23. Before we decide if we should investigate a complaint, we look at whether there are signs the organisation has got something wrong. We do this by comparing what should have happened with what did happen. We have done this and have not found any indications that something has gone wrong in either the care and treatment Mrs H received from the Ambulance Trust or the Trust.
Ambulance Trust – Non conveyance to hospital
24. Mr H complains the first attending paramedics on 1 December, did not take Mrs H to hospital for further investigations. Instead, Mr H says they told his mother she would be ‘sat waiting’.
25. Health Care Professions Council (HCPC) Standards of Proficiency for Paramedics s1.1 state the Paramedic should know the limits of their practice and when to seek advice or refer to another professional. The HCPC guidelines s15.1, state paramedics should understand the need to maintain the safety of both service users and those involved in their care.
26. It goes on to say, ‘where a patient makes a decision about their future care and treatment and that decision conflicts with what a reasonable person would do, you may question their capacity but also respecting that people are allowed to make what could be considered by others as an unwise decision’.
27. The Mental Capacity Act 2005 – Code of Practice sets out the test that must be used when a paramedic assesses whether a patient has the requisite mental capacity to make a decision.
28. The paramedic adviser noted the paramedics carried out a holistic assessment of Mrs H, including looking at her respiratory and cardiac function. The adviser said there was nothing on the documentation that indicated Mrs H was significantly unwell during the paramedics’ attendance. They proactively assessed her symptoms and ruled things out and documented pertinent negatives, for example the state: ‘no chest pain, not pale or sweaty, no wheeze’.
29. The paramedics assessment of Mrs H recognised that she had previously had two silent myocardial ischaemia (heart attacks) in the past two months. The crew had carried out all the tests they could, and although Mrs H was not unwell at this point, they suggested she went to hospital for further investigations as she was a high-risk patient. Mrs H declined this.
30. The crews’ assessment of Mrs H was appropriate, and the assessment complied with JRCALC guidelines. At the time of assessment, Mrs H was not unwell and did not appear to be having any form of cardiac event. The crew exhausted the tests they could carry out and advised Mrs H to attend hospital.
31. Mr H said the ambulance Trust “heavily leaned on us not to go to the hospital, citing that we may just end up waiting and not being seen to”.
32. Mrs H’s medical records suggest she did not want to go to hospital, and she did not want to wait in a corridor. When Mrs H chose to stay at home, the paramedics assessed Mrs H’s capacity and concluded that she had the capacity to make that decision. She signed the Patient Care Record, in the presence of her daughter who was acting as her witness, on the basis that she refused transfer to hospital. It is also noted that Mrs H’s son was present at the time.
33. A non-conveyance form and advice form was given to Mrs H. The paperwork left with Mrs H showed an ongoing care plan which considered her wishes not to go to hospital. The paramedic attendance was outside GP hours, so the paramedics advised Mrs H to contact her GP at the earliest possibility to arrange an appointment.
34. The adviser also noted that the paramedics had left Mrs H with written advice, phone numbers and with the instruction to call 999 should her symptoms return or worsen.
35. In Mrs H’s clinical records from the Trust, there is a record of a meeting held between Mrs H’s family and the Trust on 9 December. The record for this meeting states the paramedics said Mrs H was ‘ok’ but offered to take her to hospital. The children declined this as they understood it was not essential, and they did not want to go to a busy emergency department (ED) unnecessarily. They explained that her mother had to spend time on a trolley on her previous visit to the ED and they would not want her to have discomfort if not required.
36. From the evidence we have seen, it is more likely than not the risk of staying at home and the need to go to hospital were explained to Mrs H. The steps taken by the paramedics were in line with the guidelines, their assessment was thorough, the conclusion was appropriate, and the safety net advice was appropriate.
37. We appreciate that Mr H believes that his mother should have been taken to hospital. The evidence we have seen points to the fact Mrs H was advised of the need to attend hospital, but she chose not to. In conclusion, there are no indications of maladministration here. We will not be taking any further action on this part of the complaint.
Ambulance Trust – Transfer to ambulance caused Mrs H’s heart attack
38. On 1 December, a second ambulance attended Mrs H’s property as her condition had deteriorated. Mrs H was transferred from her house to the ambulance in the carry chair. Unfortunately, while the paramedics were transferring Mrs H to the ambulance, Mrs H went into cardiac arrest. Mr H believes the paramedic transferring Mrs H caused the arrest.
39. Our paramedic adviser noted that Mrs H was having difficulty breathing and stated the sitting up position of a carry chair is often the most supportive to move a patient suffering with difficulty breathing. They also noted it is very rare that a stretcher can be used in houses as they are cumbersome, heavy, cannot be used when steps are involved, and they require large amounts of room to move.
