12. Before we decide if we should investigate a complaint, we look at whether there are signs the event complained about had a negative effect which the organisation has not put right. We will explain our decision below.
Mask monitoring and moving to a side room
13. The doctor said Mr C was moved to the side room on 18 January 2021 so the family could visit during the pandemic and that it was safe for him to be in a side room overnight. He was regularly checked. The Trust only moves patients if the medical staff feel it was necessary.
14. The RCP guidance says that NEWS should be used for initial assessment of acute illness and for continuous monitoring of a patient’s wellbeing throughout their stay in hospital. Trends in the patient’s clinical responses can be tracked through regular NEWS recording. This is to give an early warning of potential clinical deterioration and the need to escalate clinical care. Frequency of monitoring ranges from 12 hourly to continuous monitoring depending on the patient’s overall score.
15. We can see Mr C’s NEWS was documented ten times on 18 January 2021. Our adviser said on all occasions his oxygen mask was in place, and he received supplementary oxygen.
16. The records show Mr C’s mask was also checked hourly that day. He needed constant reminders from nursing and medical staff to keep his mask on. He knew the risks of removing his mask and that he was non-compliant.
17. The clinical notes show the consultant phoned Mr C’s wife in the early morning of 18 January 2021 and updated her on the situation. The consultant told Mr C that he would not survive if he took the mask off.
18. Our adviser said Mr C was monitored in line with the RCP NEWS guidance on 18 January 2021. Staff could only encourage him to wear his mask, but they could not force him. He made an informed choice and had full capacity to understand the risks and benefits of removing his mask. The clinical notes show he was frequently encouraged to keep his mask on.
19. We recognise that Ms C feels the Trust should not have left her father in a secluded room where it was difficult to call for help.
20. The NMC standards says nurses should demonstrate the knowledge and skills needed to prioritise what is important to people and their families. This is when giving evidence-based person-centred nursing care at end of life. It includes the care of people who are dying, families, the deceased and the bereaved.
21. Our adviser said side rooms are intended for patients with an infectious disease and for patients at the end of life. The surgical/medical ward round shows Mr C was moved to a side room at 6pm.
22. We do not underestimate how distressing the situation was for the family. Mr C died that night, and we understand they naturally have questions about what happened. We acknowledge they feel the Trust neglected him and that Mr C should have moved back from the side room after the family visit. We can see the Trust did not want to move him overnight to avoid agitation as he was settled. Mr C was also due to be reviewed the next day. We cannot see that the Trust should have done anything different here.
23. We are satisfied there is no indication of a failing here. We think the Trust acted in line with the RCP NEWS guidance and NMC standards. We can see the Trust regularly monitored Mr C before he died and moved him to a side room overnight for comfort and dignity and to allow the family to visit freely.
Contradictory statements
24. Ms C says the Trust gave contradictory statements about her father’s end of life care. The nurse told her on 19 January 2021 that the consultant in respiratory medicine planned to put her father on end of life care. But the consultant told the family that they did not make this decision as there was no immediate concern and they planned to review Mr C.
25. Ms C also says the nurse told her that she was invited to see Mr C in the evening of 18 January 2021 because he was dying, and this was the only circumstance that the family would be asked to come in. Ms C feels this was not the case. She says the nurse invited her to visit to calm Mr C down as he was anxious.
26. We know the consultant said the medical staff felt it would be good for the family to see Mr C, boost his morale and encourage him to continue wearing the mask. The consultant accepted there was some miscommunication to the family about Mr C’s end of life care. This was about whether the nurses told them he ‘was going to be on end of life care’ or ‘was on end of life of care’. The consultant said they would review Mr C on 19 January to see if he should be placed on end of life care. The consultant said this is a decision only made after discussions with the family.
27. There is some confusion about exactly what nursing staff told the family and why they had been invited to come into the hospital to see Mr C. Either way, the family understood Mr C was on end of life care. Mr C was not actually on end of life care though. The consultant physician may have started this the following day, but they had not yet made this decision. This indicates nursing staff may have got something wrong in their communication. We can see this has caused Ms C concern and distress and contributed to her losing faith in the Trust.
28. Our Principles for Remedy ‘Getting it right’ says that public bodies should show its willingness to acknowledge when things have gone wrong, learn from its maladministration or poor service and put things right.
29. We can see the consultant physician acknowledged there was miscommunication between doctors and nurses and apologised for this during the face-to-face meeting. The consultant accepted medical staff should have been clearer that an active decision was not made. A member of the governance team also apologised during the meeting for the distress caused to the family and acknowledged they should have been better supported. The Trust said the senior matron would discuss the case anonymously with ward staff about having clearer discussions with families.
30. It is clear from Ms C’s account that this was a very difficult time for the family. We are satisfied the Trust has acknowledged the mistakes it made around the miscommunication surrounding Mr C’s end of life care. We think it has already put things right, in line with our principles. It has apologised and has taken steps that will hopefully improve the experience for other families in the future.
31. We have considered if we should ask the Trust to pay a financial remedy. To do this we would need to see that the poor communication significantly contributed to the emotional impact of the events on the family. When we weigh up what happened, we cannot see this. We do not think the family would have been significantly less distressed if the nurses had accurately told them the consultant would be considering end of life care for Mr C the next day. We think the sincere apology is enough. There is nothing further we need to ask the Trust to do.