Complaint about Mrs V’s discharge on 7 January 2021 and the impact on Mr V
29. The law says we cannot investigate a complaint where a person has (or had) the option to take legal action, unless we consider this is (or was) unreasonable in the circumstances. We have discussed this with Mrs M to understand her circumstances and the outcomes she wants. We do not consider whether legal action would succeed but whether it would be a reasonable option to look into.
30. Mrs M has instructed a solicitor about this matter, and they have begun work on the case. This means Mrs M is already taking legal action about this discharge and the impact she says it had on Mr V. It is therefore a reasonable option for her to pursue with the solicitor at this stage.
31. It is important to note that once Mrs M has completed her legal action against the Trust, she has the right to approach us again if there are any issues that are unresolved.
32. If Mrs M were to come back to us, her complaint would be outside our time limit. We would have to consider the time limit and if there were grounds for us to put this to one side.
The complaints about Mrs V’s care and the impact it had on her
33. Before we decide if we should conduct a detailed investigation of 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 below, considering each of Mrs V’s concerns individually.
Complaint about support given to Mrs V to care for her leg stumps
34. Mrs M told us that when she got Mrs V home on 22 January, Mrs V’s stump socks were filthy. She says when she removed these she found the stumps were red, angry and sore. She says the skin appeared soft and ‘mushy’.
35. We realise Mrs M is concerned that the leg stumps were infected, and that this infection may have contributed to Mrs V’s death.
36. In its response to her complaint, the Trust said Mrs V had kept her independence while in hospital and declined assistance with her personal care. However, it accepted that staff should have identified that the stump socks had not been changed and taken steps to find replacements.
37. Before we decide if we should conduct a detailed investigation of a complaint, we look at whether there are signs the event complained about had a negative effect which the organisation has not put right.
38. With this in mind, we have considered if there is evidence Mrs V’s leg stumps were infected and whether this could be linked to staff not providing replacement stump socks.
39. The records show that when Mrs V was readmitted to hospital on 23 January, a doctor noted Mrs V had lesions on her knees, which they felt were likely to be fungal. They prescribed anti-fungal cream.
40. On 29 January, a doctor examined the stumps again and noted there was ‘no weeping or cellulitis’ (infection of the skin and soft tissue). Nursing staff have noted the stumps were dry and appeared to have rashes on them.
41. It is clear from Mrs M’s account and from the records that Mrs V had a skin condition on her stumps. However, we have seen no evidence the stumps were infected. This means we cannot link the events complained about with the negative impact Mrs M has claimed.
42. We can see the Trust has apologised the stump socks were not changed and has shared the letter and response with nursing teams for the purpose of learning and reflection.
43. We hope this reassures Mrs M that the Trust has taken action to prevent a repeat of this.
Complaint about discharge on 22 January
44. Mrs M told us when she collected Mrs V from hospital on 22 January, she could not stand up and was sick in the corridor on the way to the car. She was readmitted to hospital a few hours after arriving home. We understand these events were upsetting for Mrs V and Mrs M.
45. The discharge guidance says patients should be reviewed to decide if they meet certain criteria. If they do not, then staff must consider discharge to a less acute setting.
46. General guidance in ‘good medical practice’ says doctors must give a good standard of practice and care. They should adequately assess the patient’s condition and quickly give treatment where necessary.
47. We asked our adviser what doctors would need to do to meet this guidance. They said that staff should have made sure Mrs V was clinically stable and able to continue her treatment at home.
48. The records show doctors considered Mrs V was first medically fit for discharge on 19 January. She was reviewed again by doctors on 20 and 21 January, where they reached the same view.
49. A physiotherapist discussed the options for discharge with Mrs V. She declined to go to an assessment bed and wanted to go home with the support of carers three times a day. This package of care was arranged for Mrs V.
50. The records show Mrs V was reviewed by a doctor at about 11am on 22 January. Her observations (oxygen level, rate of breathing, blood pressure, heart rate and temperature) were normal and she no longer needed oxygen.
51. She was alert, awake, talkative and had no new issues. She was eating and drinking well. She was clinically stable and had completed her antibiotic treatment. She did not meet any of the criteria set out in the discharge guidance.
52. We do not doubt Mrs M’s account of Mrs V struggling to walk and vomiting. We would like to assure Mrs V that there is no sign in the records that Mrs V had been experiencing vomiting on the ward. She had eaten lunch shortly before discharge.
53. We recognise Mrs V’s condition deteriorated quickly after discharge, which led to her readmission. However, the evidence in the records suggests Mrs V was fit to be discharged, and an appropriate package of care had been arranged.
54. In our view, the Trust’s actions were in line with the discharge guidance and ‘good medical practice’. We have seen no sign of a failing here.
Complaint about DNACPR and the treatment escalation plan
55. We understand Mrs M’s concern that by putting in place a DNACPR order and treatment escalation plan, Mrs V did not get treatment that could have saved her life. We recognise that those concerns caused her distress.
56. ‘Good medical practice’ says doctors should provide effective treatment based on the best available evidence. The end-of-life guidance says CPR generally has a very low success rate and there are burdens and a risk of doing it. It says a decision in advance not to attempt CPR can help make sure the patient dies in a dignified and peaceful manner.