40. Our adviser said ambulance crews have very limited options when moving a patient from a scene to an ambulance and often the carry chair is the only practical way if a patient is too unwell to walk themselves.
41. Our adviser said Mrs H’s observation indicated she was medically significantly unwell. The continuing deterioration of her health would have been the root cause of her cardiac arrest. Moving Mrs H onto a carry chair, and then onto the ambulance stretcher, would not have been easy or pleasant for Mrs H. The adviser said it would have been the only way the ambulance crew would have been able to get Mrs H to hospital and to a higher level of care. The transfer to the ambulance would not have been the cause of Mrs H’s cardiac arrest.
42. In conclusion, there are no indications of failings. For this reason, we will not be taking any further action on this part of the complaint.
Ambulance Trust – Delay in performing CPR
43. Mr H complains the paramedics delayed performing cardiopulmonary resuscitation (CPR) on Mrs H.
44. JRCALC “Resuscitation for Adults Advanced” 2019 supported by the UK Resuscitation Council Guidelines “Adult advance life support Guidelines” 2015 states that when there is an Out-of-Hospital Cardiac Arrest (OHCA) the paramedics should start with basic life support immediately and then start with Advanced Life Support (ALS) if the resources are available.
45. Mrs H’s clinical records note that after the cardiac arrest occurred, the resuscitation attempts commenced immediately in the form of compressions. A second crew were called and when they arrived shortly afterwards, advanced life support (ALS) was commenced. These actions were supported by the heart monitor trace evidence which shows what appears to be chest compression being delivered to Mrs H.
46. Our adviser noted this was very shortly after, and within reasonable timeframe after the recorded cardiac arrest time. The adviser noted airway support was initiated promptly, and further advanced life support skills were commenced shortly afterwards, following the arrival of the second crew. The resuscitation actions from the recorded notes appear in line with JRCALC resuscitation guidance for basic and advanced life support in adults, which itself supported by the UK Resuscitation council guidance at the time.
47. The adviser noted the efforts made by the ambulance crew were effective in that Mrs H’s heart was restarted once at the hospital, so the crew’s resuscitation attempts were of sufficient quality to enable her breathing and heart ultimately to be restarted.
48. In conclusion, we have not found any indications of a delay in the administration of life support to Mrs H. The paramedics actions were in line with JRCALC guidelines. We will not be taking any further action on this part of the complaint.
The Trust – Transfer to Hospital A
49. Mr H complains the Trust refused to transfer his mother to Hospital A after the family requested her transfer.
50. On 13 December, the family requested Mrs H be transferred to Hospital A as it was Mrs H’s wishes to be treated there. The records state the Trust made a formal referral to Hospital A and spoke to an on-call intensive care consultant. The Trust noted they provided all the information and asked for a second opinion, as well as consideration for transfer to Hospital A.
51. The records state the intensive care consultant felt there was no clinical indication for the transfer. They discussed the request for a second opinion with the clinical lead for the service at Hospital A.
52. The records state the Trust spoke to the clinical lead who said a transfer was not clinically indicated, since there would be no change in the treatment Mrs H would receive. The clinical lead recommended an MRI for neurological prognostication with neurology review, which the Trust said they had requested on 15 December.
53. On 16 December, it is noted the clinical lead had not accepted Mrs H due to the fact there was no clinical indication, and they would not change the patient’s management. The family asked for a second opinion on their transfer request.
54. On 20 December, a consultant from Hospital A attended the Trust for a meeting with the family and the Trust. The records do not provide minutes for the meeting, but they do reference what was discussed. We asked the Trust for a copy of the minutes, and they noted there were not any, just what was in the records.
55. The consultant noted that unfortunately the prognosis was poor, and treatment should be limited to: • tracheostomy (a tube inserted into the patient’s windpipe to allow them to breathe) • weaning from ventilation • no further escalation in the level of care.
56. They also noted Mrs H should not be actively resuscitated in the event of further cardiac arrest. We understand that this would have been very upsetting for the family to hear.
57. As a result of the discussion the family had with the consultant, Mrs H was not transferred to Hospital A for treatment and remained a patient at the Trust until she was discharged.
58. When the Trust was asked for its guidance on patient transfer requests, they explained they did not have a policy, but clinicians will liaise with another hospital and ask for transfer where family have requested clinicians from another hospital. If the care provision would not change and there is no clinical reason to transfer a patient, then this may be declined.
59. The clinical adviser referred us to NHS England Framework for transfer of critically ill patients which states patients should be transferred between hospitals for one of the following reasons: - • their own clinical care requires expertise unavailable in their current critical care unit or hospital, • the patient is being repatriated close to home, • treating critical care unit needs to create capacity.
60. This is echoed by the Intensive Care Society guidance which states “…Indications for such transfers include specialist investigation or treatment not available in the referring unit, lack of availability of a staffed critical care bed and repatriation”.
