Sedation and haloperidol
18. Mrs H says that given Mr A’s pre-existing conditions, the Trust sedated, and then administered haloperidol medication to her father inappropriately. She says this contributed to her father’s deteriorating condition.
19. The NICE CG103 guidance explains, for a person with delirium who is distressed or considered a risk to themselves or others, doctors should consider giving short-term (usually for one week or less) haloperidol, starting at the lowest clinically appropriate dose. The BNF guidance on haloperidol explains that elderly patients with delirium should start on 0.5mg.
20. On 12 June, the records show doctors discussed, with Mr A’s wife, using a small amount of sedative to keep Mr A calm during a head CT scan, as he was too agitated during an earlier attempt that day. The records show Mr A’s wife agreed with this decision.
21. The clinical records show the Trust administered 0.5mg of haloperidol to Mr A on 13 June before doctors attempted a head CT scan. The doctors gave this medication to attempt to calm him as he was extremely restless and previous attempts to carry out the CT scan had failed. The records show the Trust used the haloperidol on a short-term basis. We consider the Trust’s decision to sedate Mr A was in line with the NICE CG103 guidance, and in his best interests at the time. Our clinical advice supports this view.
22. We have considered Mrs H’s concerns about whether the Trust should have given her father haloperidol, given his pre-existing condition at the time. This must be very worrying for her as she has been left with doubts as to whether the Trust was right to give her father this medication. On admission, staff recorded Mr A’s pre-existing conditions as atrial fibrillation, hypertension, anaemia, and that he had a pacemaker. The BNF guidance on haloperidol does not outline any known contraindications (reasons not to administer a medication) for the medication and any of Mr A’s pre-existing conditions. This is reassuring and is evidence the Trust has acted appropriately in considering his pre-existing conditions.
23. As we explain above, the BNF guidance on haloperidol instructs doctors on how to medicate patients such as Mr A, who suffered with delirium. We can see from the records how the Trust followed the BNF guidance in administering Mr A with 0.5mg of haloperidol. We consider the Trust’s decision to administer haloperidol was appropriate and in line with guidance. We hope this provides Mrs H with reassurances over the Trust’s use of this medication.
24. Overall, we are satisfied the Trust has acted appropriately in its decision to sedate Mr A with haloperidol and we do not uphold this element of the complaint. We hope Mrs H finds this information reassuring.
Brain scans
25. Mrs H says the Trust failed to carry out brain scans on her father during his admission to attempt to identify the cause of his deteriorating condition. She considers if the Trust had carried out brain scans, it could have provided a better picture and potentially resulted in more treatment being given. The Trust explains it wanted to carry out a brain scan to rule out whether Mr A had suffered any kind of bleed on the brain to cause his nosebleeds.
26. The GMC guidance on good medical practice explains ‘in providing clinical care you must prescribe drugs or treatment only when you have adequate knowledge of the patient’s health and are satisfied that the drugs or treatment serve the patient’s needs.’
27. The clinical records show doctors were unable to carry out the head CT scans on Mr A as he was not able to remain still, despite sedation. The records show the Trust discussed this with Mrs H on 14 June. It planned to continue to monitor Mr A’s neurological observations and reassess the need for a head CT scan after the weekend. Sadly, Mr A died before the Trust had the opportunity to review and reassess him further.
28. We have sought clinical advice on this issue. For a CT scan to be useful, the patient needs to stay still. This was something Mr A was unable to do at the time of his admission because of his state of confusion.
29. Our physician adviser explains, given his condition at the time, and his inability to stay still, the Trust was left with little choice in deciding whether to continue to attempt the head CT scan. The continued use of sedation carries risks, and the Trust’s medical team needed to balance the benefit of the scan with the risks of sedation. Using stronger medication may have helped the team carry out the scan, but potentially could have caused Mr A long-term harm.
30. Our physician adviser explains, from reviewing Mr A’s clinical records, apart from his confusion being worse than usual (which happens with patients with delirium in a hospital setting) there were no other concerning signs to suggest Mr A had suffered a bleed in or around the skull. These symptoms include severe headaches, light sensitivity, slurred speech, and weakness on one side of the body, or any loss of consciousness. There was nothing that indicated a need for the Trust to carry out an urgent brain scan.
31. Taking into consideration Mr A’s condition at the time, and the failed CT scans despite the use of the sedation, we consider the Trust’s decision not to carry out a CT brain scan of Mr A was in line with the GMC guidance. We think this was in his best interests at the time and our clinical advice supports this view. Given his inability to stay still during the brain scan, and the lack of evidence to show he had a bleed on the brain, it was reasonable for the Trust to wait before deciding on any further neurological involvement. Unfortunately, given his sudden passing, this was not possible. We do not uphold this element of the complaint.
UTI
32. Mrs H believes the Trust failed to appropriately treat Mr A for a UTI during his admission. She says this caused her father’s condition to deteriorate.
33. The NICE NG109 guidance outlines for lower urinary tract infections in those aged 16 years and over, the recommended first choice antibiotic is trimethoprim, if there is a low risk of resistance. Doctors should give 200mg twice a day for three days.
34. Our adviser told us it is not clear that Mr A had a UTI at the time of admission, as he did not have any of the common symptoms associated with a UTI. These include pain when urinating, increased urination, blood in the urine, lower stomach or back pain, a high temperature, feeling hot and shivery, or a very low temperature. The clinical records show the Trust’s initial treatment plan was to carry out testing on Mr A and treat any infection when it had more information. The Trust carried out a urine test, and the results showed Mr A had an active infection. The Trust then started him on 200mg of trimethoprim twice a day on 12 June 2019, for three days. The Trust tested Mr A’s urine after the course of antibiotics had finished on 15 June. This did not grow any bacteria, showing there was no infection at the time. Based on the evidence available, we consider the treatment of Mr A’s infection was in line with the NICE NG109 guidance.
