Cardiology outpatient appointment – clinical assessment
32. Miss A says on 14 December 2018, when Mrs F attended a cardiology outpatient appointment with her son, Mr F, he told the Trust’s nurse that his mother had been very poorly and in bed for two weeks with the following symptoms: vomiting, not eating, very sleepy, and a yellow complexion. She says Mrs F’s son also told the nurse his mother ought to be admitted, but the nurse dismissed his concerns. Mr F said the nurse said Mrs F should eat little and often, but as she might have pneumonia, they were going to do a full set of blood tests. Miss A says Mrs F should have been admitted at this time. Instead, she was sent home to suffer.
33. The Trust said when Mrs F was seen at the nurse-led heart failure clinic, she was reviewed by a heart failure specialist nurse. A chest X-ray was requested at the time as Mrs F had a history of breathlessness and a reduced appetite. The chest X-ray appeared to show pleural effusions at the base of both lungs. A pleural effusion is a build-up of fluid between the layers of tissue that line the lungs and the chest cavity. It said several blood tests were taken to exclude any underlying infection and the plan was for Mrs F to return home with a prescription for antibiotics in case the blood tests showed these were needed. A consultant cardiologist and the heart failure specialist nurse both felt Mrs F was well enough to return home at this time.
34. We can see from the clinical records for 14 December, Mrs F reported shortness of breath on minimal exertion and that for the last two to three weeks Mrs F had experienced a reduced appetite and acid reflux (heartburn). She told the nurse that the day before she had experienced an episode of dizziness and had sustained a fall while getting up from bed, and she was remarkably tired. There was no reference in the nurses’ notes to Mrs F having reported being in bed for weeks, vomiting, or having a yellow complexion.
35. We asked our cardiology adviser to help us understand what should have happened when Mrs F attended the clinic on 14 December. Our adviser said the clinical assessment was comprehensive and the documentation was thorough, and Mrs F was assessed in line with NICE guideline (NG106) ‘Chronic heart failure in adults: diagnosis and management’ (1.4.12; 1.13). This says not to withhold treatment with a beta-blocker solely because of age but to introduce them in a 'start low, go slow' manner. Our adviser went on to say Digoxin, a beta-blocker medication, used to treat various heart conditions, was therefore added to control her atrial fibrillation (irregular heartbeat). There was no concern at that time about her kidney function.
36. Our cardiology adviser said it should be noted that this appointment was at a heart failure clinic and not a general cardiology or general medical clinic. The clinic was run by specialist nurses who specifically manage heart failure, albeit supervised by a consultant cardiologist. Liver function tests were not done, which our adviser says is acceptable as clinical examination did not suggest liver abnormality. Sadly, Mrs F deteriorated and was admitted to hospital three days later with evidence of pancreatic cancer.
37. We do recognise there is a difference between the symptoms that were reported by Mrs F and her son at this appointment, but in the absence of any other evidence to the contrary, we are unable to reconcile this difference further.
38. On balance, based on the above, we are satisfied that the Trust’s assessment of Mrs F on 14 December, and its decision not to admit her at this time, were in line with the relevant guidance and standards. We understand why Miss A feels Mrs F should have been admitted to hospital immediately, as she was no doubt very poorly. However, we have not found failings in relation to the cardiology clinic’s assessment of Mrs F nor its decision not to admit her that day.
Request for a wheelchair
39. Miss A says Mrs F was very weak this day and at the end of the appointment, Mrs F’s son requested a wheelchair for him to use to take Mrs F back to the car. She says clinic staff refused to provide one, saying Mrs F could walk. Miss A says Mrs F did not have the energy to walk, so her son had to carry his mother back to her car. Once home, she says Mrs F went straight to bed, physically exhausted.
40. The Trust says Mrs F’s son did ask whether a wheelchair was available. Nursing staff told him that they could request one as a priority, but there might be a delay in one being available. It said it was Mrs F’s son’s decision to take her to the car himself.
41. There is no reference in the clinical records of the request for a wheelchair being made. We reviewed the Trust’s portering policy. The policy refers to four stages of patient need (level zero to level three). Outpatients are categorised as level zero. Level zero also includes those patients ‘requiring hospitalisation where needs can be met through normal ward care’. The only difference between these two is that if a patient is being admitted, a Health Care Assistant (HCA) is also required to accompany the patient. As discussed above, we have not seen evidence that Mrs F should have been admitted. In any case, it would not have meant anything different except that an HCA would have been needed to accompany her. There is no requirement for wheelchairs to be provided within any specific time guidelines.