61. Our adviser noted the overall consensus amongst literature and guidance is no patient should be subjected to an intervention that is not in their best interest. They noted Mrs H did not have any of the indications to be transferred to another unit and it was not in her best interest. The adviser said transferring Mrs H to another hospital could have subjected her to risk of transfer without any evidence of added benefits or an improved outcome.
62. Intensive Care Society Guidance states the decision to transfer a patient is a joint responsibility between referring and receiving clinicians. The adviser noted the Trust contacted Hospital A to request a transfer, and Hospital A concluded there was no clinical indication to transfer the patient. The adviser agreed with Hospital A’s decision.
63. The Trust also asking Hospital A for a second opinion was in line with the Ombudsman’s Principles of Good Administration. Our principles say public bodies should do what they say they are going to do. They also say, where appropriate, public bodies should deal with customers in a coordinated way with other provides to ensure their needs are met.
64. When Mrs H’s family requested a transfer to Hospital A on 13 December, the Trust acted promptly and had requested the transfer on the same day. By the 15 December, the Trust had a response from Hospital A and explained this to Mr H. A second opinion was asked for on 18 December, and an appointment was arranged for the consultant to attend the Trust on 20 December.
65. We acknowledge and appreciate this must have been a very upsetting time for Mr H and his family as it was his mother’s wishes to be treated at Hospital A. Based on the information we have seen, and from considering the national guidance, we have found no indications of failings. The Trust contacted Hospital A promptly and asked for three opinions in total on the transfer of Mrs H, and Hospital A concluded there was no clinical indication for the transfer. For this reason, we will not be taking any further action on this part of the complaint.
The Trust - Prescribed antiepileptic medication
66. Mr H complains the Trust prescribed Mrs H antiepileptic medication despite her not having a seizure. He believes this contributed to her death and caused him and his family distress.
68. When the Trust expected Mrs H was having seizures it carried out an Electroencephalography (EEG). This is a test where electrodes are placed on the patient’s head to record brain activity.
69. Our adviser said the EEG checks for brain activity at that moment in time. That means if the patient was having a seizure at the time of the EEG, the EEG would detect it. If the EEG did not show any seizure activity, it does not mean that the patient did not have a seizure before the EEG was conducted.
70. Our adviser said while Mrs H was not having a seizure at the time of the EEG, this did not categorically mean she did not have one earlier.
71. Our adviser explained the frequency of seizure, in the context of hypoxic brain injury after a cardiac arrest, is quite high at up to 40%. Mrs H had twitching of the left arm and left side of her face, so the clinician treated her with antiseizure medication on the assumption it was seizure activity.
72. The UK Resuscitation Council Guidelines: Post Resuscitation Care Guidelines – Control of Seizures suggests antiepileptic drugs and a sedative to treat seizures after cardiac arrest. The clinical adviser stated the Trust were correct to prescribe antiseizure medication.
73. In conclusion, we have found no indications of failings by the Trust administering antiseizure medication. For this reason, we will be taking no further action on this part of the complaint.
Trust – Do Not Attempt Cardiopulmonary Resuscitation (DNACPR)
74. Mr H complains the Trust put in place a DNACPR on 20 December, without the family’s consent. Mr H explained his family and his mother are of Sikh religion and are therefore pro-life.
75. On 9 December, the Trust had a meeting with Mrs H’s family where her condition was explained to them. The records note Mrs H had multiple episodes of cardiac arrest requiring repeated CPR. With every episode of cardiac arrest, her brain injury was becoming worse, and her heart was getting weak. They noted they were going to continue to treat her actively, but it was not appropriate to perform CPR as it was not in her best interests.
76. The family informed the Trust that they did not agree with this. The conclusion of the meeting was that the family required time to discuss it amongst themselves. The family were informed it was a medical decision, but the Trust wanted to involve and inform the family about the medical opinion. The doctor noted he would not authorise a DNACPR decision without discussing it with the family again.
77. On 13 December, Mrs H had an episode during the night which required a short period of CPR.
78. The records state on 16 December the Trust asked Mr H whether, if their mother had another cardiac arrest, would they allow natural death rather than resuscitate as this would be kinder to her. The family said no, as their mother would not have agreed to this. The Trust said they respected this.
79. The records refer to an entry on 19 December, which states Mrs H was noted for CPR and there was consideration around changing this following the consultant’s review on 20 December.
80. The consultant had a meeting with the Trust and patient’s family on 20 December. The records state ‘after discussion with and question from the son it was decided that treatment would not be escalated, limits on treatment would be put in place and a DNACPR was appropriate. Furthermore, a surgical tracheostomy would be appropriate and would be carried out at the earliest opportunity.’ The records also note that one brother agreed with consultant’s decision. Following this meeting, an entry was made on 20 December, which said ‘TEP now in place and patient is DNACPR’.
