Monitoring of and treatment for constipation
20. Mrs M complains Mr M’s constipation was not managed properly throughout his admission. She questions if this led to him having constipation, and ultimately, to his bowel perforating on 22 March.
21. The Trust has said nursing staff completed a bowel chart for Mr M, to record his bowel movements each day. Most days he was recorded as having normal motions. It said Mr M was given regular medication to prevent constipation and he was passing stools in the days leading up to 22 March.
22. BMJ guidance for constipation provides a flowchart with recommendations for how clinicians should approach treatment for constipation. For chronic constipation, meaning where it has been occurring for a long time, the flowchart says that if initial treatment of lifestyle advice and increased medications do not work, stool softeners and/or laxatives can be tried.
23. Mr M’s lists of medications he was taking on admission included the laxative Laxido. This prescription was continued throughout his admission.
24. The BMJ guidance also says that if constipation remains unresolved with the use of laxatives or stool softeners, the patient can be given a stimulant laxative. This type of laxative works by stimulating the nerves that control the muscles in the intestines.
25. As well as Laxido, Mr M was also prescribed senna and glycerol suppositories as needed. These are both types of stimulant laxatives. We consider the choices of medication to treat Mr M’s constipation were correct and in line with the BMJ guidance for treating this condition.
26. The nursing records show Mr M was regularly given Laxido and senna. There are some dates where he was not given Laxido and it is noted this was because it was ‘not required’. When reviewing the stool charts, these match the dates Mr M had a bowel motion.
27. Mr M was only given the glycerol suppository once on 28 February. We can see this matches with him not having a bowel movement for a few days, and then had a few days of only having small motions. After being given the suppository, he went on to have multiple motions on 28 February, and one the following day.
28. Our nursing adviser has explained the nursing staff correctly administered Mr M’s medication and it was appropriate to withhold the Laxido on the occasions they could see this was not needed. The team were closely monitoring him and adjusting his laxatives as needed. This approach meets the standards set out in NMC guidance which says nurses should ‘deliver the fundamentals of care effectively’.
29. In terms of monitoring Mr M’s bowel motions, nursing staff completed a stool chart and commented on his bowel motions in their written notes. This stool chart records both the type and quantity of stools each day and is based on the Bristol stool chart. This is a seven point scale used to measure the types of stool ranging from type one: separate hard lumps that are difficult to pass, to type seven: entirely liquid. Types one or two indicate the person has constipation, types six and seven indicate diarrhoea.
30. On his admission on 1 February, Mr M was documented as having constipation. The stool chart shows that in the days following his admission, he did not pass stools for five days. On 6 February, he passed a type four normal consistency stool. He passed further type four stools on the following two days and a doctor noted the constipation was resolved by 8 February.
31. The bowel charts for February largely show Mr M passed medium and large stools that month. With reference to the Bristol stool chart, they were type four and five which is a normal stool consistency. There continued to be gaps in Mr M passing stools, with a further period of a few days at the end of February where he did not pass anything and another period of a few days at the start of March.
32. Our physician adviser has explained these gaps in Mr M passing a motion would not be unusual for someone who has chronic issues with constipation. When looking at the overall period, the fact that his bowels were opening with relative consistency shows that the laxatives were working. Along with the regularity of motions, it is also as important to consider the consistency of the stools, and the records say Mr M’s were always either type four or five, meaning a normal, soft consistency.
33. When looking more closely at the days leading up to 22 March, Mr M passed motions on all but one day. The qualities are mostly documented as being small or very small, with one medium sized motion on 21 March. The consistencies were all type four and five, meaning they were normal. The nursing records do not document that Mr M was suffering with any abdominal pain or discomfort.
34. Following careful consideration of the records, we consider Mr M was prescribed an appropriate treatment regime for constipation that meets the BMJ guidance for this condition. We are also satisfied the medical team and nursing staff closely monitored Mr M’s bowel motions and his laxatives were administered appropriately.
35. We are sorry to hear of Mrs M’s concerns and can understand why she has questioned if Mr M’s condition was correctly managed. We hope we have been able to clearly explain why we do not have concern with care provided by the Trust in this part of the complaint.
Hydration for the week 15-22 March
36. Mrs M questions if nursing staff met Mr M’s hydration needs in the week leading up to him experiencing a perforated bowel. She is concerned that staff did not make sure he had drinks on a day she was not there and that a lack of hydration made his constipation worse.
37. The Trust has said the fluid charts show Mr M had a changing fluid intake over the dates in question. Nursing staff did not complete the charts consistently however, and it noticed that the notes contained details of drinks given to Mr M that are not recorded in the charts. This makes it difficult to know with accuracy what his fluid intake was.
38. Despite this, the Trust says nursing staff felt he was drinking well on many days. It says he was offered regular drinks and tests of his kidney function did not show any serious concern that would indicate a problem with his hydration.