42. Again, the Trust and Mrs F’s son have reported differing recollections of what was said on 14 December 2018. It is difficult to be certain about the conflicting information, and it is unlikely that these differences could be reconciled, especially given the time that has passed since. In the absence of any further evidence therefore, on balance, we can only conclude that there is insufficient evidence for us to say there was a failing in relation to Mrs F’s son’s request for a wheelchair. We do understand it must have been very difficult for Mrs F’s son at the time. Given how poorly his mother was, he would no doubt have wanted to get her home as soon as possible.
Blood test results
43. Miss A says following Mrs F’s cardiology appointment, the blood tests taken on 14 December were not available over the two days that followed. She says she believes they should have been marked as urgent. Then on the morning of 17 December, the Trust rang Mrs F and her family and told them her blood results were clear. She said at this time, Mrs F was still in bed and was deteriorating, so they called her GP. Her GP did a home visit that day. After reviewing Mrs F, the GP called immediately for an ambulance. Miss A says on arrival at A & E, Mrs F was diagnosed with severe dehydration and her kidneys were not functioning. She was also jaundiced, had low blood pressure, and her liver function was impaired.
44. The Trust say that due to an oversight, the blood test results were not checked until 17 December. These results were clear in terms of a chest infection. However, they did indicate that Mrs F’s kidney function was impaired. The Trust says this should have been reported to Mrs F. As we know, Mrs F had already been admitted to hospital by then and in the Trust’s view, the abnormal kidney function would not in itself have necessarily meant admitting her any sooner.
45. We asked our cardiology adviser what should have happened with Mrs F’s blood tests. Our adviser said there was no reason to request the tests urgently, and the management plan the Trust had put in place on 14 December was appropriate and reasonable, with a plan put in place for her to be contacted by phone. Our adviser went on to say the purpose of the blood test was to check whether there was a need for antibiotics to treat an infection, and the outcome of this was that there was no need for antibiotics. They said this may explain why Mrs F was reassured about her blood results being clear, i.e., that there was no evidence specifically of a chest infection.
46. Our adviser refers to sections of a letter from the cardiologist to Mrs F’s GP on 21 January 2019, which support this. For example, it includes the following: “the (blood) results were not available when I left the clinic at the end of the day. Prescription prepared to be given to patient if it is needed. [Mrs F] needed to be started on antibiotics if the inflammatory markers are high. The levels came out as not significantly high. Hence, there is no indication for the antibiotics. I have left two messages on [Mrs F]'s phone on Monday to inform her that there is no need for antibiotics”.
47. Our cardiology adviser says nevertheless, given the abnormal kidney function, a follow-up call was indicated. GMC Good Medical Practice guidelines emphasise the importance of being transparent and involving patients in decision-making. These guidelines also say doctors must give patients the information they want or need to know in a way they can understand. In this case, although the blood results were satisfactory in terms of a possible chest infection, our cardiology adviser says the abnormality of Mrs F’s renal function was not shared with her, and it should have been.
48. In summary, while Mrs F was on appropriate treatment for heart failure, when it became apparent that her renal function had become impaired, it should have been acted upon promptly and was not. Mrs F required hospital admission shortly after the clinic visit and despite rehydration, sadly died from advanced pancreatic cancer ten days afterwards. Our adviser said it should be noted that although rehydration after admission resulted in an improvement in renal function, clearly Mrs F’s pancreatic cancer itself was sufficiently advanced to cause her death. This could not have been avoided by any different action that might have been taken either during, or shortly after, her outpatient visit.
49. We consider while it would not have changed the outcome for Mrs F, the Trust’s delay in reporting her blood test results and then not discussing her impaired kidney function with her, was a failing on the Trust’s part.
50. It is for us to consider what the impact of these failings had on Mrs F. Although our adviser said the abnormal renal function result would not have necessarily required admission to hospital, they also said such a call would likely have uncovered Mrs F’s generally worsening clinical condition. This may have prompted an earlier face to face review, specifically to assess her hydration status, and adjust any medications that may have aggravated renal dysfunction. They said it is likely that when reviewed, Mrs F would have been admitted sooner.
