25 February 2020
19. Mrs N considers it was inappropriate that doctors sent her husband home from hospital without investigating his neutropenia. She feels they should have done more than simply prescribe antibiotics.
20. The Medical Adviser told us there are no specific national guidelines about investigating neutropenia for patients who have not received chemotherapy. Good Medical Practice says doctors must provide a good standard of care. It says they should adequately assess patients, taking their history into account and examining them if needed. It says they should promptly provide or arrange suitable advice, investigations, or treatment where necessary. Doctors must refer patients to another practitioner when this serves the patient’s needs and consult colleagues where appropriate.
21. The first doctor to assess Mr N diagnosed a chest infection. They noted a low neutrophil count but no signs of fever. They prescribed oral antibiotics, arranged further blood tests, and planned to seek a second opinion from a haematologist. Later that day another doctor suggested Mr N had neutropenia and a virus. They asked Mr N’s GP to arrange further tests. They also asked the GP to discuss with a haematologist if there was no improvement.
22. The Medical Adviser said doctors should have considered arranging further investigations to manage neutropenia. He said doctors should have arranged a discussion with a haematologist while Mr N was in hospital. He suggested we obtain further clarification from a haematologist.
23. The Haematology Adviser confirmed there are no specific guidelines relating to neutropenia in Mr N’s situation. There were no other concerns with his blood test results. Based on what the Haematology Adviser has said our view is, if a haematologist had been asked for advice, they would likely have supported the decision to discharge Mr N with a request for a follow up appointment in two to four weeks. It is unlikely they would have undertaken further tests on 25 February 2020. It should be noted this was at the start of the Covid-19 pandemic when haematology clinics were being closed. This means it is unlikely Mr N would have been able to attend a follow up appointment in any case.
24. We find the doctors carried out adequate assessments when they reviewed Mr N on 25 February 2020. Ideally, they could have discussed Mr N’s case with a haematologist before discharging him. But we cannot say they fell below any specific standard when they instead asked Mr N’s GP to contact the haematologists if necessary. They gave Mr N suitable advice and treatment. The doctors followed Good Medical Practice.
25. We do not uphold this part of Mrs N’s complaint.
Falls management
26. Mrs N says nurses did not do enough to prevent her husband from falling following his admission to Hospital A on 29 March 2020. She says her husband had a severe infection and nurses should have prevented him from walking to the bathroom alone.
27. Nurses should have followed the Falls Guideline. This says health professionals should identify patients who are at risk of falling. This includes all hospital inpatients aged 65 and over. Nurses should carry out a multifactorial risk assessment for people at a high risk of falling. They should intervene to reduce the risk of these patients falling and ensure they address any environmental problems (for example flooring and lighting).
28. The clinical records show nurses carried out a multifactorial falls risk assessment for Mr N on 29 March 2020. They did not identify Mr N had a high risk of falls. The records also show the nurses established he was independent with mobility. There was no indication Mr N needed extra support in this respect or that nurses should have prevented him for walking to the bathroom alone.
29. But, on 29 and 31 March 2020 staff observed Mr N had episodes of postural hypotension. This refers to temporary low blood pressure when standing from a sitting or lying position. The Nursing Adviser said this would have posed a significant risk to Mr N even though he could move independently. Yet nurses failed to refer to this in the multifactorial falls risk assessment.
30. While nurses generally followed the Falls Guideline, they failed to take Mr N’s postural hypotension into account. We find this was below the relevant standard.
31. Patient falls are not always an indication of poor care. Most falls in hospitals are unwitnessed and it is difficult to stop a patient falling even if an individual member of staff is assigned to closely observe them. Research has shown that interventions that are tailored to individual patients can reduce the risk of falls. But interventions cannot prevent all falls.
32. We cannot conclude this failing led to any detriment for Mr N. Even if nurses had put things in place to try and reduce his fall, he could still have gone to the bathroom alone and fallen. In any case, the fall is unlikely to have contributed to Mr N’s death. The Medical Adviser told us Mr N died because of the devastating stroke he had on 19 April 2020. This was not linked to the fall. There is no evidence he suffered any significant injury on 1 April.
33. We find nurses fell below the relevant standard in terms of falls management. We do not consider this led to any injustice for Mr and Mrs N. We partly uphold this part of Mrs N’s complaint.
