Following Mr U’s death, staff packed away his belongings while Mrs A was on her way to the hospital
18. Before we decide whether 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 and have not seen any signs something has gone wrong.
19. Mrs A complains that following Mr U’s death, when she returned to his room she found it had been emptied of his personal belongings. Mrs A said this was very insensitive and upsetting, as this was a personal thing she should have been given the opportunity to do. Mrs A says the staff were aware she was five minutes away and should have been more sensitive.
20. The Trust said dealing with deceased patients’ property is the responsibility of the nursing staff. The property should be bagged and sent to the bereavement office. The Trust explained this policy is in place to reduce the burden on relatives and to reduce the risk of fraud, theft of or dispute over a patient’s property. It said the bereavement office releases property once the next of kin has been verified.
21. The guidance for staff says to pack personal property, showing consideration for the feelings of those receiving it and in line with local policy.
22. Our adviser said the Trust packs a patient’s property for two reasons. Firstly, it is considered helpful and is part of the care-after-death process to tidy a patient’s property. Secondly, there can be disputes over a patient’s property, and the Trust cannot presume who is the next of kin.
23. We can see in the medical records the Trust’s ‘Care after Death’ document, which says property and patient records are to be transferred directly to the bereavement liaison office. In our view, the Trust acted in line with the guidance for staff and local policy (‘Care after Death’) when packing away Mr U’s belongings.
24. We understand how upsetting it was for Mrs A to return after Mr U’s death to find his belongings had been packed away and moved. The Trust apologised to Mrs A that it did not clearly explain the policy, including the reasons why she was unable to pack away Mr U’s belongings herself.
25. The Trust also acknowledged staff could have waited for Mrs A to return and say her final goodbyes to Mr U before packing away his belongings. The Trust apologised to Mrs A and said staff should have been more compassionate and sympathetic.
26. Based on what we have seen, we think there is no sign the Trust did not act in line with the guidance for staff by packing Mr U’s belongings away.
The Trust did not pick up on or treat Mr U’s deterioration when it should have done
27. Mrs A said Mr U was unwell from 24 August 2019. Mrs A said Mr U deteriorated rapidly from this date, and the Trust should have picked up on this deterioration and acted on it sooner. Mrs A said the Trust should have performed tests to determine the cause of his deterioration.
28. On 25 August, Mr U had a national early warning score (NEWS2) score of six. NEWS2 is a tool used to detect clinical deterioration. A NEWS2 of five or above requires an urgent review by the doctor. A score of seven or above is the highest escalation and requires an assessment by the critical care team.
29. The Trust said it followed the NEWS2 escalation and the on-call doctor reviewed Mr U. A respiratory consultant also assessed Mr U and, after discussions with Mr U and his family, the consultant prescribed antibiotics and fluids. The Trust acknowledged a raised NEWS2 earlier that day had been missed but said it would not have changed Mr U’s care or treatment.
30. The GMC’s ‘Good Medical Practice’ says if doctors assess, diagnose or treat patients, they must promptly provide or arrange suitable advice, investigations or treatment where necessary.
31. Our adviser says Mr U’s deterioration began on 25 August, when his NEWS2 was six. We can see this deterioration was picked up on, as the weekend on-call doctor reviewed Mr U at 10.14am and immediately spoke with Mrs A regarding his deterioration.
32. Different doctors reviewed Mr U again at 12pm and 6pm, and both discussed Mr U’s condition with Mrs A. The Trust performed a physical examination and started Mr U on antibiotics and IV fluids.
33. On 26 August, we can see a junior doctor and registrar saw Mr U and reviewed his blood test results. We can see documented long discussions regarding Mr U’s condition. Based on what we have seen, we consider the Trust acted in line with the GMC's ‘Good Medical Practice’, as it picked up and acted on Mr U’s deterioration promptly.
