5. Mr N complains the Trust’s district nurse team did not give his mother her medication on the morning of 11 December 2020.
6. Because nurses did not give her this medication, he says his mother had a seizure and died.
7. Mr N wants the Trust to make service improvements to prevent the same thing happening again.
8. On 17 November 2020, Mrs N’s GP referred her to the Trust’s district nursing team so nurses could support her with her insulin regime at home. The district nursing service finalised these arrangements on 26 November.
9. Mrs N had a district nurse visit scheduled for the morning on 11 December. The nurse did not make this visit.
10. One of Mrs N’s carers saw her in the morning. They visited again a few hours later, only to find that she had sadly died.
11. During its complaint process, the Trust acknowledges the nurse did not visit Mrs N. It says the nurse needed to remain with the patient they saw before Mrs N. The nurse did not tell their team leader about this. Therefore, the team leader did not know they needed to allocate another nurse to see Mrs N.
19. Mr N complains that on the morning of 11 December 2020, the Trust’s district nurses did not give his mother her medication. He says she was diabetic and she needed insulin to manage this. He added that she needed medication to prevent her from having seizures.
20. He says the district nursing team had taken responsibility to administer these medications to her during their visits. His mother was struggling to do this herself because of her failing eyesight. Prior to 11 December, he says nurses had been visiting three times per day. They arrived in the morning, afternoon, and early evening.
21. The Trust have acknowledged that nurses missed the morning visit to administer Mrs N’s medication.
22. As the nurses failed to attend, they did not assess Mrs N’s need for the insulin they were responsible for giving her. We explain this further from paragraph 23. However, even on the balance of probabilities, we cannot say if they should have given her insulin that morning. We explain this further from paragraph 36.
23. After the referral Mrs N’s GP made to the Trust’s district nurses, to help her with her insulin, the district nursing team held a planning meeting to discuss supporting her.
24. They noted Mrs N had a care plan in place already with her local hospice. However, she was independently managing her insulin, and she was reluctant to accept help from district nurses with this. That said, nurses noted her GP said she was becoming increasingly confused over the past couple of weeks due to her recent brain tumour diagnosis.
25. On 24 November, the Trust held an MDT meeting. The different healthcare professionals involved in Mrs N’s care attended. This included her GP. The MDT agreed the Trust’s district nurses should supervise Mrs N with her insulin because she was starting to struggle with it. Her GP agreed to send them a summary about her insulin regime.
26. During the district nurse’s visit to Mrs N, on the morning of 25 November, nurses discussed with Mrs N the plan to take over her insulin regime. They added they were awaiting confirmation from her GP about her insulin regime and the appropriate doses to give her. Mrs N agreed to this plan and clarified with nurses the insulin she normally took each day.
27. Mrs N’s GP sent the district nurses details of her insulin regime on 26 November. This set out nurses needed to visit her in the morning, afternoon, and the evening to assess her need for insulin.
28. Nurses added this information into their care plan for Mrs N. During each visit, they needed to check her blood glucose level. If this indicated she needed insulin, the nurses should administer it.
29. We recognise Mrs N had other medications. The evidence we looked at indicates her family arranged her other medications be placed into a dosette box so she could take them.
30. The Administration of Medicines Guidance, section 1, says nurses can only administer medications to their patients in accordance with a prescription.
31. The prescription, agreed through Mrs N’s GP, authorised nurses to administer her insulin. We understand Mr N says that on 11 December, nurses should have given her medication to prevent her having seizures. Our nursing adviser explains, in line with the Administration of Medicines guidance, the Trust’s district nurses could only administer Mrs N’s insulin, not her other medications.
32. On this basis, we cannot see nurses failed to give Mrs N the medication they should have given her, specifically to prevent her having seizures. Their role was to supervise her insulin regime.
33. We recognise Mr N says nurses were responsible for medication for his mother’s seizures. The records available to us show Mrs N, and the healthcare professionals involved in her care, agreed she would continue to take this medication herself from her dosette box. As these records document agreements between these parties at the time they made them, we have decided they provide stronger evidence about the role the nurses had.
