4. Mr X complains the district nurse did not attend to his mother on 7 June 2021 when he was concerned about her discoloured arm and deteriorating condition.
5. Mr X believes that if the district nurse had seen his mother, they would have identified how ill she was and referred her for treatment, which may have improved her outcome. Mr X also said the circumstances of his mother’s death affected his mental health and sleep.
6. Mr X would like an apology and service improvements.
7. Mr X explains the district nurse did not arrive at 10am on 7 June 2021 as expected, so later in the evening he called an ambulance. It took over eight hours to arrive. The next day his mother was taken to the local hospital in the early hours of the morning and admitted with sepsis. She sadly died after a short period in hospital.
12. Mr X says after contacting the district nurses several times, he was told they would visit at 6pm. However, a nurse did not arrive at that time and when he called again in the evening, he was told the district nurse would now visit the next day. Unfortunately, Mr X’s mother’s condition deteriorated, and she was admitted to hospital by ambulance after a long wait. Mr X believes if the district nurse had visited as expected, then they may have noticed his mother's worsening condition earlier and been able to do something.
13. In its complaint response the Trust said because of the high volume of visits the district nurse service needed to do, unfortunately the nurse’s visit was delayed. The Trust said the visits to Mr X’s mother were planned to be twice a week, as per the tissue viability nurse advice, and there was no known reason for the district nurse to visit urgently on that day.
14. The Trust added the patient notes only show Mr X spoke to a member of the community nursing team in the evening when he called after a referral from 111. The Trust said Mr X advised the nurse that he had changed his mother's dressing due to them being soaking wet and asked when the district nurse would next visit. They advised this would be on the next day. The Trust said Mr X seemed to be happy with this and no further concerns were raised about his mother’s condition. The Trust said patient records show that Mr X only reported his mother’s worsening condition when he called the ambulance service later that day at 8.40pm.
15. Before we decide if we should investigate a complaint, we look at whether there are signs the Trust got something wrong. We do this by comparing what should have happened with what did happen. We have done this and we have not found any signs that something went wrong.
16. Our nursing adviser advised the records show the district nurses attended Mr X’s mother twice a week for wound care. The frequency of visits and the dressings used was as per tissue viability nurse advice given on 16 April 2021. The tissue viability nurse and district nurse visited again on 13 May and the frequency of visits stayed at twice a week. There was another visit on 3 June. There was no change to the frequency of visits at this time, and no reason for increasing the visits.
17. Our nursing adviser explained the district nurse would follow the advice given to them from the tissue viability nurse and this is line with the NMC national standards for nurses:
‘demonstrate knowledge of when and how to refer people safely to other professionals or services for clinical intervention or support’.
18. Further guidance from the NMC code says:
‘8.1 respect the skills, expertise, and contributions of your colleagues, referring matters to them when appropriate 8.5 work with colleagues to preserve the safety of those receiving care 8.6 share information to identify and reduce risk
13.2 make a timely referral to another practitioner when any action, care or treatment is required 13.3 ask for help from a suitably qualified and experienced professional to carry out any action or procedure that is beyond the limits of your competence’.
19. The records show that Mr X rang the district nurses at 7.27pm on 7 June to say the dressings ‘to her feet’ were ‘soaking wet’. It is documented that he had changed the dressings and he was told the next visit would be the next day.
20. The Trust followed the advice of the tissue viability nurse to visit Mr X’s mother twice a week. When there is pressure on the district nursing service, wound care visits cannot be made at a specific time. District nurses will try to keep to set days and times, but if this is not possible due to service demand, the appointment may have to be delayed to the next day. This would still mean Mr X’s mother would have been seen in line with the plan of two visits a week. We note Mr X believes that if the district nurse had attended they would have seen how unwell his mother was. However, district nursing is not an emergency service. Patient deterioration secondary to sepsis would need an emergency response, and this would not have changed even if a district nurse had visited.
21. In summary, we have looked at the evidence carefully to see if we should investigate further. However, considering the available evidence and guidance there are no signs of failings on the part of the Trust. We recognise the death of Mr X’s mother was a distressing experience for him and we hope we have clearly explained the reason for our decision.
1. We have considered Mr X’s complaint about Nottinghamshire Healthcare NHS Foundation Trust (the Trust).
2. We have looked at the available evidence to see if we should do a detailed investigation of the complaint. However, having considered the evidence carefully we have not seen any signs of service failure. We therefore will not be carrying out a detailed investigation.
3. We recognise that the death of Mr X’s mother was a distressing period for him and we are sorry for any added upset our decision causes.