Nil by mouth diet
15. Before we decide to undertake a detailed investigation into a complaint, we look at whether there are signs the organisation has got something wrong. We have done this and have not seen any indications that something has gone wrong.
16. Mr R says the Trust’s decision to put his wife on a nil by mouth diet from 19 to 22 August 2020 caused her to lose a stone in weight. He says she was left ‘traumatised by the lack of basic care’ and this led to her overall condition significantly deteriorating.
17. The ESA guidelines state: ‘patients need to be starved six hours of food and two hours of clear fluids prior to any general anaesthetic to prevent the content of the stomach filling up the lungs during surgery’.
18. The Trust placed Mrs R on nil by mouth so that she would be available for surgery from the first available slot of any day, which our adviser explained is usually 8am. It appears this decision was in line with the ESA guidelines.
19. The GMC guidelines say clinicians have a duty to: ‘keep the nutrition and hydration status of your patients under review. You should be satisfied that nutrition and hydration are being provided in a way that meets your patients’ needs’ (paragraph 109).
20. The Trust's final response explains it is normal practice with patients booked on the emergency list to keep the patients on nil by mouth. It also explains surgeons often try and keep patients prepared for surgery as long as possible, so any opportunity to operate can be taken. It also explained Mrs R was allowed to drink in the mornings when it was assumed the procedure might be carried out later that day, and that she was given intravenous fluid throughout her stay to keep her hydrated.
21. The Trust explained it would not start any form of additional ‘intravenous’ nutrition, unless the clinicians felt it was likely a patient would not be getting any food for more than five days. It explained the nutritional team had made an appropriate referral on day four, but as Mrs R was admitted later that day for surgery the referral was not needed.
22. The Trust also explained that clinicians kept monitoring Mrs R throughout her stay and observed she remained stable. The Trust’s view is that delaying the operation did not lead to any damage to Mrs R’s health.
23. We can see from the records that, when it became clear other emergency cases would take priority over Mrs R’s surgery, Trust staff clearly documented they offered her a preoperative Nutricia drink. This is a food for special medical purposes for use under medical supervision. It is designed to switch patients from a fasted to fed state before surgery and to give fluids.
24. Although there is no record of Mrs R having eaten during the period between 19 and 21 August, we can see in Mr R's complaint to the Trust he says she was offered food in the evening of 19, 20, 21 and 22 August, which she declined due to not feeling like eating.
25. The Trust says being nil by mouth for more than five days would have highlighted a nutritional need and we can see the nutritional team made a referral on 22 August (day four).
26. The records show Mrs R’s operation was delayed by four days. We can see that Trust staff made her aware of this promptly, apologised for the delay and started Mrs R’s fluid intake.
27. There are no indications in the records that Mrs R went without fluid for an unnecessary or prolonged period. We can see that staff offered her food and drink when it became clear there could not be an operation on that day, which Mrs R declined.
28. The records show that Mrs R was unable to eat until after the procedure had taken place and had said she could not eat at home before admission, due to feeling sick. Our surgical adviser said it is likely this was the key factor to her weight loss, and the nil by mouth diet did not lead to further weight loss or her deterioration.
29. In summary, it appears the Trust acted in line with the ESA guidelines and GMC guidelines. The Trust had kept Mrs R nil by mouth, as required by the ESA guidelines. It had kept Mrs R’s nutritional status and fluid intake under review in the four days she was waiting for her surgery, which appears to be in line with the GMC guidelines.
30. We recognise the difficult time Mrs R and her family went through and the impact this had on them. We hope our explanation helps Mr R to gain closure and reassurance about what happened.
Delay in surgery
31. Mr R says Mrs R had to wait four days for an emergency operation. He says the Trust failed to transfer his wife to a different hospital, despite an oncologist diagnosing Mrs R as an emergency.
32. The Trust’s final response explains the hospital had an unusually high number of emergency procedures and the operating theatres were running at maximum capacity. This meant it treated patients who were of a higher priority to Mrs R first, and this sadly delayed her surgery by four days.
33. The GMC’s ‘Good medical practice’ says doctors should ‘provide a good standard of practice and care. If [they] assess, diagnose or treat patients, [they] must:
· adequately assess the patient’s conditions, taking account of their history (including the symptoms and psychological, spiritual, social and cultural factors), their views and values; where necessary, examine the patient · promptly provide or arrange suitable advice, investigations or treatment where necessary · refer a patient to another practitioner when this serves the patient’s needs.’
34. According to the National Confidential Enquiry into Patient Outcome and Death guidance, there are four categories of emergency patients:
· ‘IMMEDIATE – Immediate life, limb or organ-saving intervention – resuscitation simultaneous with intervention. Normally within minutes of decision to operate · URGENT – Intervention for acute onset or clinical deterioration of potentially life-threatening conditions, for those conditions that may threaten the survival of limb or organ, for fixation of many fractures and for relief of pain or other distressing symptoms. Normally within hours of decision to operate · EXPEDITED – Patient requiring early treatment where the condition is not an immediate threat to life, limb or organ survival. Normally within days of decision to operate · ELECTIVE – Intervention planned or booked in advance of routine admission to hospital. Timing to suit patient, hospital and staff.’