34. With respect to insulin, our nursing adviser explains, in line with section 17 of the Administration of Medicines Guidance, nurses should have assessed Mrs N’s need for insulin on the morning of 11 December.
35. They should have checked her blood glucose level, and whether this indicated they should give her insulin. If, after this assessment, nurses needed to withhold insulin, they needed to document the reason. As nurses did not attend Mrs N, this did not happen at all. This was a failing in care.
36. While nurses failed to assess Mrs N’s need for insulin, we consider it is not possible to say whether, even on the balance of probabilities, nurses should have given her insulin on 11 December had they visited.
37. Our nursing adviser explains the need to give Mrs N insulin would have been based on the nurse’s assessment of her blood glucose at the time. As nurses did not do an assessment, we do not know if this would have indicated she needed insulin.
38. We have also looked at what happened in the days leading up to 11 December. The information we have seen shows nurses checked Mrs N’s blood glucose levels and assessed her need for insulin, in line with the Administration of Medicines Guidance. During some of these visits, nurses did not give her insulin.
39. On the evening of 8 December, nurses did not give Mrs N insulin. Our nursing adviser explains district nurses made this decision based on a valid assessment of her blood glucose level, which fluctuated in the days leading up to 11 December.
40. During the nursing team’s visits in the afternoon and evening of 9 December, they assessed Mrs N needed insulin. However, she declined to have these injections.
41. Section 2.5 of the NMC Code says nurses must respect, support, and document a patient’s right to accept or refuse care or treatment. They acted in line with this guidance on 9 December.
42. During the other visits from 8 to 10 December, nurses assessed Mrs N needed insulin and they administered it for her.
43. Weighing up this evidence, we cannot say whether it is more likely that if the nurses had assessed Mrs N, they would have given her insulin. Based on the evidence, in the days before 11 December, there is a significant possibility, either the assessment may have indicated she did not need to take insulin, or she may have refused to have it.
44. We recognise, as nurses did not assess Mrs N’s need for insulin when they should have, this leaves Mr N with unanswered questions.
45. He will never know whether they should have given her insulin. We understand this means he will never know what might have happened. And whether the failure of the nurses to assess her need for insulin, and perhaps administer it, played a part in her death. We recognise this uncertainty has caused Mr N distress.
46. We also recognise our findings make Mr N aware of events he was previously unaware of. We note he says district nurses were responsible for the medication he says his mother was taking to prevent her seizures. We recognise he was not aware his mother declined to take her insulin at times. We acknowledge learning about these events has been upsetting for Mr N.
47. The Trust has not yet put right the impact we have identified in paragraph 44 and 45.
48. Our Principles say, where poor service or care has led to injustice or hardship, public bodies should try to offer a remedy that returns the complainant or person affected to the position they would have been in otherwise. If this is not possible, the public body should compensate them. This can include:
· an apology, explanation, and acknowledgment about what happened · remedial action, which may include reviewing or changing a decision or the service given, revising procedures to prevent the same thing happening again, training or supervising staff, or a combination of these things.
49. During its complaint process, the Trust acknowledged the nurse, due to see Mrs N, did not get in touch with their team leader to tell them they could not visit her. It apologised this resulted in the Trust’s failure to send a nurse to Mrs N.
50. The Trust said the nurse who should have seen her that morning worked for an agency it used. The Trust said it raised concerns with the agency about what happened so it could investigate further.
51. We are pleased to see the Trust has taken these steps. That said, we have decided there is more the Trust should do.
52. In its responses to Mr N, the Trust has not recognised the missed visit meant nurses did not assess Mrs N’s need for the insulin they were responsible for managing. It has not recognised the impact we have identified in paragraph 45 which stems from this.
53. Therefore, the Trust has not provided things our Principles indicate are appropriate, for example, an acknowledgment and apology about this.