39. NMC’s ‘The Code’ says hydration is one of the essentials of care. Nurses should make sure patients always have access to hydration and do not leave people unaided if they need help to drink.
40. On admission, it was documented Mr M had poor oral intake and was dehydrated. On 8 February, a doctor wrote instructions that the nursing team should encourage his fluid intake. Mr M was reviewed throughout his admission by the Speech and Language Team (SALT) who assessed his swallow function. They noted his ability to swallow fluctuated and made recommendations for his food and fluids.
41. To monitor Mr M’s fluid intake, nursing staff completed fluid balance charts. These are intended to be completed each day to document how much a person has had to drink, and how much urine they have passed. At the end of each day, the values should be totalled to make sure the levels are balanced. This allows clinicians to make sure a person is having enough fluid. For Mr M, who had been diagnosed with dehydration and had problems with swallowing, this monitoring was particularly important.
42. Mr M’s fluid intake was recorded by nursing staff in fluid balance charts, in food and fluid charts and in the written nursing notes. We have referred to all three documents in our consideration.
43. For 15 March, there is no fluid balance chart. The food and fluid chart documents he had cups of tea and water throughout the day. The nursing notes comment he was eating and drinking.
44. The fluid balance chart for 16 March documents Mr M had several drinks between 9am and 10pm. The food and fluid intake chart only documents a drink he had with his breakfast, but the rest of the chart was not completed. The nursing notes say his oral intake was good on this date.
45. The fluid balance chart for 17 March documents Mr M had several drinks between 6am and 6pm. There is no food and fluid intake chart for this date. The nursing notes at 4.45am say he had fluids within reach.
46. On 18 March, the fluid balance chart shows Mr M had three drinks between 9am and 12pm, there is then a gap until he had a drink at 10pm. The food and fluid intake chart says Mr M had a drink at breakfast, lunch, and dinner. At 11am, the nursing notes said he was eating and drinking well. Later in the day it was documented he had fluids in reach.
47. The fluid balance chart for 19 March documents Mr M had a drink at 6am, and one at 10pm. The food and fluid intake chart only records the food he ate at breakfast and lunch and does not document any fluids. The nursing notes say he was eating and drinking well without any issues.
48. The fluid balance chart for 20 March documents Mr M had a number of drinks throughout the day between 9am and 6pm. There is no food and fluid intake chart for this date. The nursing notes say he was eating and drinking well.
49. On 21 March, the fluid balance chart shows Mr M had drinks between 6am and 10am with a gap to his next drink at 5pm. The food and fluid intake chart only document one drink given with his breakfast. The nursing notes say he was tolerating a ‘good amount’ of fluids that day and that he was assisted with drinking.
50. On 22 March, the fluid balance chart documents Mr M did not have a drink until 10pm. The food and fluid intake chart does not document any drinks given that day. A nursing note from the early morning says he was eating and drinking well.
51. In terms of urine output, the nursing notes say Mr M was incontinent of urine (passing urine when you do not mean to). The fluid balance charts vary quite significantly in their record of output. On 16 March, there are six entries for urine output, whereas on 19 and 20 March, only one urine output measure is documented.
52. The NMC’s ‘The Code’ says nurses should:
• ‘keep clear and accurate records relevant to [their] practice • complete all records at the time or as soon as possible after an event, recording if the notes are written sometime after the event • identify any risks or problems that have arisen, and the steps taken to deal with them, so that colleagues who use the records have all the information they need’.
53. The documents we have reviewed show obvious differences in what Mr M was given to drink. Our nursing adviser has said the fluid balance charts are not good enough.
54. If we looked only at the fluid balance charts, these would suggest Mr M went hours without being given fluids or passing urine. However, when reviewed alongside the food and fluid intake charts and nursing notes, it appears that staff gave Mr M a lot of drinks that were not documented in the balance charts. This means any balance totals would be inaccurate and of little value to staff trying to monitor if he was being kept adequately hydrated.
55. The records do not comply with the standards set out in the NMC guidance. While it is clear Mr M was being given drinks and was passing urine, we cannot say if his hydration needs were being met. There is also no evidence that nursing staff reviewed the fluid balance charts and raised concerns about the gaps in documentation so this could be addressed. We consider the standard of documentation and lack of action by nursing staff to escalate this concern is a failing.
56. Mrs M has told us she is concerned that if Mr M was not being given enough fluids, this could have made his constipation worse.
57. Dehydration occurs when the body loses more fluids than it takes in. Our nursing adviser has said this can cause constipation. Other signs Mr M may have been suffering with dehydration would be if he had abnormal kidney function, if he was agitated, or was feeling more unwell.