51. We can see that the Trust has apologised for the errors in relation to the blood tests. It says a different cardiology specialist nurse was on duty on 15 December, when the results became available, and the results were not checked by the nurse. It says the nurse has reflected on the incident to improve their care. It also says lessons have been learned, including the need for better handover arrangements and improvements to be made to the flagging system of significant abnormal results.
52. We asked our cardiology adviser whether these improvements were sufficient to prevent such errors occurring in future. Our adviser said the Trust’s response is reasonable and appropriate. It has put in place a system whereby abrupt deterioration in kidney function is automatically flagged up to indicate an acute kidney injury (AKI), and the Trust have put in place a system that will reduce such similar issues. We have also asked the Trust to update us on what steps it has taken and how this is being monitored. It said, the cardiology and biochemistry department’s clinical lead has confirmed the following:
· our heart failure nurses now ensure that all blood tests taken in clinic are sent with an urgent request form and that a robust follow up plan for review of the results is made. Follow up of the results remains the responsibility of the requesting clinician, however if they are unable to follow up the results personally, the responsibility is handed over to an appropriate colleague or on call clinician. The recent implementation of remote access to blood tests results has also benefitted follow up arrangements considerably.
· there is now an established AKI alert system in use at the Trust, with abnormal results flagged up to the requesting clinician/on call team.
53. The Trust has also provided us with a copy of its updated pathology handbook which says (at page 29):
· Abnormal results: the following table below indicates critically abnormal results which will be communicated to the requesting clinician at all times where contactable.
· Where not contactable, or out-of-hours, the following will be followed.
1. Inpatients – the ward will be contacted 2. Outpatients - will be bleeped to the Medical Registrar 3. Results will be telephoned to the NHS emergency service 111.
4. If contact cannot be made, the Clinical Lead for Biochemistry will be alerted.’
54. In our view, this shows the Trust has taken this matter seriously and taken learning from it. The steps it has taken are sufficient by way of minimising the possibility of this kind of mistake in future.
55. In summary, not reporting the abnormal kidney result was a failing, and this should have been done on the day the result was available. This may have led to Mrs F being admitted. We believe this failing did lead to injustice for Mrs F, as it was a missed opportunity to review and assess her sooner.
56. The Trust has already acknowledged and apologised for its failings in relation to Mrs F’s blood test results. We are also satisfied it has also made suitable service improvements to avoid this happening in the future. We believe the steps the Trust has already taken have sufficiently put right the impact its failings caused. Therefore, we conclude that there is nothing further we should ask of them in relation to this aspect of the complaint. We have not found any unremedied injustice. We appreciate this must have been a worrying time for Mrs F’s family and hope they will be reassured that the Trust has taking learning from this complaint.
Monitoring on the afternoon of 24 December 2018
57. Miss A says nursing staff waited too long to consult with a doctor about not being able to measure Mrs F’s blood pressure on 24 December. Miss A says at 3pm, Mrs F was taken to have an Endoscopic Retrograde Cholangiopancreatography (ERCP). An ERCP, is a procedure which combines X-ray and the use of a long, flexible, lighted tube to diagnose and treat problems in the liver, gallbladder, bile ducts, and pancreas. She returned to the ward at just after 4pm, but Miss A says she was not alert or awake. A nurse came along at around 6pm to check on Mrs F. She says the nurse went to take Mrs F’s blood pressure using Mrs F’s left arm. The nurse could not get a reading, and Miss A says the nurse then tried using Mrs F’s right arm. The nurse got a low reading. She says she asked the nurse if she should be alarmed, and the nurse said no. They said Mrs F had come in with low blood pressure and they were aware of this. Miss A says this did not reassure her.
58. The Trust has said Mrs F did have low blood pressure on admission which was caused by diminished body fluid. The treatment plan included doing daily intravenous fluids throughout Mrs F’s admission. This would have increased her fluid circulatory volume and maintained her blood pressure within acceptable parameters. It says her blood pressure remained low but stable, her urinary output was continually measured, and her renal function was slowly improving. It says her blood pressure continued to be recorded every two to four hours up until her return for the ERCP on 24 December. It says Mrs F was given sedation during the procedure which would account for her being sleepy when she returned to the ward and that her intravenous fluids were restarted at 4.30pm. The on-call doctor reviewed her at 7pm. They noted she was comfortable and easily rousable and her blood pressure was back to her baseline.
