District nurses did not act on Mr M’s discoloured urine
14. NICE Urinary tract infection (catheter-associated): antimicrobial prescribing guidance explains that antibiotics are only needed if the patient is symptomatic (you do not just look at the colour of urine): • the longer a catheter is in place, the more likely bacteria will be found in the urine; after one month nearly all people have bacteriuria (the presence of bacteria in the urine) • antibiotic treatment is not routinely needed for asymptomatic bacteriuria in people with a catheter.
15. NMC: The Code: Professional standards of practice and behaviour for nurses, midwifes and nursing associate’s guidance explains nurses should: • 13.1 accurately identify, observe, and assess signs of normal or worsening physical and mental health in the person receiving care
16. Ms O says district nurses should have acted when they visited Mr M at home due to his discoloured urine, the colour being an indicator something may have been wrong. She says her father’s carers and her mother raised concerns about this, following his discharge and between 7 and 12 May. However, district nurses did not seek to investigate further why he had discoloured urine despite concerns raised.
17. In its response, the Trust notes Mr M’s clinical records make two references to Mr M’s urine on 8 and 11 May 2020. His records on 8 May document a catheter change due to an increase in sediment which caused discomfort and a potential blockage. The Trust also says Mr M’s records on 11 May document staff were asked to review his urine as it was noted to be slightly dark in colour. It says there is no further evidence which suggests the colour of Mr M’s urine was raised as a concern by any party outside of these two visits.
18. Our senior nurse adviser explained for context that a patient’s urine can be discoloured for many reasons, some of which do not require any clinical action. An example of this is antibiotics and laxatives which can cause urine to look dark and brown in colour and no clinical action is required. Dehydration and any urinary infections can also cause urine to look dark brown and this would require action to be taken.
19. As explained in NICE guidance, patients with catheters (as in Mr M’s case) can have bacteria in their urine without the need for antibiotics. It is therefore important, in line with NMC guidance, for nurses to identify if there were any other symptoms Mr M was experiencing such as a fever, pain, vomiting and confusion.
20. We reviewed Mr M’s clinical records. On 8 May it is documented his catheter was blocked and he had sediment in his urine. Apart from this, nurses documented him as being comfortable. Our senior nurse adviser explained that as Mr M was presenting asymptomatic, (which means a patient presents with no visible symptoms) no further action was required.
21. On 11 May, it is documented Mr M’s carers reported he had discoloured urine in his catheter bag. This is documented in the district nurses’ records as ‘slightly dark’ and no other concerns were documented. Nurses gave general hydration advice and the nurse in charge was asked to review Mr M the next day, 12 May. In the absence of any other symptoms, our senior nurse adviser explained that clinically it was appropriate that no further action was needed. Therefore, we consider the actions of the district nurses were in line with the NICE and NMC guidance we have explained earlier.
22. NMC: The Code: Professional standards of practice and behaviour for nurses, midwifes and nursing associate’s guidance explains nurses should: • 4.1 balance the need to act in the best interests of people at all times with the requirement to respect a person’s right to accept or refuse treatment.
23. On 12 May it is documented Mr M was now showing visibly as symptomatic with pain, vomiting and raised temperature. However, in the morning, when a possible hospital admission was discussed with him, Mr M declined admission to a hospice or hospital. A further visit was then arranged for later that afternoon.
24. Our nursing adviser explained Mr M had the capacity to make his own decisions, which should be documented and respected.. NHS guidance on capacity further means the ability to use and understand information to reach a decision, and communicate any decision made. Therefore, we consider nurses acted in line with the above NMC guidance at this visit and in line with this guidance.
25. During the afternoon of 12 May, it is documented Mr M was clinically assessed and triggered the SEPSIS pathway (a pathway of clinical care). This was owing to a combination of presenting conditions. Mr M was now showing a high temperature, low oxygen levels and a high pulse which our senior nurse adviser explained indicates possible sepsis. In response to this, an ambulance was then called after Mr M agreed ‘calling the paramedics was the best course of action.’