58. In terms of whether Mr M was experiencing constipation from 15 to 22 March, as noted above, we have seen he passed stools on all but one day that week. The consistency of the stools was normal, and while the amounts were mostly small, it is documented he passed a large stool on the early morning of 22 March. There is no indication he was struggling to pass stools that week.
59. When considering if Mr M was affected in other ways by a dehydration, a blood test on 15 March showed Mr M’s urea levels were raised. There can be a number of causes for this, including dehydration. The records show Mr M’s urea levels varied throughout his admission however and were sometimes above normal levels. No blood tests were taken again in the following days so we cannot say if the level of urea in Mr M’s blood had changed leading up to 22 March.
60. There is no record in the nursing notes that Mr M was agitated or expressing any discomfort during the week in question. He did not show signs of pain and the records describe him as being ‘stable’, ‘settled’ and ‘appearing comfortable’.
61. In summary, there is no evidence to show a lack of fluids caused Mr M’s physical condition to worsen between 15 and 22 March. However, we understand that being unable to reach a robust view of whether he was kept well hydrated means we cannot reassure Mrs M of the care Mr M received. This uncertainty is an injustice to Mrs M.
62. The Trust has said it recognises the standard of records was not good and its ward sister has raised this as a concern for improvement on the ward. It has since seen an improvement in the completion of fluid balance charts.
63. While we are pleased the Trust has identified this concern and has taken action to address this, we do not consider it has yet gone far enough. Mrs M wanted to know that the Trust had done all it could for Mr M and we have not been able to reach this conclusion. We therefore consider the Trust should provide a further explanation to Mrs M of how it is assured that its nursing staff are monitoring and providing good hydration for its patients.
64. We partly uphold this part of the complaint and set out our recommendations at the end of this report.
Investigation and treatment of symptoms on 22 March
65. Mrs M has told us she visited Mr M on 22 March. She says he was not behaving as usual and when she and the HCAs were moving him back to bed, they could smell faeces. After the HCA tried cleaning him with a tissue, Mrs M says the HCA agreed his bowels were blocked and he was dehydrated, and she would tell a nurse.
66. Mrs M complains Mr M was not given any treatment until his condition started to deteriorate in the early evening when he developed a temperature and vomited. She questions if with earlier action, Mr M’s perforated bowel could have been avoided.
67. A doctor reviewed Mr M before Mrs M arrived. It is documented he was in bed and was confused. He said he felt he had something in his throat. The doctor recorded that overall Mr M looked well and was not chesty. The plan was to carry out a urine test and chase his blood test results.
68. Our physician adviser has commented it would not be unexpected for someone with dementia to be noted as being confused. Mr M’s comment that he felt he had something in his throat was something he had raised for the past few days and he had been given treatment for thrush.
69. It is not clear from the records why a urine test was requested, but the Trust has said this was to rule out infection. It is likely the blood test had been requested to check Mr M’s platelets as he was taking medication to treat a condition that causes excessive platelets in the blood.
70. Nursing notes from the early hours of 22 March say Mr M passed a large stool of a normal consistency. We note this was not documented on his stool chart. He was then further reviewed a few hours later. The observation chart shows his observations were in the normal ranges and his overall NEWS score was zero indicating that he was stable.
71. A NEWS score records six different measurements including temperature, heart rate and level of consciousness. The higher the overall score, the greater the concern for the patient as this indicates deviation from normal levels.
72. Mr M’s stool chart says that early that morning he passed a very small stool of a normal consistency. Two hours later he was given the laxatives senna and Laxido.
73. The records do not document Mrs M’s attendance in the morning, or the conversation she had with the HCA. We are sorry to hear of her experience and understand this must have been very worrying and upsetting for her.
74. While there is no record of the conversation, we can consider the checks that were completed by nursing staff approximately 45 minutes after Mrs M says she spoke with the HCA. The observations taken at 12.30pm were all within normal ranges and Mr M had a NEWS score of zero. He was recorded as being alert, as not suffering with any pain and his temperature was normal.
75. Along with passing two motions that morning of normal consistency, he had also passed normal stools on 20 March and on 21 March. He was not showing any signs of discomfort or pain to suggest he was struggling with constipation.
76. From the available records, we do not have concern with the care provided on the morning of 22 March. There are no indications in Mr M’s observations that he was more unwell or that action was necessary in response to his condition at that time.
77. The next records from this date are nursing observations taken at 5.11pm. These show Mr M had a raised temperature, but everything else remained within normal limits. His NEWS score remained at zero.
78. The Trust’s guidelines for ‘patient observation and monitoring’ says that nurses should ‘use their clinical judgement to assess frequency of observations, where other signs or symptoms exist and are cause for concern and increase frequency of observations and escalate to medical team despite a low/ normal NEWS’.
79. The nurse who assessed Mr M at 5.11pm clearly had concern about Mr M’s elevated temperature as they alerted the on-call doctor about this. They also increased the frequency of observations and next assessed him at 6.37pm. This assessment showed Mr M’s temperature had further increased and his pulse rate had increased. He was not documented as being in any pain and was alert.