59. When considering whether Mrs F was suitably monitored, the relevant standard is: Royal College of Physicians (2017) ‘National early warning score (NEWS 2). Standardising to assessment of acute illness severity in the NHS’.
60. Our nursing adviser says NEWS 2 should be used for initial assessment of acute illness and for continuous monitoring of a patient’s wellbeing throughout their stay in hospital. By recording the NEWS 2 on a regular basis, the trends in the patient’s clinical responses can be tracked to provide early warning of potential clinical deterioration and provide a trigger for escalation of clinical care.
61. NEWS 2 measures six physiological parameters: 1. respiration rate 2. oxygen saturation 3. systolic blood pressure 4. pulse rate 5. level of consciousness or new confusion 6. temperature.
62. This guidance says, if the patient scores 3 in any one of the above parameters, or between 5-6 across all parameters, there should be an ‘urgent response’ and if the patient scores 7 or more across all parameters there should be an ‘emergency response’.
63. On reviewing the clinical records, it is difficult to read the times that Mrs F’s NEWS 2 was taken on 24 December 2018. At what appears to be around 4pm that day, Mrs F’s systolic blood pressure was within normal ranges, as in normal for the purposes of NEWS 2.
64. Later that evening, Mrs F’s systolic blood pressure had dropped, and she scored 5 on NEWS 2. When a patient scores 5, this requires an urgent response.
65. Our nurse adviser said what this means should happen, is a registered nurse should immediately inform the medical team caring for the patient and there should then be a one-hourly minimum repeat of NEWS 2 assessments. An hour later, NEWS 2 was repeated and Mrs F’s systolic blood pressure had dropped further, and she scored 6 on NEWS 2, indicating that she was clinically deteriorating. The clinical records show that this was escalated to the medical team, who were already on the ward. Up until 10:10pm therefore, when NEWS 2 scoring was repeated, the monitoring and escalation of Mrs F’s blood pressure monitoring was in line with the Royal College of Physicians (RCP) standards referred to above.
66. A further hour later though the time is unclear) Mrs F’s blood pressure dropped further, despite the medical plan that had been put in place at 10pm (increasing her IV fluids). She scored 6 on NEWS 2, which indicates they must immediately inform the medical team caring for the patient. It is noted from the clinical records that Mrs F was urgently reviewed at midnight. Thus, escalation and monitoring of Mrs F remained in line with RCP standards up until midnight on 24 December.
67. Mrs F’s NEWS 2 was then recorded on two further occasions. The first appears to be shortly after midnight and the second a couple of hours later. It is documented that the medical team were then again asked to see Mrs F due to unrecordable observations in the early hours of the morning and they arrived seven minutes later. Sadly, shortly afterwards, Mrs F was pronounced dead.
68. In summary, the monitoring and escalation of Mrs F’s low blood pressures on NEWS 2 was in line with national standards up until a couple of hours before her death. There is however a gap until the unrecordable observations at around 3am when monitoring and escalation was not in line with national standards.
69. We asked our nurse adviser what the impact of the missing assessment had on Mrs F. Our adviser said Mrs F was very unwell throughout the evening of 24 December, and into the early hours of 25 December. She was last medically assessed at midnight prior to her death in the early hours of the morning. It is therefore unlikely that the gap in NEWS 2 monitoring from the nursing staff had any impact on the outcome for Mrs F.
70. Although there was a failing in terms of this delayed NEWS 2 check, we cannot link this directly to any clinical impact or other injustice for Mrs F or her family. We cannot see therefore that there was any injustice caused by the delayed NEWS 2 assessment.
Suitability of ward
71. Miss A complains that the Trust did not transfer Mrs F from a geriatric ward to the Intensive Care Unit (ICU). Mrs F was moved from the Medical Assessment Unit to a geriatric ward, as apparently there were no beds on the gastroenterology ward. Miss A says as Mrs F’s low blood pressure was life threatening, she should have been transferred to the ICU.