35. We can understand Mrs H’s concerns about the failure to treat Mr A for a UTI and understand why this would cause her distress at what was already a difficult time. We consider the Trust appropriately treated Mr A for a UTI during his admission, in line with the NICE NG109 guidance.
Medication on 9 June
36. Mrs H says the Trust failed to administer any medication to Mr A during his admission on 9 June. She considers this caused her father’s condition to deteriorate.
37. As outlined above, the GMC guidance on good medical practice explains ‘in providing clinical care you must prescribe drugs or treatment only when you have adequate knowledge of the patient’s health and are satisfied that the drugs or treatment serve the patient’s needs.
38. We can see Mr A attended the Emergency Department (ED) the evening of the 9 June. It completed an assessment of him two hours later, and admitted him onto a ward in the early hours of the 10 June. The clinical records show the Trust’s planned treatment was to wait for the results of the urine test before deciding on any further treatment. The Trust tried to give Mr A pain relief when he was transferred onto the ward, however the records show he declined this.
39. We have sought clinical advice as to whether the Trust’s decision to wait before administering any medication was appropriate. From reviewing the clinical records, our physician adviser explains they do not suggest Mr A was suffering from any infection at the time of admission on 9 June. Mr A was offered pain relief in the early hours of 10 June, however he declined this.
40. Taking this into consideration, the decision to hold off on treatment until doctors had a clear clinical picture of Mr A was appropriate and in line with the GMC guidance.
Nursing observations
41. Mrs H considers the Trust failed to carry out appropriate nursing observations during her father’s admission. She says the nurses failed to identify signs his observations were unsatisfactory and outside of normal parameters. We have requested clinical advice as to whether the Trust carried out appropriate nursing observations on Mr A during his admission.
42. From reviewing the clinical records, we can see the nurses carried out two different types of observations on Mr A during his admission, they were early warning scores (EWS) and general nursing observations. There are two different sets of guidance which are appropriate for these two types of observations. For ease of understanding, we have split this into separate sections.
EWS
43. EWS are used to provide early warning of potential clinical deterioration and are used to decide whether escalation is required.
44. The RCP guidance outlines patients scoring 0-4 on EWS are deemed to have a low clinical risk, requiring a ward-based response. The minimum frequency of monitoring should be 12-hourly, increasing to four to six-hourly for scores of one to four, unless more or less frequent monitoring is considered appropriate by a clinical decision maker. For scores between five and six, the frequency of monitoring should be increased to a minimum of hourly.
45. We can see from reviewing Mr A’s observations, the Trust carried out appropriate EWS observations at least every 12 hours when he scored a zero. This indicates he was clinically stable and showed no signs of deterioration. When the EWS increased to between one to four, the records show nurses carried out observations every four to six hours. This is in line with the RCP guidance. Our nursing adviser has also reviewed the records and explains Mr A did not require any escalation of observations until the morning of 16 June, when he sadly passed away. We consider the Trust carried out appropriate EWS observations of Mr A.
General observations
46. Mr A had comfort rounds, SSKIN (skin, surface, keep moving, incontinence & nutrition) bundles, and enhanced care observations due to his cognitive status.
47. Our nursing adviser explains there is no national standard for how frequent observations should be. The Trust policy explains, for general observations once a shift a nurse should sit with a patient to assess their health and wellbeing. It says for enhanced care observations, staff should observe patients visually every 15 to 30 minutes and a regular summary of the patient’s condition, care and treatment must be entered.
48. We have reviewed the clinical records and see on every day during his admission, the nursing team competed a regular assessment of Mr A’s needs. The records show nurses completed the necessary comfort rounds and SSKIN bundles. This meant his position was changed or checked regularly to ensure his skin did not break down and his comfort needs were addressed. We consider the Trust completed general observations on Mr A, in line with its local policy.
49. As Mr A was agitated throughout the admission, he required additional enhanced observations. We can see from the clinical records the Trust completed regular enhanced care observations every three hours. We consider the Trust completed enhanced observations in line with the Trust’s policy and our clinical advice supports this view.
50. Overall, we are satisfied the nursing staff at the Trust completed regular observations of Mr A, and we do not uphold this element of the complaint.
Action following complaint
51. Mrs H says during the Trust’s original investigation of her complaint, the Trust identified failings and explained, following its investigation, it would make improvements to the service to prevent these things from happening again. Mrs H says, despite her requests for this information, the Trust has not provided her with any evidence it has taken the actions it outlined to her. We have contacted the Trust about these requests, and the Trust has explained it has no record of Mrs H requesting evidence of the action taken.
52. The Principles outline how organisations should not just provide an individual remedy, but should ensure all feedback and lessons learnt from complaints contribute to service improvement. It outlines how organisations should ensure they outline any changes they have made to prevent the problem reoccurring.
53. The Trust said it would work with the ward during the daily huddles to emphasise the importance of clear communication. This would also go to the directorate level governance group for discussion and learning across the department. It said it implemented ‘two-hourly’ confirm rounds, where nurses would go to all their patients every two hours to check they are comfortable.
54. The Trust has provided us with evidence of the actions taken following Mrs H’s complaint, and how it plans on implementing the changes proposed in the complaint response. It provides an owner for each of the learning points, any updates on the actions, and the date when the owner will complete each action. From reviewing the action plan, it includes all the actions referred to in the response letter, each with an owner, and any updates.
55. The proposals detail how it plans on preventing the problem from reoccurring, and the dates in which it completed the actions. This is reassuring to see and evidence the Trust has taken the complaint seriously. This is in line with the Principles.
56. We consider the Trust has taken appropriate action following its investigation of Mrs H’s complaint. We do not uphold this element of the complaint.