54. Mr N wants the Trust to make improvements to prevent a repeat of what happened to his mother. For nurses to assess a patient, and administer any prescribed medication they are responsible for, they must first visit the patient. This did not happen in Mrs N’s case.
55. We appreciate, in response to Mr N’s complaint, the Trust identified why the missed visit happened. However, it has not explained to Mr N any procedural changes it made to try and prevent this happening again. The Trust says it spoke to the agency the nurse worked for about what happened, but it gives no further detail about this.
56. The Trust has since told us about recent service changes it has made, and changes it is currently planning. We consider these are positive changes which should reduce the chance of the Trust repeating the mistakes it made in Mrs N’s care.
57. We note the Trust has implemented or planned these changes during our investigation of this complaint. They have not come about directly from its own investigation into Mr N’s complaint. Also, the Trust is yet to provide Mr N with information about these changes. Our Principles indicate this is something the Trust should do.
58. As we have decided there is further work for the Trust to do to put things right, we have made recommendations to the Trust (below).
59. We understand any recommendations we make cannot change what happened to Mrs N. We also recognise Mr N seeks answers about whether nurses could have prevented her death. We appreciate our findings cannot provide closure on this, and this is upsetting for Mr N. We hope we have clearly explained why we cannot provide the definitive answers he seeks.
1. Mr N complained to us about the Trust’s district nursing service. He says nurses did not visit his mother (Mrs N) as planned. He considers his mother’s death could have been avoided if the nurses had visited and given his mother her medication. We recognise this has been a difficult time for Mr N.
2. We found the nurses failed to assess Mrs N’s need for insulin in the morning of 11 December 2020. We are unable to conclude whether, even on the balance of probabilities, nurses should have given her insulin. Therefore, we cannot say whether giving Mrs N insulin contributed to her death.
3. We consider this leaves Mr N with unanswered questions about his mother’s care and her death. We recognise he has found this distressing. We cannot see the Trust has put this right. Therefore, we have decided to partly uphold this complaint.
4. We have made recommendations to the Trust to put things right. We have set these recommendations out at the end of our report.
60. In considering our recommendations, we have referred to our Principles. These say, where poor service or maladministration has led to injustice or hardship, the organisation responsible should take steps to put things right.
61. To put things right for Mr N, we are asking the Trust to: · acknowledge its district nurse service did not assess Mrs N’s need for insulin on the morning of 11 December 2020, when it should have · acknowledge this leaves Mr N with unanswered questions about whether nurses should have given her insulin, and whether this played any part in her death · apologise about the distress this uncertainty caused around his mother’s care and death.
62. We ask the Trust to write to Mr N within one month of our final report and send us a copy of this letter.
63. Our Principles also say public organisations should look for continuous improvement and should use the lessons learnt from complaints to make sure they do not repeat maladministration or poor service.
64. To improve its service, the Trust has explained to us it has now used Mrs N’s case for training purposes across its nursing service. It explains it has already started audits on district nurse activities.
65. It has explained it is procuring a system to help managers track the movements of district nurses. This is so managers can see if they need to reallocate nurses to see patients in similar circumstances to Mrs N.
66. The Trust says these changes are new, and it is currently developing the change outlined in paragraph 65. On this basis, it cannot yet measure what impact these changes have had on its service. The Trust says it would like to share the changes it is making with Mr N and update him later about the impact they have.
67. Therefore, we ask the Trust to write to Mr N within one month of our final report to explain the service and training changes it has made already, and the changes it is developing. We also ask that the Trust explains what impact it expects these changes to have.
68. When the Trust has implemented its system to track the movements of its district nurses, we ask that the Trust writes to Mr N to confirm this system is in place and explain how it works.
69. We also ask that the Trust writes to Mr N on, or by, 30 December 2022 to provide its update and assessment on what impact all its changes have made on its service.
70. We ask that the Trust sends us copies of all the above correspondence. We also ask that the Trust shares this information with Care Quality Commission (CQC) and NHS Improvement (NHSI). We recommend the Trust anonymises Mr N when it shares this information with these regulators.