72. The Trust said Mrs F’s care could be managed on the medical ward without specialist intervention. It also says, after discussing Mrs F’s prognosis with her on 20 December, Mrs F was agreeable to ward-based care only. It said a request was made to transfer her to the gastroenterology ward, but unfortunately no beds were available. However, the Trust said its speciality teams, including gastroenterology, would still give advice if a patient was not on their home ward, and the clinical care and monitoring of patients on the care of the elderly ward is at the same level as that on the gastroenterology ward.
73. We asked our gastroenterology adviser whether Mrs F should have been moved to another ward. Our adviser said Mrs F was referred to the Intensive Care Team on arrival to the Hospital on 17 December 2018. She was reviewed by the Critical Care team in a timely manner. An accurate assessment of Mrs F’s problems is documented and a decision not to admit to Intensive Care was made. Admissions to intensive care decisions are based on a number of parameters, but principally relate to the level of organ support required (such as breathing support, blood pressure support, kidney replacement therapy and so on).
74. Our gastroenterology adviser refers us to the ‘Guidelines on admission to and discharge from intensive care and high dependency units’ (Department of Health, 1996). This lists the criteria for admission to intensive care units. Our gastroenterology adviser says at the point of Mrs F’s critical care review, none of these parameters had been met. Advice on when to re-refer was given in the medical notes. They said then an overarching decision not to refer Mrs F to Intensive Care was made 20 December, in the partially completed ‘treatment escalation plan’. Treatment escalation plans are tools to prevent unnecessary or futile interventions. In this case, care was limited to ward based interventions (such as fluids and antibiotics).
75. Our gastroenterology adviser says there is no documented ‘details of discussion with patient and family’ on this treatment escalation plan, however the medical notes state discussions regarding diagnosis and limitations of treatment were had. The patient was noted to be alert and orientated, which is a phrase common throughout Mrs F’s notes consistently documented by nursing as well as junior medical reviews.
76. The period of care between admission on 17 December and the documented decision not to further refer to Intensive Care on 20 December, is accompanied by entries in the notes supporting an improving clinical picture with low but stable blood pressure and improving kidney function. Mrs F reported feeling much better. Since physiological parameters had improved since the initial critical care review, our adviser says there would be no reason to refer for intensive care admission.
77. Our adviser also said after Mrs F was initially listed for transfer to a gastroenterology specialist bed, she was reviewed by the gastroenterology team while on the geriatric ward. She was also reviewed by the gastroenterology team after her ERCP on 24 December. On the night following the ERCP procedure, on 24 December, the physiological observations (NEWS 2 scores) were documented, logged for actions, and repeated in keeping with Royal College of Physician guidance.
78. In summary, the Trust’s decision not to transfer Mrs F to the ICU was in keeping with relevant guidance. She did not require an intensive care bed on admission, and care on the geriatric ward was of the same level as she would have been provided with on a specialist gastroenterology ward.
79. Based on this advice, which is supported by the relevant clinical records, we are satisfied that the Trust’s actions were in line with the relevant standards and guidance. We have not identified any failings in relation to this part of the complaint.
Communication with family about Mrs F’s condition
80. Miss A says on 20 December, Mrs F told the family that a doctor had told her that although she had cancer, they may discharge her from hospital and arrange outpatient treatment, because she was not well enough to receive treatment at that time. She says Trust staff provided conflicting advice to Mrs F about her assessment, diagnosis, prognosis, and treatment plan. Miss A also says the Trust did not inform the family that Mrs F had cancer, or the type of cancer she had, and did not discuss the treatment for her cancer and potential hospital discharge with the family.
81. Miss A says Mrs F was not of sound mind during this admission and therefore she was not able to reliably pass on information to the family about her diagnosis, prognosis, or treatment. She says the family requested information about Mrs F’s condition on several occasions, but staff did not arrange for them to speak with a doctor. She says this led to the family feeling very frustrated, upset, and confused about Mrs F’s condition and treatment. For the family, it seemed Mrs F died very suddenly and without warning. Miss A said this prevented the family from preparing for Mrs F’s death and the family were not able to say goodbye to her before she died.