34. In our view, Mr U began to deteriorate on 25 August. The Trust documented it had spoken with Mr U at 10.14am and discussed his treatment plan. The Trust documented Mr U had a severe non-reversible disease, COPD, and it did not believe taking blood and doing investigations would change the outcome in the long term. The Trust discussed focusing on Mr U’s comfort and dignity, and it documented Mr U’s agreement.
35. We understand this was a very distressing time for Mrs A. We can see Mr U began to deteriorate on 25 August. We have seen no signs the Trust did not act on this to quickly arrange suitable treatment. Based on this, we have seen no signs the Trust did not act in line with the GMC’s ‘Good Medical Practice’ in picking up on and treating Mr U’s deterioration.
The Trust did not inform Mrs A of Mr U’s deterioration
36. Mrs A said a doctor did not discuss Mr U’s condition with her until 27 August. Mrs A said Mr U began to deteriorate on 24 August and, considering his condition, it is unacceptable this was not discussed with her until 27 August. Mrs A said she was not made aware of how critical Mr U’s condition was on the day of his death.
37. In the Trust’s response, it apologised to Mrs A for not making her aware of Mr U’s condition. The Trust also apologised for Mrs A not feeling listened to on the ward.
38. The GMC’s ‘Good Medical Practice’ says doctors must be considerate to those close to the patient and be sensitive and responsive in giving them information and support.
39. Our adviser says Mr U had been medically stable until 25 August, when he had a NEWS2 of six. The weekend doctor reviewed Mr U on 25 August, and it is documented he immediately informed Mrs A of Mr U’s deterioration. This appears to be in keeping with the GMC ‘Good Medical Practice’.
40. We can see the Trust documented speaking to Mrs A about Mr U’s deterioration at 10.14am (by phone) and 12pm (in person) on 25 August. It appears this conversation focused on Mr U’s comfort and symptom management.
41. The Trust documented speaking to Mrs A in person at 3pm on 26 August. The notes suggest the Trust explained how unwell Mr U was and again said the focus was on symptom management.
42. We understand the Trust contacted Mrs A by phone at approximately 9am on 27 August to tell her how poorly Mr U was and that she needed to come to the ward. At 10.45am, we understand the consultant spoke to Mrs A and the family in person. The notes suggest the Trust explained Mr U’s deterioration at that time.
43. The consultant noted he told Mrs A that Mr U’s condition was critical and that he could die if the interventions did not work. The consultant said he felt he had highlighted during the discussion how critical Mr U’s condition was and that the family understood this.
44. We understand Mrs A and the Trust have different views of what occurred, and we have conflicting evidence here. We appreciate Mrs A has said she was not told of Mr U’s condition until 27 August. The medical records are a clinician’s account of what happened and of what they told the family.
45. Due to the conflicting evidence, it is difficult for us to reach a view on what was said and, just as importantly, what was understood during these conversations.
46. We have considered the various conversations that appear to have occurred and the level of detail in the Trust’s account of what was said. Considering this, we are persuaded those conversations between the Trust and Mrs A did happen and the Trust did share relevant information with Mrs A.
47. Based on this, we have found no signs the Trust did not follow the guidance in keeping Mrs A informed of Mr U’s deterioration. We understand Mrs A will be disappointed by this, and we hope our decision does not cause her further distress.
On 27 August 2019, the consultant told Mrs A oxycodone and lansoprazole caused the bleed
48. Mrs A said the consultant told her Mr U had a bowel bleed caused by medication (oxycodone and lansoprazole) and the Trust was attempting to reverse this. Mrs A said this contributed to Mr U’s death.
49. In the Trust’s response, it said Mr U had developed renal failure. Due to this, the effects of some of his medications may have increased, although the doses had not changed. The Trust said the consultant told Mrs A that Mr U was drowsy and was given flumazenil and naloxone to reverse the effects of oxycodone and lansoprazole, respectively. The Trust said Mr U became more alert after receiving these two medications.
