the Trust should have considered discharging Mr A to die at home. He was too unstable and would not have survived the transfer process. Attempting to transfer Mr A home would have potentially compromised his safety and dignity.
101. In summary, we have found no failings in the Trust’s decisions about the limit of Mr A’s treatment or his suitability for CPR. We think the Trust failed to communicate its decisions fully and failed to document its decisions, in line with guidance and the instructions on the RESPECT form. We can see this has led to Mrs A feeling she and her husband were not appropriately involved in decisions, adding to her distress about her husband’s experience.
102. We have not seen evidence that persuades us Mr A was unable to participate in decisions.
103. We also have not found the Trust should have identified earlier that Mr A was dying.
104. We partly uphold this part of the complaint and are making recommendations to the Trust.
Recorded causes of death
105. Mrs A disputes how the Trust completed her husband’s death certificate. She questions why it included dilated cardiomyopathy, as this was treated by his heart transplant, and why it included diabetes, as she says this had been well managed. She questions why it did not include CKD and pneumonia. She also questions why the doctor who signed the death certificate was not the one who had been on duty when her husband died.
106. Regarding the recorded causes of death, the guidance for doctors tells them to record the immediate, direct cause of death. They then must record any events or conditions that started the sequence that led to the death.
107. Mr A died from COVID-19 infection. The guidance says it is acceptable to record COVID-19 as a direct, or underlying, cause of death. His pneumonia was related to COVID-19 so did not need to be listed separately. The fact Mr A was a transplant recipient on anti-rejection drugs, and diabetic, all lowered his immune system which contributed to the severity of his illness. Therefore, including diabetes and his original heart condition was in line with the guidance.
108. Our physician adviser explained the CKD did not directly contribute to Mr A’s death and was almost certainly due to his diabetes and anti-rejection drugs. These were already included on the death certificate. It was not necessary to include CKD separately.
109. Concerning the doctor who signed the death certificate, under the Coronavirus Act 2020, changes were made to the death certification process (schedule 13). Under the Act, a doctor not involved in a patient’s final illness is permitted to complete the death certificate if they are able to state, to the best of their knowledge and belief, the cause of death. The Trust acted in line with the Act when completing Mr A’s death certificate.
110. From the information considered, we find the Trust completed Mr A’s death certificate in line with the relevant guidance. We do not uphold this part of the complaint.