82. In its complaint response letters, the Trust said on the afternoon of 19 December, a gastroenterology registrar reviewed Mrs F. They explained that they had discussed the result of her computed tomography (CT) scan with her. The scan had shown the possibility of a pancreatic lesion and biliary obstruction (blocked bile duct). They told Mrs F there was a possibility the lesion may be cancerous. It says discussions concerning actual and potential diagnosis are always held directly with the patient when they have full mental capacity, as Mrs F did.
83. The Trust also said on 20 December, a Senior House Officer also had a discussion with Mrs F. It is documented that at this time, Mrs F was alert and orientated. The House Officer explained to Mrs F that there was a mass in her pancreas, which was likely to be cancerous, and that there were limited treatment options. The doctor discussed the question of resuscitation with Mrs F. Mrs F agreed to receive ward-based care only. The Trust said it is entirely up to the patient to decide whether to inform family members of their diagnosis, but the medical team are always happy to have discussions with the family if the patient agrees and wants this to happen.
84. We can see from the clinical notes, there is no record of any attempts to contact Mrs F’s family or next of kin to update them on her condition. Nor is there any reference to any discussion with Mrs F as to whether she would like her family to be updated. Similarly, there is no reference to Mrs F’s family requesting an update from the clinical or nursing teams. However, our gastroenterology adviser said this may be that not all Trusts record this information in medical case notes. We do know the plan at this time was to have an ERCP to examine the pancreatic and bile ducts. The consultant gastroenterologist met Mrs F’s family on the ward on the day this took place, the afternoon of 24 December, at which point the doctor told the family about the planned ERCP procedure and Mrs F’s treatment plan.
85. Our gastroenterology adviser said although there is no formal mental capacity assessment undertaken anywhere in the notes, there are multiple references to Mrs F being “alert and orientated” and “orientated to TPP” (time place and person). There are also references to her being “cooperative, alert, responsive, fully conscious and being able to fully understand and respond appropriately”. They say when making decisions around a patient’s capacity to make informed decisions, the guidance from the General Medical Council (Cardiopulmonary Resuscitation and Consent 2008) and the Resuscitation Council, is that patients are assumed to have capacity. However, if there are concerns about capacity, a formal capacity assessment should be undertaken and documented.
86. The notes do not demonstrate any concerns around Mrs F’s cognitive ability or capacity to make decisions. Mrs F was able to sign a consent form for the ERCP procedure on 24 December, and the documentation says, “no cognitive impairment”, further supporting the Trust’s conclusion that Mrs F did have full mental capacity.
87. There is no reference in the clinical records as to whether Mrs F wanted or did not want her family updated with regards to her cancer diagnosis or resuscitation status. Our gastroenterology adviser says guidance on decisions relating to cardiopulmonary resuscitation (CPR) are provided by the British Medical Association, the Resuscitation Council (UK) and the Royal College of Nursing 2016 (known as the ‘joint statement’) state: “Where a patient has capacity, their agreement should be obtained before discussing their condition and any decision about CPR with other people, including family members”. Our gastroenterology adviser says there is a requirement in this guidance that the instruction to share information is recorded in the notes.
88. In addition, GMC guidance ‘Consent: patients and doctors making decisions together 2008’ says, “You should accommodate a patient’s wishes if they want another person, such as a relative, partner, friend, carer or advocate, to be involved in discussions or to help them make decisions”. Furthermore, the guidance advocates “involving …people who are close to the patient when making advanced care planning”. There is no evidence in the notes that Mrs F was invited to involve friends or family members in the discussions about her likely cancer diagnosis or her resuscitation status. In summary, although Mrs F was deemed to have capacity to make decisions about her care, there were missed opportunities to include family members, which were not taken and recorded.
89. In our view, the Trust should have had a discussion with Mrs F about whether she would like her family to be involved in discussions about her clinical condition, such as her diagnosis, prognosis, resuscitation status and treatment plan. It may have been that Mrs F preferred not to share this or felt she could communicate this for herself. However, she should have been given the opportunity to state her wishes about this, and a record of this discussion should have been documented in the clinical notes. Not doing so is a failing on the part of the Trust.
90. It is understandable that the family were left feeling frustrated and confused about Mrs F’s diagnosis and treatment. Her death would have seemed very sudden to the family, and we can understand why they felt they were not properly prepared for it. We can see how this would have been very upsetting for Mrs F’s family. For this reason, we do see there is a link between this failing and the injustice this caused Mrs F’s family. We make recommendations below for how the Trust should put this right.