50. The BNF says oxycodone and lansoprazole are not contraindicated (that is, unsuitable for the case in question) and can be given together. Oxycodone and lansoprazole do not cause gastrointestinal (GI) bleeds (bleeding in the digestive tract).
51. The Trust said it documented on 27 August that the GI bleed was related to frailty, prolonged hospital stays and numerous comorbidities.
52. We can see the Trust spoke to Mrs A on 27 August and told her it was worried about a GI bleed. Our adviser says lansoprazole is the treatment given for GI bleeds, and oxycodone is an opioid painkiller. We have seen no sign the Trust did not act in line with the guidance by prescribing these medications.
53. Our principles says public bodies should communicate effectively, using clear language.
54. We have been provided with conflicting accounts of the conversation on 27 August. Mrs A said the consultant told her oxycodone and lansoprazole caused the bleed. The consultant has documented he told Mrs A they suspected a GI bleed and that oxycodone and lansoprazole had made Mr U drowsy. We recognise Mrs A does not agree with this version of events.
55. On the balance, we think the Trust acted in line with our principles. Given what the BNF says about oxycodone and lansoprazole, and the Trust’s records, we have seen nothing to suggest the Trust would have told Mrs A these drugs were responsible for the GI bleed.
56. We understand this will be upsetting for Mrs A, but we hope the assurance that oxycodone and lansoprazole do not cause GI bleeds will be of some comfort. From what we have seen, there are no signs of a failure in the Trust’s communications with Mrs A about the effects of oxycodone and lansoprazole.
A post-mortem was not conducted after his death
57. Mrs A said she requested a post-mortem for Mr U four times and the consultant dismissed these requests. Mrs A said she expressed a strong desire for a post-mortem, and the consultant decided not to have one, as he said Mr U would not have wanted one.
58. The Trust said the consultant spoke with Mrs A on 30 August 2019 about a post-mortem. The consultant documented that Mrs A said a post-mortem was not necessary and that, if she had continued to request one, the consultant would have arranged for one. The Trust acknowledges Mrs A disagrees with this version of events.
59. The medical certificates guidance says the law requires that where a doctor can issue a medical certificate of cause of death, they should do so.
60. Our adviser tells us there are two types of post-mortems. One is via a referral to the coroner if, for example, the doctors are unable to give a cause of death or the patient died after an operation. The coroner then decides whether a post-mortem is required.
61. The other is a hospital post-mortem. This will be performed in cases where the hospital thinks there might be something to learn from the post-mortem, and this requires consent from the next of kin. More information about this can be found on the NHS website.
62. In this case, it appears Mrs A was asking for a post-mortem as she did not agree with the cause of death. Our adviser tells us this does not meet the criteria for a post-mortem. If none of the criteria has been met, the hospital team will issue a death certificate in line with guidance.
63. Mrs A said she is concerned no reference was made to the role medication (oxycodone and lansoprazole) played in Mr U’s death and she wanted a post-mortem. As explained in paragraphs 50 and 56, oxycodone and lansoprazole do not cause GI bleeds.
64. We can see during a phone call with Mrs A, after Mr U had sadly died, the consultant documented Mr U’s cause of death. The consultant noted he told Mrs A the cause of death was a GI bleed and a background of numerous comorbidities. They documented that Mrs A accepted this.
65. We acknowledge Mrs A’s version of events differs from that of the Trust. It is difficult for us to reach a view on what occurred based on the conflicting evidence we have available.
66. What we can say is we have seen no signs the Trust did not act in line with the information on the NHS website by not completing a post-mortem. The medical certificates guidance says to issue a death certificate if doctors can do so. As the cause of Mr U’s death was known, the death certificate was completed in line with the guidance, and there was no need for a post-mortem to complete it.
Mr U was prescribed a lower dose of 2.5mg of oxycodone on discharge when he was taking 5mg while at the Trust
67. Mrs A says that on Mr U’s discharge from the Trust on 15 July 2019, he was only prescribed 2.5mg of oxycodone instead of 5mg. Mrs A said that while he was admitted to the Trust this had been increased to 5mg. Mrs A is concerned the lower dose of 2.5mg was not sufficient when Mr U was at home.
