Issue 1 – Discharge from the ED on 8 June
15. Before we decide if we should do 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.
16. Miss H says Mrs D should have been kept in hospital. She was unable to keep any food or drink down and had vomiting and diarrhoea.
17. The NICE guidance says discharge from the ED should be considered if a patient with confirmed or suspected COVID-19 meets the following criteria:
• oxygen saturations above 95% (which reduce to no less than 92% on exertion) • an early warning score (EWS – a numerical score based on people’s vital signs) below three • there is no other reason to admit the patient.
18. This is reflected in the Trust’s guidance, which also says people being sent home should be given safety netting advice. This is advice on what to do if the person’s condition changes or gets worse.
19. The doctor in the ED who assessed Mrs D noted she was positive for COVID-19, but did not have a cough or breathlessness (two common respiratory symptoms of the disease). They wrote her main symptoms were diarrhoea and vomiting and although she was eating and drinking less, she was managing sips of drinks.
20. Mrs D’s vital signs were normal, other than slightly reduced oxygen saturations. They were 95%, and a normal level is 96% and above. Her EWS was one. Her chest and abdomen were normal when examined.
21. Our adviser explained the findings of the assessment and blood test results did not show any signs of dehydration or serious illness that needed admission to hospital.
22. Based on the outcome of their assessment, and in agreement with a senior doctor, the doctor discharged Mrs D and gave safety netting advice.
23. We can see Mrs D met the discharge criteria that was in place at the time. We consider the Trust’s decision to send her home was in keeping with the NICE and Trust guidance. There are no signs the Trust got anything wrong here. We hope this helps to resolve Miss H’s concerns about the matter.
Issue 2 – Asking Mr D to collect Mrs D
24. Miss H complains on 8 June the Trust told Mrs D to get Mr D to collect her, as the wait for ambulance transport was too long. This meant Mr D, who was isolating at home with COVID-19, had to come to hospital to collect Mrs D.
25. In its response to the complaint the Trust explained the doctor did not know Mr D had COVID-19. It reviewed its records, including documentation from the ambulance crew, and saw nothing to show staff knew about this at the time.
26. We have also carefully reviewed Mrs D’s records and can see nothing to say that staff knew Mr D was isolating at home with COVID-19.
27. While we do not dispute Miss H’s account, we can see there are conflicting accounts of what happened. We have seen no further evidence to help us establish what staff knew at the time, so it is not possible for us to say whether the Trust got anything wrong. We recognise this may disappoint Miss H, but we are unable to consider this matter further.
Issue 3 – Care provided in the ED on 10 June
28. Miss H says her mother was left without blankets, was not given enough to eat and drink, and was left on a commode when she was in the ED on 10 June. She said that a member of her family ended up going to the ED to help Mrs D.
29. We reviewed Mrs D’s records to see if these would help us establish what happened, and there was no mention of these issues.
30. We considered the Trust’s explanation given in its complaint response. It explained there were capacity issues in the department which meant Mrs D had to wait ten and half hours to move to a ward. It said it checked Mrs D hourly and offered refreshments during this time.
31. It said staff could not remember problems with bedding on that night, but any issues with blankets are usually escalated. It apologised to Miss H for Mrs D’s experience and explained it has increased its linen supply in the department to meet the demand of the higher number of patients attending.
32. There are different accounts of what happened, and there is not enough information to help us establish what happened on 10 June. We cannot say whether the Trust got anything wrong, so we cannot consider the issue further.
33. We also note the Trust has offered Miss H an apology and explained an improvement it has made. This outcome is more than we could achieve for Miss H as there is not enough information for us to investigate this matter further. We hope this gives her some reassurance.
Issue 4 – Visiting
34. Miss H is unhappy the Trust did not let Mrs D have any visitors, and only let family see her after she died.
35. At the start of the COVID-19 pandemic visiting across the NHS was suspended. The NHS visiting guidance in place in July 2021 said visiting was being reintroduced across the NHS in a ‘very careful and covid-secure way’. It gave NHS organisations guidance on how to allow visiting where possible but said that organisations needed to have careful visiting policies, as the health and safety of patients, communities and staff remains a priority.
36. The Trust’s visiting policy, issued shortly after the NHS guidance, said it was now reintroducing visiting across its hospital sites in a phased manner, with three levels of restrictions (level three being most restrictive to level one being least restrictive).
37. In level two and three areas, visiting was restricted except for exceptional circumstances (with fewer exceptions in level three). These included end of life care, maternity care, or patients requiring additional support due to communication problems or cognitive impairments. The policy did not explain what triggered an area being level one, two or three.
38. In its complaint response the Trust explained there were visiting restrictions in place. It said visiting was only permitted in exceptional circumstances, which included expected end of life. It said most patients in the ICU have a high risk of dying, so visiting is only permitted if death is expected (for example, if treatment is not working or has to be withdrawn).
39. It explained that until Mrs D’s sudden and serious deterioration in July, she was not considered to be at the end of her life.