26. Our community nurse adviser also reviewed Mr M’s clinical records. They explained that with someone who has advanced pancreatic cancer, ascites is a common finding due to occlusions (complete or partial blockage of a blood vessel) or pressure within the biliary tract. In Mr M’s discharge summary on 7 May, his blood results are documented, and from these blood tests, Mr M’s albumin levels were low which suggests concerns around his liver function.
27. Albumin is a serum/protein which can be excreted in urine, causing urine to darken. Our adviser says low levels of this as well as darkened urine can suggest, sadly, that someone is possibly nearing their end of life.
28. Therefore, to summarise, despite Mr M having discoloured urine, there were no indications documented in his records that he was acutely unwell between 7 and 11 May, with no symptoms not related to his existing cancer presenting until the nurses’ further observations on 12 May. When he did present with further symptoms, action was taken. As such, we consider staff acted in line with the guidance we have explained and have therefore found no failings.
District nurses did not take appropriate action to call an ambulance on the morning of 12 May for Mr M
29. Ambitions for Palliative and End of Life Care framework highlights that although patient choice can change, and therefore is not a fixed issue, this can add complexity to decisions at the end of life, but health care professionals should act in a way to respect and meet patient choice as far as possible.
30. Ms O says district nurses did not take appropriate action or call an ambulance based on her father’s presentation on the morning of 12 May. Mr M’s clinical records indicate Ms O made a telephone call herself to the district nursing service as she was concerned about her father’s mood and symptoms.
31. In its response, the Trust says district nurses have documented entries in the morning of 12 May that Mr M was unable to take his medication and appeared unwell. It says the district nurse advised Ms O that her father needed to be escalated for a review by his GP for his medication and condition. It also says this was deemed the most appropriate action as the district nurse felt in her clinical judgement that Mr M’s presentation was due to a progression of his pancreatic cancer.
32. Mr M had a palliative diagnosis of pancreatic cancer and clearly stated that he did not wish to receive oncology treatment or return to hospital. Our community nurse adviser says this highlights that Mr M’s prognosis was poor and his death was sadly to be expected sometime soon after he was discharged from hospital on 7 May.
33. Prior to this, on 24 March, Mr M’s records document a telephone conversation with Ms O in which she explains that her father’s wishes were to remain at home. It also appears he held capacity to make this decision. In addition to this, on 12 May, Mr M’s GP records document his GP discussed with the district nurse readmission to a hospital or hospice. The district nurse asked Mr M about this and his records state he declined this saying ‘no, no, I don’t want to go anywhere.’
34. His district nursing records state, ‘GP has advised hospice admission or hospital however Mr M declining.’ Therefore, at this stage, we consider district nurses took appropriate action and did not call an ambulance following Mr M’s wishes that he did not want to go anywhere at this point. The nurses also acted in line with the framework we referred to earlier, respecting Mr O’s choices (as capacity present) and we have seen no failings with this approach.
35. Following this, in line with this framework, it appears Mr M’s choice to go to hospital suddenly changed in the afternoon of 12 May. From our analysis of Mr M’s clinical records, we note in a statement from the senior staff nurse (SSN), it says, ‘Mr M agreed that calling the paramedics was the best course of action.’ Following this, an ambulance was called to his home, and he was then admitted to hospital. We have provided this for background information to lead into the next concern Ms O has raised about district nurses not staying to provide a verbal handover to paramedics.
District nurses did not stay to provide a verbal handover to the paramedics on the afternoon of 12 May
36. The National Health Service’s response to the COVID-19 pandemic says as part of the overall ‘social distancing’ strategy to protect staff and patients, the public should be asked to greatly limit visitors to patients, and to consider other ways of keeping in touch such as phone calls.