68. The Trust says it is unable to explain this, as 2.5mg is not the recommendation on Mr U’s discharge note.
69. The BNF says oxycodone can be prescribed initially at 5mg every four to six hours, with the dose increased if necessary, according to the pain severity. It says some patients may require higher doses than the maximum daily dose, up to a maximum of 400mg per day.
70. We can see on the discharge note dated 15 July 2019 the Trust prescribed Mr U a 5mg oxycodone tablet every 12 hours. It also prescribed an additional 2.5mg to 5mg oxycodone oral liquid as required, with a dosage interval of two hours.
71. We understand Mrs A has said Mr U was only prescribed 2.5mg to be taken at home. Looking at the evidence available, we think it is likely Mr U was prescribed 5mg with a further dose of 2.5mg to 5mg as required, rather than just 2.5mg. Our adviser says this dosage is in line with BNF dosage instructions.
72. Based on what we have seen, we have seen no signs the Trust only prescribed 2.5mg for Mr U to take at home. As explained above, Mr U was prescribed a 5mg oxycodone tablet twice daily, with additional 2.5mg to 5mg oral liquid when required. In our view, the Trust acted in line with the BNF, and there is no sign anything went wrong here.
On 27 August 2019, the consultant performed end-of-life interventions against family wishes
73. Mrs A said Mr U did not want any end-of-life interventions and that these wishes were not respected. Mrs A said the Trust performed a blood transfusion on 27 August 2019 against the family’s wishes and gave flumazenil and naloxone to reverse the effects of an upper GI bleed.
74. The Trust said that during a conversation with Mrs A and the family on 27 August 2019, Mr U’s family asked the Trust to do everything possible. The consultant said Mr U would need a blood transfusion, IV antibiotics and fluids, and Mr U’s family agreed for this to take place.
75. Mrs A said the consultant told her daughter he would wait for Mrs A to arrive at the hospital before beginning the blood transfusion. Mrs A said he did not do this, and the transfusion had begun before she arrived despite clear instructions being given that no intervention should take place. Mrs A said the family had not told the consultant they wanted everything done, as he had documented in the medical records.
76. As discussed, flumazenil and naloxone were given to reverse the effects of oxycodone and lansoprazole, which had made Mr U drowsy. Flumazenil and naloxone were not given in relation to Mr U’s GI bleed or any other medical condition. These medications were not given to preserve Mr U’s life but to stop drowsiness. For this reason, we will not be looking at these medications as an end-of-life intervention.
77. We can see the consultant completed a transfusion authorisation and checklist form. This form documented a request for two units of blood. The chart for recording pre-, during- and post-transfusion observations was not completed.
78. We have seen no sign this blood transfusion took place. Our adviser confirms there is documentation about a blood transfusion being requested but Mr U sadly died before this could be done.
79. In the Trust’s complaint response, it said there is no reference to a blood transfusion being in progress and the documentation only relates to a transfusion being requested. In a phone call with Mrs A after Mr U’s death the consultant said they had tried fluids and antibiotics, and Mr U was due to have a blood transfusion.
80. We have received conflicting information from Mrs A and the Trust about this conversation. Mrs A said she did not want any end-of-life interventions to take place, but the consultant documented that she had agreed for these to happen. We do not have enough evidence to be able to form a view on what was said between Mrs A and the Trust during this exchange.
81. Mrs A said a blood transfusion had taken place against her wishes as an end-of-life intervention. We can see from the evidence a blood transfusion was requested, but we have seen no signs it took place.
82. Based on this information, we will not investigate further as we have seen no signs the end-of-life interventions Mrs A referred to took place. We recognise Mrs A does not agree with this version of events, and we understand how disappointing this will be. It is not our intention to cause Mrs A any further distress. We understand how much Mr U’s death has affected her.