Medical treatment after the fall
34. Mrs N believes doctors should have done more to ensure her husband had not suffered a significant injury following his fall on 1 April 2020. She says he developed a headache over the following days and doctors did not investigate it. She believes her husband had a stroke in the time between two CT scans on 2 and 9 April.
35. Doctors should have followed the Head Injury Guideline when reviewing Mr N after his fall. This sets our circumstances when doctors should arrange an urgent CT scan of the head. It also sets out the actions healthcare professionals should take when managing patients who have symptoms following a head injury. They should also have followed Good Medical Practice as detailed earlier in this report.
36. Before 7.45am on 1 April 2020 a health care assistant found Mr N lying in a bathroom. She called for help and a nurse attended. They took him to his bed and recorded his observations. These were all normal. The nurse arranged for a doctor to attend. The doctor arrived at 10.30am. They examined Mr N and noted he had bumped his head. The doctor did not identify any other concerns.
37. Mr N did not meet any of the criteria for an urgent CT scan. Doctors arranged this for him the next day (2 April 2020). The scan did not suggest any new problems needing attention. It showed evidence of an old stroke. Mr N did not have any injuries directly linked to the fall. The clinical records contain no reference to any scan on 9 April. The next scan took place on 19 April. Our provisional view is the healthcare professionals involved in Mr N’s care followed the Head Injury Guideline. There was no requirement for them to arrange a second scan sooner than they did.
38. The Haematology Adviser told us Mr N’s condition had changed when he returned to hospital on 29 March 2020. Blood test results were abnormal and there was evidence of abnormal cells (called blasts) when doctors analysed his blood. A bone marrow biopsy then allowed doctors to diagnose leukaemia. But before treatment could start, Mr N developed weakness and had a massive stroke on 19 April 2020. This stroke happened because of a blood clot in the vessels leading to the brain and was not directly linked to any bleeding associated with leukaemia or the fall.
39. The Haematology Adviser told us the stroke could have happened at any time. Had Mr N started treatment for leukaemia this event was just as likely to happen and would have prevented any further chemotherapy. Because Mr N’s platelet (small cells that helps blood to clot) levels were reduced doctors would not have been able to provide him with thrombolysis (the usual treatment to dissolve blood clots). The Medical Adviser also considered thrombolysis would not have been suitable for Mr N at this stage.
40. We find doctors followed Good Medical Practice and the Head Injury Guideline when treating Mr N after the fall on 1 April 2020. They adequately assessed him and arranged the further treatment and investigations he needed.
41. The Haematology Adviser said Mr N had an awful disease that progressed rapidly, and he had a very poor prognosis. He explained how, even with intensive treatment, it is very unlikely the outcome would have been different for Mr N. We can see how Mr N’s death had a devastating impact on his wife and family. There is no evidence in the clinical records that doctors fell below the required standards. We do not uphold this aspect of Mrs N’s complaint.
Catheter
42. Mrs N says a doctor instructed nurses to use a catheter. He says nurses failed to do this and it left her husband in severe pain.
43. THE NICE Quality Standard says service providers should ensure facilities are in place to enable staff to safely insert and maintain catheters. Healthcare professionals should ensure catheters are correctly inserted, looked after and removed safely.
44. A doctor reviewed Mr N on 31 March 2020. The doctor observed Mr N had difficulty when urinating on the previous night but felt better at this point. The doctor suggested catheterisation if had any further difficulties or pain. Staff inserted the catheter later that day and noted it was draining well. The catheter remained in place following Mr N’s move to Hospital B. Staff completed a catheter nursing plan throughout both admissions.
45. We can find no evidence to suggest there was a delay in staff providing Mr N with a catheter. We recognise Mrs N is likely to disagree with this, particularly as the Trust incorrectly stated in its complaint response that its staff only provided a catheter from 5 April 2020. We are persuaded by the number of records and the detail they contain about Mr N’s catheter.
46. We find nurses followed the NICE Quality Standard when they maintained Mr N’s catheter during his hospital admissions. We do not uphold this issue.
Nutrition
47. Mrs N says her husband ‘starved’ and staff left him dehydrated for five days. She says he usually had a good appetite, but his sore throat made it difficult for him to eat. She believes more should have been done to help him with nutrition. She says his food intake should have been monitored sooner.