35. Our adviser explained having considered Mrs R's clinical presentation and the operation she needed, this meets the 'expedited' category for prioritisation, as her colonoscopy was needed within a few days but was not needed to prevent loss of life. Given this, the decision to delay Mrs R’s surgery to treat the higher priority patients who had more immediate life-threatening conditions was in line with the guidance.
36. In line with GMC guidelines, clinicians should ‘give priority to patients on the basis of their clinical need’. The evidence indicates the decision to delay Mrs R's surgery to treat the higher priority patients who had more immediate life-threatening conditions was appropriate.
37. We considered whether the Trust should have transferred Mrs R to another hospital once it became apparent that her surgery would be delayed. Our surgical adviser explained transferring patients from one hospital to another for surgery was not an appropriate solution. This is because there is a greater risk that transferring the patient would result in them being put on a new surgery priority list and this would likely mean a further delay in having the operation.
38. In line with GMC guidelines, a patient should only be referred to another hospital if it is better placed to meet their medical or surgical needs. The evidence indicates as this Trust was able to care for and carry out Mrs R’s surgery, there would have been no need to transfer her elsewhere.
39. The evidence also indicates Trust staff considered Mrs R’s clinical presentation adequately and correctly assessed Mrs R as a patient who required an emergency procedure. It appears the Trust treated her at the earliest opportunity which is in line with the above GMC guidelines. We recognise that the wait for the operation was very traumatic for Mrs R and the family. Our view is that the delay was not due to any failings by the Trust as there was an unusually high demand for emergency treatment during this time. The Trust appropriately managed its resources during this unprecedented time, and it appears the Trust’s actions were in line with the relevant guidelines.
Record keeping
40. Mr R says the Trust did not keep accurate records about the time Mrs R became nil by mouth. Mr R believes the ‘casual manner’ by which the Trust maintained the records showed staff did not give Mrs R the reasonable care, consideration and understanding she deserved.
41. The GMC’s ‘Good medical practice’ says doctors should ‘formally record your work’ and it should be ‘clear, accurate and legible’.
42. The GMC's 'Standards of proficiency for registered nurses' says nurses will be able to ‘write accurate, clear, legible records and documentation'.
43. The Trust’s final response explains it could not see evidence of the exact period of time Mrs R was asked to be put on nil by mouth. It also explains it is documented that Mrs R was on nil by mouth throughout her stay.
44. A review of the medical records from 19 to 22 August 2020 shows the surgical team reviewed Mrs R daily and recorded their decision to keep Mrs R on nil by mouth. There are records of the Trust administering intravenous fluids. The Trust also documented that it offered apologies to Mrs R when she could not have the surgery as planned.
45. The records show Trust staff clearly documented that they offered Mrs R food and drink when the surgery was not going to take place. Our adviser confirmed Trust staff made detailed and robust notes about Mrs R’s nil by mouth care plan and gave their view that the notes are of a good standard and in line with the above GMC guidelines.
46. The impact Mr R has outlined relates to the period between 19 and 22 August and not the initial nil by mouth start date and time. This being documented would not have contributed to the overall impact of the time the Trust placed Mrs R on nil by mouth.
47. In summary, we recognise Mr R’s concerns about start times not having been documented. We are satisfied the staff made clear, accurate, detailed, and robust notes about Mrs R’s care plan and were in line with the above GMC guidance.
Complaint handling
48. Mr R says the Trust’s investigation was not impartial as it was carried out by a Trust staff member. He also feels the complaint response was incomplete as it was based on poor record keeping and suggests the Trust did not carry out a robust investigation of his complaint.
49. Our Principles of Good Complaint Handling say organisations should investigate complaints thoroughly and fairly, basing their decisions on the available facts and evidence, and avoiding undue delay. They should deal with complaints objectively, fairly and consistently, so that similar circumstances are handled similarly. Any different decisions about two similar complaints should be justified by the circumstances of the complaint or complainant.
50. It also says they should ask a member of staff who was not involved in the events leading to the complaint to review the case. The organisation can still put things right quickly for the complainant where appropriate.
51. Having read through the Trust’s response and reviewed the evidence provided to demonstrate the actions it has taken in response to the complaint, it appears the Trust took the complaint seriously. It responded to the concerns raised by Mr R empathetically and provided a clear explanation of who had been involved in responding to Mr R’s complaint, based on the points he had raised.
52. We consider it a standard approach for the Trust to ask an investigator who has the relevant clinical expertise, but who is not involved in the patient's care and treatment. We can see this is what happened during the local complaints process, and this appears in line with our principles.
53. We are satisfied that the documents and records used to help the investigation of Mr R’s complaint with the Trust were detailed and robust enough to provide a thorough response to his complaint. Our view is that the Trust carried out an impartial and thorough investigation based on the information available to it.
54. The Trust also took the time to reply to further correspondence from Mr R providing further acknowledgement of the impact his experience had on him. It provided an apology and full explanation of what happened during Mrs R’s care.
55. We hope this gives some reassurance that the complaint was investigated following the correct process and by someone with the relevant experience.