40. The Trust also explained that these restrictions are in place once a person has died, but the nurse who allowed Mrs D’s family to see her after she died was acting outside of these restrictions on compassionate grounds.
41. We asked the Trust for more information about the visiting restrictions that were in place in the ICU at the time. It did not explain whether level one, two or three restrictions were in place. Instead, it said that in May 2021 it began piloting the gradual reintroduction of visitors to low-risk patients at some ICUs across the Trust.
42. At this time, the ICU stayed closed to visitors, and this was the case until late July 2021 after the pilot was complete. By November 2021 the Trust had gradually increased visiting on the ICU to three times a week.
43. It appears that at the time Mrs D was in the ICU, level two or three restrictions were in place, which means visiting would only have been allowed in exceptional circumstances.
44. The relevant exceptional circumstance here was end of life. As explained, the Trust did not consider Mrs D was at the end of her life before her sudden and unexpected deterioration in July.
45. It therefore appears the Trust acted in line with its policy and the national guidance when it restricted visiting. There are no signs it got something wrong here. We understand this does not change the fact Miss H could not see Mrs D at such an important time, but we hope it reassures her that there were reasons for this.
Issue 5 – Updates about Mrs D’s condition
46. Miss H says the doctors and nurses did not keep to the agreed twice daily updates when Mrs D was in intensive care. She said the family often had to call for an update.
47. The NMC guidance says nurses must ‘share with people, their families and their carers, as far as the law allows, the information they want or need to know about their health, care and ongoing treatment sensitively and in a way they can understand’.
48. The GMC guidance says doctors must ‘give patients the information they want or need to know in a way they can understand’ and ‘be considerate to those close to the patient and be sensitive and responsive in giving them information and support’.
49. Mrs D’s medical records say medical and nursing staff updated her family on her condition every day between 13 June and 9 July.
50. We can see most updates were twice a day, but there were four times where only one update was given. On one of those days staff met with the family in person. Most of the records say staff made the telephone call, but there are some entries which show Miss H was the one to make contact.
51. We consider the Trust acted in line with the NMC and GMC guidance when it gave Mrs D’s family information on her condition every day.
52. We accept it was not ideal for Miss H to have to call for updates, and for there to be four days where she only got one update. We realise this caused frustration and worry. However, the NMC and GMC guidelines do not say how often updates should be. There are no signs these errors fell so far short of what should happen to suggest a failing.
Issue 6 – Confusing information from the Trust
53. Miss H says the Trust gave unclear updates with mixed messages about Mrs D’s prognosis and treatment. She says this meant the family were left not knowing what was happening, which added to their distress. Miss H describes two specific incidents.
54. Firstly, she says on 16 June a nurse updated Mr D and said preparations were being made for Mrs D to go onto a ventilator (a machine that helps with breathing), but a more senior nurse later said there were no plans for this.
55. In its response to the complaint the Trust explained the senior nurse remembered having to speak to Mr D about the call, and it became clear there had been a misunderstanding. It said it was not its intention to cause distress and apologised that the information given at the time was unclear.
56. The second incident Miss H describes was on 5 July when a doctor met with her and Mr D. She says they gave confusing information about whether Mrs D would be treated.
57. The doctor’s record of the meeting says they explained Mrs D’s condition had not improved and she now had kidney failure. They felt treatment for the kidney problem was not in Mrs D’s best interests, and she may not survive. The plan was to continue to monitor the situation over the next few days.
58. Miss H and Mr D contacted the Trust later that day. They worried the doctors were stopping all treatment and giving up on Mrs D because of her age.
59. The following day the doctor spoke with Miss H and Mr D again. They apologised for the confusion and assured them Mrs D was continuing to have treatment. The doctor also explained again Mrs D’s kidney problems, their views about treating this, and their concerns about her survival.
60. In its response to the complaint the Trust explained what happened. It also noted there had been some confusion and apologised that the family felt the messages on 5 July were unclear.
61. Miss H also says communication with staff was difficult at times because of their strong accents. The Trust apologised if this was the case and noted that communication was also further affected by staff wearing personal protective equipment (such as masks and visors).
62. Before we decide if we should do 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. Our principles of good complaint handling say organisations should take steps to put things right when they make a mistake.
63. The Trust has accepted there were times where the family were confused about what was happening, or communication was unclear, and have offered explanations and apologies for this. It did this at the time of the incidents, and when it investigated the complaint.
64. We consider this is an appropriate and fair resolution. We could not achieve anything further for Miss H beyond what she has already achieved by complaining. We hope this helps to resolve her concerns.
Conclusion
65. Overall, we have not identified any signs the Trust got something seriously wrong in the care it provided to Mrs D, or in the service it provided Miss H and her family.
66. There were times where communication caused confusion, and the Trust has taken steps to put this right. We know Miss H’s concerns are important to her, and we hope the explanation for our decision brings her some reassurance.