37. Royal College of Nursing guidance recommends reduced physical contact, and suggested use of virtual technology to reduce the need for a physical presence.
38. Ms O says district nurses did not stay at the home to provide a verbal handover to the paramedics on the afternoon of 12 May. She says if it was due to the COVID-19 situation, there were other areas of her home that could have been utilised for them to be present to conduct the hand over.
39. In its response, the Trust says a handover was provided to the ambulance service via both the 999 call and a written entry regarding the senior staff nurses (SSN’s) assessment which was documented and available for the paramedics to review. It also reflected on this and agreed in hindsight that other areas on Mr M’s property could have been used for a face-to-face handover and apologised for any distress caused.
40. Our community nurse adviser explained in May 2020, UK health services were working under extreme unprecedented pressures, with individuals and teams being exposed to increased stress and demands due to the COVID-19 pandemic. Therefore, the actions of the district nurses are considered in this context.
41. As referenced in both the NHS’ response and RCN guidance we have referred to earlier in this section, staff were required to greatly limit and reduce their physical contact where possible. Our community nurse adviser says there is no evidence from the records that the district nurses were required to remain in the home to deliver treatment and support to Mr M up to the point the paramedics arrived to provide a verbal handover. There is also no evidence to suggest nurses leaving Mr M’s home, to wait in their car, put him or his health at risk of any further deterioration.
42. As such, whilst there were other areas of Mr M’s home which could have been used for a verbal handover, we consider the nurses were acting in line with NHS’ response and RCN guidance in minimising contact, and had provided their written handover for continuity. We have therefore seen no failings with this approach.
District nurses attempted to avoid going into Mr M’s home and asked his wife to administer his insulin
43. NICE guidance on the management of diabetes says clinicians should have specific aims to supports the person and their family members and carers in developing attitudes, beliefs, knowledge, and skills to self manage diabetes.
44. For background context, the RCN article on district nursing during the COVID-19 pandemic explains about the increased pressures nurses faced during this period regarding caseload demand.
45. Ms O says district nurses attempted to avoid going into her father’s home and asked her mother to administer her father’s insulin. She says to put some context into this, her mother is 76 years old, is suffering with her own ill health and was confused with all her father’s medications.
46. In its response, the Trust says it is evidenced that district nurses attended daily to Mr M to administer insulin and take blood glucose readings. A conversation between a district nurse and Ms O regarding her concerns about her mother having to administer her father’s insulin did take place on 24 March.
47. Ms O was told that due to the COVID-19 pandemic, self-care, or assistance from family to provide certain tasks was being advised to all patients, to minimise the risk of exposure for the most vulnerable, to any possible COVID-19 infection which could be carried and brought in by the nursing team, thus putting them at increased risk.
48. From seeking advice from our community nurse adviser, we can see that in line with the NICE guidance we referred to, even in COVID-19 non-pandemic times, self-care and family care is seen as an appropriate approach to monitoring and managing diabetes in the community. Therefore, it seems sensible this approach was initially explored and discussed with Mr M and his wife.
49. We understand why Ms O has raised concerns that her mother was asked to administer her father’s insulin, given her age and that she was confused with the medications he had to take. We consider the nurse acted in line with NICE guidance and in the context of the current situation of increased pressures nurses were facing with their caseloads.
50. We also note from Mr M’s records that once Ms O raised concerns in March 2020 with the nurses that her mother was on the verge of a nervous breakdown, had heart conditions and should therefore not be asked to take on anything else for her husband, we have seen nothing documented she was asked again to take responsibility for the administration of his insulin.
51. We recognise this has been a difficult time for Ms O and her family with the loss of Mr M and the stress, worry and anxiety caused. Having given full and careful consideration to all points raised and seeking further independent specialist advice, we have seen no failings within the care and treatment provided.
52. In summary, this concludes our final report and on behalf of the Ombudsman we thank Ms O for her time, patience, and engagement with us in conducting our work