48. Nurses should have followed the Nutrition Guideline when caring for Mr N. This says clinicians should screen all inpatients on admission to hospital for malnutrition or the risk of them becoming malnourished. They should repeat this weekly or if there is a cause for concern such as unintentional weight loss or poor wound healing. The Nutrition Guideline suggests clinicians should consider nutritional support for people who have eaten little or nothing for more than five days and are likely to eat little or nothing for the next five days or longer.
49. The clinical records show nurses completed a nutritional assessment when doctors first admitted Mr N to hospital on 29 March 2020. The nurses at Hospital B repeated the assessment on 4 April and again on 12 April. On each occasion they did not consider Mr N was at risk of malnutrition or was losing too much weight. There was no requirement for them to complete food charts to monitor what Mr N was eating. Despite this they completed food charts on occasion.
50. The Nursing Adviser told us nurses only partially completed food charts (from 7 to 10 April and then from 15 to 19 April 2020). But they noted in other records how much Mr N ate. They also documented his fluid intake when required. The records do not suggest Mr N was eating ‘little or nothing’ although he was eating less than he had been at home. For example, on 16 April 2020 the charts suggest he only ate breakfast. On the next day he ate breakfast and supper.
51. Nurses referred Mr N to a dietician. On 11 April 2020 the dietician recommended high energy snacks and fluid supplements. A dietician reviewed Mr N again on 18 April. They noted he was not eating enough but this was variable. They questioned whether oral thrush was affecting his ability to eat. The dietician planned to encourage Mr N to take nutritional supplements. She said food charts should continue. Staff also referred Mr N to speech and language therapy (SALT) for a swallowing assessment, which took place on 22 April.
52. Mr N had a stroke on 19 April 2020. Doctors changed his plan after this. They noted Mr N had reduced consciousness and could not eat. Doctors chose not to provide him with a feeding tube as they aimed to keep him comfortable towards the end of his life.
53. The Nursing Adviser told us staff made appropriate referrals to dieticians and SALT when they had concerns about Mr N’s nutrition. Dieticians prescribed appropriate supplements and nurses provided these for Mr N, although he could not take them on some occasions.
54. There is no evidence in the records to suggest Mr N was ‘starved’ or dehydrated. Nurses followed the Nutrition Guideline when they assessed his nutrition. While Mr N did not lose a significant amount of weight, nurses made appropriate referrals when they were concerned about his nutrition. We recognise Mrs N considers nurses should have done more. There was no requirement for nurses to complete daily food charts when assessments had not shown Mr N was at risk of malnutrition.
55. We find nurses followed the Nutrition Guideline. We do not uphold this part of Mrs N’s complaint.
Oral thrush
56. Mrs N says oral thrush was major obstacle to her husband being able to swallow. She wants to know why staff did not treat it.
57. The Oral Health Guideline says healthcare professionals should review mouth care for inpatients every day and carry out a risk assessment when patients arrive in hospital. It explains how they can reduce the risk of patients getting oral thrush by brushing teeth twice a day and providing adequate hydration. It explains how the first line treatment for oral thrush is nystatin or miconazole (antifungal medications).
58. There is no evidence nurses carried out a mouth care risk assessment for Mr N. Nurses completed daily ‘rounding’ charts during Mr N’s admission. The section on mouth care was often incomplete. However, the charts do show nurses gave drinks to Mr N which would have reduced his risk of developing thrush.
59. Nurses established Mr N had oral thrush on 6 April 2020. They put a care plan in place. But this did not include any reference to what Mr N’s mouth care was like on admission. Other records show nurses occasionally assisted him with oral hygiene. On 2 to 11 April nurses offered a mouthwash, but Mr N often refused to use it. Doctors prescribed nystatin for Mr N by 13 April.
60. The Nursing Adviser said nurses were ‘inconsistent’ in terms of the mouth care they gave to Mr N. There is little detail in the records to show they properly evaluated his needs in this respect. While there were some interventions these were clearly insufficient and delayed.