80. We consider the nurses proactive approach to Mr M’s condition was in line with the Trust’s policy. It also complies with the NMC’s ‘The Code’ which says nurses must make sure that people’s physical needs, ‘are assessed and responded to’ and that they should meet ‘the changing health and care needs of people during all life stages’.
81. The records say that at around 7.30pm, Mr M became restless. Observations recorded a NEWS score of one, but observations taken a minute later show his NEWS score was four. He had a raised score due to a further increase in his pulse rate and he was displaying signs of pain. The nurse recorded he was uncomfortable, but responsive.
82. The nurse called the on-call doctor to ask them to review Mr M. Shortly after this, Mr M vomited. Five minutes later, the on-call doctor attended to review him. By this time, Mr M had a NEWS score of 11 due to a very high pulse rate, high blood pressure, significant pain, low oxygen levels, a high respiratory rate and confusion.
83. This was a very quick decline and our physician and nursing advisers have explained these symptoms likely indicate when the perforation occurred. Our physician adviser has explained a perforation causes a quick progression of symptoms because as matter escapes the bowel, it causes the person to experience pain and discomfort. There can be a number of causes for a bowel to perforate including constipation, inflammation, ulcers, a hernia, forceful vomiting, and trauma.
84. The doctor assessed Mr M, examined his chest, and requested a number of tests. They started Mr M on intravenous antibiotics (directly into the vein) and fluids and requested a review from a senior clinician. They also carried out an ECG to check the electrical activity of his heart, requested a chest X-ray and further blood tests.
85. Our physician adviser has confirmed these were appropriate actions to taken to try and understand why Mr M’s condition had suddenly declined. These actions comply with NICE guidance for ‘acutely ill adults in hospital: recognising and responding to deterioration’. This says that healthcare professional should ‘initiate appropriate interventions, assess response and formulate an action plan’ when reviewing patients who have deteriorated and there is medium to high concern for them.
86. A registrar went on to review Mr M later that night and considered the results of the chest X-ray. This showed gas under his diaphragm, suggesting a likely perforation. The registrar examined him and noted Mr M had tenderness over his abdomen. They explained to Mrs M and her son that sadly, Mr M was not well enough for any further tests or treatment and was going to die. The plan was to provide care to keep him comfortable.
87. We are very sorry to hear of these sad events and understand it must have been very shocking and upsetting for Mrs M to see Mr M’s condition change so quickly.
88. Nursing staff continued to observe Mr M that night at more regular intervals. Over the next two days, the records do not document he was experiencing any pain and he was often sleeping. This indicates that he was kept comfortable.
89. In terms of the decision made about treatment on 22 March, our physician adviser has explained that Mr M was very frail and had a number of existing illnesses. As well as this, he also had aspiration pneumonia. This is an infection of the lungs caused by material being breathed in instead of swallowed and can be a serious condition in itself.
90. When a person is frail, their ability to tolerate stress on their system is low and it dramatically decreases their chances of recovery. Putting Mr M through further tests and surgery would likely not have been in his best interest. Our physician adviser has said that attempting surgical treatment for the perforation would likely not have changed the sad outcome in this case.
91. We consider the decision made for how to manage Mr M’s condition meets GMC standards of Good Medical Practice that says doctors must, ‘provide effective treatments based on the best available evidence’. They should also ‘take all possible steps to alleviate pain and distress whether or not a cure may be possible’.
92. We are sorry to hear of Mrs M’s concern that she felt nursing staff did not take appropriate action when she alerted them to Mr M’s condition that morning. While we do not dispute what Mrs M has told us, following careful review of the available information for 22 March, we do not consider there were signs before the early evening that Mr M was becoming more unwell. The perforation occurred suddenly and we have not seen anything to suggest that clinicians should have acted earlier to provide different care.
93. When nursing staff became aware of Mr M’s changing condition, we consider they acted quickly to alert the medical team and carried out more regular observations. We consider the medical team carried out a detailed examination and assessment and made an appropriate decision for the management of his condition. For these reasons, we do not uphold this part of the complaint.
Conclusion
94. Mrs M has told us how distressing the events of 22 March were. We understand why she has questioned if action could have been taken at an earlier time to stop Mr M’S bowel from perforating. It is clear she cared very much for him and wanted the best care for him.
95. Through our work, we consider the Trust appropriately monitored and treated Mr M’s constipation. On 22 March, we do not consider the medical or nursing teams missed earlier indications that Mr M was deteriorating. We do not have concern with the standard of care provided on this date. In terms of whether Mr M was kept well hydrated, we have been unable to decide this. While we cannot link a medical impact to this, we consider this will cause Mrs M uncertainty and distress.