57. We can see doctors put a DNACPR order and treatment escalation plan in place on 23 January. The records show that when doing so, the medical team considered Mrs V’s prognosis and other illnesses. They concluded that because of that, CPR and escalation beyond ward level care would not benefit Mrs V.
58. Mrs V was already getting treatment for pneumonia. Our adviser said that sadly there was no other treatment that would have helped her, and there was no realistic prospect of a successful outcome with CPR.
59. They said patients with other diseases and/or post-COVID-19 pneumonia tend to fair very poorly in intensive care. For those reasons it was very unlikely Mrs V would have survived.
60. In our view, the Trust’s decision making was in line with the guidance.. Having compared what happened with what should have happened, we have seen no signs that something went wrong.
Complaint about treatment for infection
61. Mrs M is concerned about the treatment Mrs V had for infection on her final hospital admission.
62. Mrs V was transferred to a side ward on admission due to ESBL cultures being found on a previous admission. This was to prevent the spread of a bacteria which does not respond well to antibiotic treatment.
63. ‘Good medical practice’ says doctors should provide or arrange suitable advice, investigations, or treatment where necessary. When Mrs V was admitted, she did not have any clinical signs of urine infection, so she did not require any treatment. This was in line with the guidance.
64. Turning to the treatment for pneumonia, when Mrs V was readmitted, it was 19 days after she had first had symptoms of COVID-19. This meant she did not have an active COVID-19 infection at that time, so did not require specific COVID-19 treatment.
65. The pneumonia guidance sets out the type of antibiotics that should be prescribed for pneumonia that has been picked up in the community. The records show doctors prescribed amoxicillin, co-amoxiclav and clarithromycin. This was in line with that guidance.
66. Mrs V completed the antibiotics and her C-reactive protein (CRP, a protein which responds to inflammation) levels were normal which indicated a good response to the antibiotic treatment. Her temperature had come down to normal, her chest was clear, and she no longer needed oxygen. These were signs the pneumonia had settled.
67. When Mrs V developed a temperature on 4 February, she was not showing any signs of pneumonia or sepsis. Doctors considered she may have a urine infection and began treatment with antibiotics. Our adviser said a temperature is often due to urine infection and CRP does not tend to go very high with such an infection.
68. In our view, it was in line with ‘good medical practice’ to give effective treatment to treat Mrs V for a possible urine infection at that time, while waiting for urine test results to return.
69. Unfortunately, on 5 February Mrs V deteriorated quickly. Doctors suspected sepsis and, because she was unconscious, the possibility of a stroke. Tests were done to identify the cause of the sepsis.
70. While waiting for the results, doctors put Mrs V back on IV co-amoxiclav. This is an antibiotic which would have covered the common causes of sepsis, such as meningitis, pneumonia and urine infection. This was in line with ‘good medical practice’ to provide effective treatment.
71. Sadly, Mrs V’s rapid deterioration continued before any test results confirmed the cause of her sepsis.
72. Having compared what happened against what should have happened, we have seen no signs that anything went wrong in how the Trust treated Mrs V for infection.
73. We accept Mrs M’s understandable confusion about what doctors told her about pneumonia being the cause of Mrs V’s death and the death certificate stating her death was COVID-19.
74. We asked our adviser about this. They told us that sepsis is a clinical syndrome rather than a disease. Sepsis always has a cause, so this rarely appears by itself on a death certificate. They said COVID-19 would have been noted as the cause of death, rather than sepsis, because it was the most likely root cause of Mrs V’s sepsis and her death.
75. We hope this reassures Mrs M about the cause of Mrs V’s death and the treatment she received.
Complaint about nutrition and hydration
76. In its complaint response, the Trust accepted that its documentation about the measures taken to monitor and meet Mrs V’s nutritional needs fell below the expected standards. Food records were incomplete, staff did not weigh her, and food diaries showed Mrs V had eaten minimally and sometimes declined meals.
77. We can see the Trust has apologised to Mrs M that Mrs V’s treatment and care were not at the expected standard. To improve its nutritional care, it has created a new nutrition nurse role and has shared learning with the nursing teams to raise awareness of the importance of nutritional care.
78. Her complaint letter and the responses have been shared for learning and reflection with the nursing team and at care governance meetings. The Trust’s actions in accepting and apologising for its errors and taking steps to improve its service are in line with our ‘Principles for Remedy’.
79. However, Mrs M is understandably concerned that the lack of nutrition contributed to Mrs V’s decline.
80. Before we decide if we should conduct a detailed investigation of a complaint, we look at whether there are signs the event(s) complained about had a negative effect which the organisation has not put right. We have therefore considered the impact the lack of nutrition had on Mrs V and what action the Trust has taken.
81. We know Mrs V sadly died from post-COVID-19 pneumonia. We asked our adviser about the impact of inadequate nutrition on Mrs V’s condition. They said inadequate nutrition does not mean a patient will not be strong enough to fight off infection. There is no serious impact on the immune system from inadequate nutrition.
82. We have not found any indication the lack of adequate nutrition led to a decline in Mrs V’s condition. We hope this reassures Mrs M that it would not have affected Mrs V in that way.
83. We know how strongly Mrs M feels about what happened, and we thank her for sharing her experience with us. We hope this statement clearly explains the reasons why we have decided not to take further action on her complaint.