61. We find nurses did not follow the Oral Health Guideline. The Medical Adviser told us failings in mouth care increased the likelihood of Mr N developing oral thrush. It is possible Mr N may have avoided thrush if there had been no failings in care. While this could have affected his ability to swallow it could not have contributed to the decline in Mr N’s health which was due to a stroke and leukaemia.
62. We can see how oral thrush would have been uncomfortable for Mr N and distressing for his wife. It affected his ability to swallow food. There is a possibility the discomfort and distress could have been avoided if nurses had given him appropriate mouth care. But it is possible thrush could still have developed even if nurses had provided consistent care. We partly uphold this aspect of Mrs N’s complaint.
End of life decisions
63. Mrs N says doctors completed a Respect form ‘behind her back.’ She says doctors did not ask for her views about resuscitation or tell her what they had decided. She says doctors did not give her husband the best chance to survive his illness when they withdrew treatment from him on 19 April 2020. She does not accept it was the right decision to withdraw nutrition and medication.
64. The End of Life Guideline explains how in some circumstances active treatments may only prolong the dying process or cause the patient unnecessary distress. It says there is no obligation on doctors to prolong a patient’s life irrespective of the consequences for them. It says doctors should make decisions based on whether treatment will be overall benefit. It says high quality treatment towards the end of live should include palliative care that focuses on managing pain and other distressing symptoms.
65. The End of Life Guideline says doctors should involve patients in discussions about whether treatment and care would benefit them. When a patient does not have capacity for such discussions they should involve those close to the patient in their consideration.
66. The End of Life Guideline says doctors must consider the patient’s palliative care needs at an early stage and take steps to manage any pain, breathlessness, agitation or other distressing physical or psychological symptoms that they may be experiencing. It says doctors must consider the burdens or risks of assisting with nutrition and hydration against any benefits such an action is likely to bring.
67. Mrs N told us one of the doctors called her on 19 April 2020 to say her husband had experienced a massive stroke and was ‘not very responsive.’ The records show Dr D (Consultant Haematologist) reviewed Mr N at 11.40am. He was awaiting scan results. But he considered it likely Mr N would be for palliative care only. Dr D noted ‘wife aware, she would be keen for full active treatment… Aware that on top of acute leukaemia [he has] had a massive stroke.’
68. At 12.25pm on 19 April 2020 Dr D completed a Respect form. This confirmed Mr N did not have capacity to make any decisions. Dr D documented he considered the focus should be on symptom control rather than continuing with life-sustaining treatment. He marked the form to suggest he had consulted with relevant family members and listed Mrs N as an emergency contact.
69. Dr D also completed a form entitled ‘Priorities of Care.’ He noted Mr N was likely to die within a few days. He said Mr N did not have capacity to make decisions about his care and treatment. Dr D said a ‘decision [had been] made in the best interests of the patient’ and he had discussed this with Mrs N. Mrs N says she later met a doctor on the ward who gave further details. She says doctors led her to believe her husband would survive for weeks or months. She says she was not involved in any discussions about stopping food or medication.
70. The records show Mrs N was present on the ward at 3pm. Dr D updated her and noted Mrs N was ‘aware we are optimising his comfort.’ Dr D’s opinion was there was no need to continue observations for Mr N. Later that day a nurse noted staff had updated Mr N and his family regarding the end of life plan.
71. The Medical Adviser told us doctors should have considered the End of Life Guideline when making decisions about Mr N’s care. Doctors considered the stroke on 19 April 2020 was a ‘terminal event.’ They decided to provide palliative care rather than continuing with active management. They considered it was inappropriate to continue with active nutrition. The Medical Adviser said this was in line with the End of Life Guideline.
72. The evidence in the clinical records shows doctors made Mrs N aware of their proposals for end of life care. They also noted her preference for continuing active treatment before making the decision as set out in the Respect and ‘Priorities of Care’ forms. Doctors involved Mrs N appropriately and followed the End of Life Guideline.
73. We can see how distressing the events around 19 April 2020 were for Mrs N and her family. Clearly, she does not consider doctors did enough to take her views into account and feels they could have done more to allow her husband a chance of recovering from his illness. We find doctors considered her views appropriately. They made decisions based on the overall benefit to Mr N. Sadly, Mr N’s stroke and his other health problems meant he could not have survived his illness. Doctors followed the relevant guidelines. We do not uphold this issue.