81. On 22 December, the family had a discussion with the doctors at the hospital. They explained that they were unhappy the DNACPR. The Trust explained the rationale behind the decision and said a further meeting would be held to discuss the DNACPR.
82. The records show on 22 December, Mrs H’s daughter had a discussion with a medical professional who explained, following discussions with the neurosurgeon on Friday 20 December, the decision was made her mother would not be for DNACPR.
83. On 23 December, after the Trust received the complaint, the Trust noted in the records that Mrs H was for full resuscitation after legal team advice. This remained in place until Mrs H was discharged.
84. NHS Guidance states that DNACPR is a medical team decision that can be made by a doctor even if the patient or family does not agree. The doctor makes the final decision and does not have to give treatment they do not think will work. The law does not require a family’s consent to DNACPR.
85. General Medical Council Cardiopulmonary Resuscitation ethical guidance also states that when considering attempting CPR, you should consider the benefits, burdens, and risks of treatment that the patient may need if CPR results in the return of a spontaneous circulation.
86. It also states that if a patient lacks capacity to make a decision, doctors should consult those close to the patient as part of the decision making process. You should also consider whether successful CPR would likely be an overall benefit to patient.
87. Our adviser noted the Trust followed the correct procedure about making DNACPR decisions. As Mrs H did not have capacity to make the decision, the Trust consulted the family on 9 December. The family informed the Trust of their wishes and requested a second opinion which the Trust complied with.
88. The adviser said it was clearly documented that treatment limitation and DNACPR order was agreed with family members on 20 December, during the meeting with the consultant from Hospital A. When this was questioned by the family, the Trust obtained advice from the legal team.
89. From the evidence, we see the treating team made every reasonable effort to accommodate Mrs H’s family wishes and did not make any significant decision without careful consideration and involvement of one or more of Mrs H’s children.
90. NHS Guidance confirms whilst doctors should consult the patient and/or their family, the doctor has the final say. The Trust consulted the family and made the decision jointly. When the Trust found out that the family was unhappy, they obtained further advice from their in-house legal team who advised them to remove the DNACPR. The Trust did this. From 23 December, until Mrs H was discharged, she was for CPR.
91. We appreciate this must have been a very traumatic time for the family given the different of opinion between the family and the Trust. We understand Mr H has expressed concern that the Trust were not proactive in treating his mother. We thought it would be useful to tell them, the adviser also said that while Mrs H was a patient at the Trust, the Trust continually actively treated her and there is no evidence of undertreatment at any point during her stay in hospital.
92. In conclusion, we have found no indication of maladministration in the Trust’s handling of Mrs H’s DNACPR decision. For this reason, we will be taking no further action on this part of the complaint.
Trust - Sepsis treatment
93. Before we decide if we should conduct a detailed investigation of a complaint, we look at whether there are signs the events complained about had a negative effect which the Trust has not put right. Having done so, we cannot link the events complained about with the negative impact Mr H has claimed.
94. On 31 December, Mrs H was started on the ‘Sepsis unknown-origin pathway’. Mr H complains the Trust did not treat Mrs H’s sepsis soon enough.
95. NICE guidance for the treatment of sepsis states to give broad spectrum antimicrobial at the maximum recommended dose without delay (within one hour of identifying that they meet any high-risk criteria in an acute hospital setting).
96. Mrs H’s medical records state on 31 December, an emergency event was noted that afternoon. The Trust prescribed Mrs H amoxicillin, under the sepsis of unknown origin pathway protocol.
97. When the Trust realised Mrs H was mildly allergic to amoxicillin, they modified her treatment and prescribed meropenem and gentamicin after a discussion with a microbiologist.
98. The records do not state what time Mrs H was given meropenem. They also do not state what time Mrs H was given gentamicin. We do know, however, that by that evening, Mrs H had been given the antibiotics as the records say, ‘started on meropenem (plus stat gentamicin)’.
99. NICE guidance states that antibiotics should be prescribed within one hour of high-risk cases or in a timely manner. The records indicate that within an hour of the Trust suspecting sepsis, Mrs H was given amoxicillin. When the Trust realised she was allergic a request was put through for a different antibiotic. While we do not know what time the different antibiotics were given to Mrs H, our clinical adviser said the fact Mrs H did not go into septic shock showed that the antibiotics were prescribed in a timely manner and worked to treat the sepsis. For this reason, even if we were able to identify Mrs H could have been given the treatment earlier, we could not link it to the claimed impact.
100. In conclusion, the Trust prescribed appropriately treated Mrs H’s sepsis. We do not know for certain when Mrs H was given the meropenem and gentamicin, but the fact she did not go into septic shock shows that the medication was given in a timely manner. On this basis, there is no unremedied injustice. For this reason, we will be taking no further action on this part of the complaint.