The Trust’s communication with the family about Mrs F’s death.
91. Miss A complains Trust staff waited two hours to notify Mrs F’s husband that his wife had died. When the Trust called Mrs F’s husband early that morning, due to his age and hearing loss, he did not hear the phone. She says the Trust then contacted Mrs F’s son an hour later, and nearly three hours after Mrs F had died. He was not told that his mother had died. Instead, he was wrongly told that ‘her breathing was not good, and he should attend the hospital’. When he did, nobody approached him and he only discovered his mother had already died when he reached her bed and opened the curtains, to find her. Miss A said the Staff nurse told Mrs F’s son they had contacted him the previous evening to tell him his mother had died early that morning. However, a doctor then told him that in fact Mrs F had died earlier.
92. The ward initially said nursing staff did try to contact who they thought was Mrs F’s son, using the telephone number given on the A&E department attendance record. However, the next of kin details for Mrs F were the same as those given for her home address. There was then a delay in trying to obtain the correct contact details for her son. It is considered good practice for the admitting nurse to check that contact details for patients are all correct when they are transferred to the ward. This did not happen in this case, and the Trust apologised for the delay this caused in contacting Mrs F’s son. It said it would reinforce the importance of good practise with the nursing teams and ward managers.
93. The Trust also said, nursing staff are reluctant to inform the next of kin over the phone in cases of sudden or unexpected death. It said this is always difficult because they do not know if the next of kin is vulnerable, or how they would take receiving such news over the phone. In these cases, informing the next of kin in person is usually best, as it is a more controlled situation where advice and support can be given. It said nursing staff should however have met Mrs F’s son on his arrival on the ward, and it apologised for the distress not doing this had caused Mrs F’s son.
94. The clinical records document: “pts family has been called and her son has come and has been with pt”. However, several hours later, it is documented that there was a phone conversation with “daughter/niece” ... saying that “patient’s son was called at around 6am when the patient had died, but he was informed that the patient was still breathing…”. This does support the fact that hours after Mrs F’s death, her son was contacted and told she was alive.
95. We asked our nurse adviser what should have happened following Mrs F’s death on 25 December. Our adviser said, if they were unable to reach Mrs F’s husband because he did not hear the phone, then it would have been right that her son was contacted. This is in line with good clinical care and treatment. The next of kin will be attempted first. The son was then contacted. There is no evidence within Mrs F’s records that there was any difficulty in reaching her son by phone.
96. Our nurse adviser also said while it is often preferable to inform family face to face when an unexpected death has occurred, this is not an excuse for being untruthful and saying that the patient is still alive. They say nurses should never misinform family about the clinical condition of their family member. In accordance with national guidance, communicating with patients, their family and carers is a vital part of the process of dealing with patient’s safety incidents (National Patient Safety Agency, November 2009. Patient Safety Alert: NPSA/2009/PSA003. Being Open. Supporting information). Nurses also have a ‘duty of candour’. The nursing governing body (the Nursing and Midwifery Council) says: “As a doctor, nurse or midwife, you must be open and honest with patients, colleagues and your employers”.
97. Our nurse adviser says as Mrs F’s son had been wrongly told over the phone that his mother was still alive, he should have been met on the ward and informed of her death. In accordance with the NMC (2015) ‘The Code: Professional standards of practice and behaviour for nurses and midwifes’ (section 5.5) the Trust should “share with people, their families and their carers, as far as the law allows, the information they want or need to know about their health, care and ongoing treatment sensitively and in a way they can understand”.
98. Based on this advice, which is supported by the relevant clinical records, we have concluded that the poor communication with Mrs F’s family was a failing on the part of the Trust.
99. As discussed above, Mrs F’s family were not aware of her diagnosis and prognosis, therefore it must have been an awful shock for her son to learn she had died when he arrived at her hospital bed. It is understandable that he would have been devastated. We do conclude this failing did lead to injustice for Mrs F’s son.
100. The Trust has apologised to the family for not ensuring Mrs F’s son was met at the ward entrance to be told about his mother. It has not apologised for not telling the truth on the telephone. Nor has it taken learning from this aspect of the complaint. We have made recommendations for how the Trust should remedy this.