Issue one: concerns about the delay in Mr U being seen
16. Mrs U explains on 8 January 2021 an ambulance took Mr U to the Trust’s A&E department with complaints of breathing difficulties. She complains despite him being triaged as a level three priority there was a delay of over eight hours in him being seen by a doctor.
17. We are sorry to hear about these concerns and appreciate it must have been difficult for Mr U to wait a long time with his breathing difficulties. It must also have caused distress to Mrs U.
18. The Trust has acknowledged failings and that there was a delay in Mr U being seen. It says in its investigation report dated 26 July 2021:
‘He was ascribed triage category 3 which is deemed “urgent” and should ideally be seen within one hour according to the scale used. While this is the standard to which we aspire, due to the increase in attendance on this day it was difficult to meet on this occasion. We do aim to see patients according to their clinical priority and work is ongoing to try and make improvements in our timeliness of seeing patients supporting with increase in our medical workforce.
The wait for Mr U to be seen was much longer than we would wish or intend, and we can only apologise for that’.
19. We find that the Trust acted in line with our Principles for Remedy, which say ‘public bodies should promptly identify and acknowledge maladministration and poor service and apologise for them’.
20. We have considered whether this was an appropriate outcome given how Mrs U says the events affected her. She says the delays led to her suffering distress and upset and we accept this.
21. Our Severity of Injustice Scale helps us to consider the appropriate remedy based on the impact suffered. We think the distress Mrs U experienced falls within level one of the scale. The scale says for such cases we will usually consider an apology to be an appropriate step to make up for the distress. Based on this, we think the Trust’s apology is an appropriate remedy for the distress Mrs U suffered.
22. Mrs U also says the delays led to her husband’s deterioration and death. She says this was because, as a sufferer of MND, he was at risk of hypercapnia (raised carbon dioxide (CO2) levels). In response to this concern the Trust says:
‘In Mr U’s case his oxygen levels both in the ambulance before arrival and in the department were 93-94% on room air and he was fully alert with a respiratory rate of 18 which is within the normal rates. Though no blood gas was completed initially to confirm, these findings would make it unlikely he was retaining CO2.’
23. The records support the Trust’s account, specifically that Mr U arrived in A&E at 2.08am on 8 January 2021 and was triaged immediately as a triage category three. The adviser explains the Manchester Triage System guidance, which is the scale used by the Trust, recommends that a clinician should review patients assigned a priority of three within one hour.
24. Mr U was assessed by an advanced nurse practitioner (ANP) at 8.20am, over six hours after he arrived in A&E.
25. The adviser explains that at the time of the events, A&E departments were under extreme pressure. He says this was because of a combination of increasing patient numbers, reductions in hospital bed availability leading to overcrowding in the A&E department, lack of staff and resources in general and the continuing effects of the COVID-19 pandemic. This account is supported by an insight report conducted by the Royal College of Emergency Medicine.
26. Therefore, we think the Trust’s explanation that the department was exceptionally busy at the time of Mr U’s presentation is reasonable.
27. The records document Mr U’s National Early Warning Score (NEWS). NEWS is a tool developed by the RCP that improves the detection and response to clinical deterioration in patients. Mr U’s NEWS was two on arrival. It then increased to four at 5.20am and reduced progressively to two again at 2.30pm.
28. A score of between zero and four indicates a low to medium clinical risk. A score of five or six is a medium risk. Seven and above indicates a high risk.
29. Therefore, although we accept there was a delay in Mr U being seen by a doctor, his recorded NEWS scores do not show that his condition worsened. There was no sign he was at a medium or high clinical risk of deterioration during his wait to be seen. His NEWS scores remained between two and four. He was also recorded as a two after he had been seen by the ANP at 2.30pm.
30. In relation to the CO2 levels, the adviser explains the records show one entry for a measure of Mr U’s CO2 levels during his time in A&E. This was a blood gas test (a blood test taken to measure oxygen and CO2 levels) at 8.54pm by a member of the on-call team, which shows the CO2 level is normal.
31. The adviser explains raised CO2 levels are commonly associated with patients feeling confused or drowsy and complaining of a headache. We have seen no evidence in the documentation of any of these symptoms or signs during Mr U’s stay before his blood gas test. Based on this, there is no evidence to suggest Mr U suffered with raised CO2 levels during his wait for a doctor’s assessment.
32. We have found no evidence the delays in Mr U being seen led to a deterioration in his health or led to his death. We think the Trust’s actions also make up for the distress Mrs U experienced and therefore we do not uphold this part of the complaint.
Issue two: concerns about Mr U’s observations
33. Mrs U complains the Trust did not observe Mr U appropriately while he waited for a doctor to see him. She complains this led to a deterioration in his health.
34. The Trust says ‘the observations were checked according to the current guidance, a doctor was informed of any areas of concern’. It also says at 2.30am ‘observations were recorded, these included, oxygen saturations, heart rate, blood pressure, pulse, temperature and blood glucose monitoring. The results of these observations indicated a NEWS score of two’.
35. As explained above, we have identified that the professionals took Mr U’s NEWS scores during his wait. These were recorded as between two and four. Our adviser explains using the NEWS tool helps detect and respond to clinical deterioration in adult patients. This is supported by the NHS England guidance ‘National Early Warning Score (NEWS)’.
36. We have seen no evidence Mr U did not receive the appropriate observations.
37. The RCP guidance says a score of between one and four means monitoring should take place at a minimum frequency of every four to six hours. The records show Mr U’s observations took place at 2.30am, 5.20am, 6.40am, 7.35am and 10.38am. This frequency of observations is in line with the RCP guidance.
38. Based on this, we find no failings, as the evidence suggests Mr U received the appropriate observations during his wait in A&E.
39. We do not uphold this part of the complaint.
Issue three: concerns about food and drink not being offered
40. Mrs U complains there is no evidence of Mr U being offered food or drink other than a sip of water during his time in hospital.
41. The Trust says ‘we acknowledge Mr U did spend a long time in the department and did not have any food to eat, only sips of water. We can only apologise for this. One of the staff nurses who looked after Mr U states this was mainly due to him being unwell; he was using his Bilevel positive airway pressure (BIPAP) machine to try and improve his condition’.
42. BIPAP is a treatment used to help with breathing.
43. We are sorry to hear about this concern and can appreciate how distressing it must have been for Mrs U to hear that Mr U did not eat during his time in hospital.
44. The records show Mr U was using his BIPAP mask from 5.20pm, which our adviser tells us makes eating and drinking impossible. There is no evidence Mr U was given anything to eat or drink in A&E. The adviser explains there is no evidence of a medical reason for Mr U not to have had anything to eat or drink before he started on BIPAP.
45. Paragraph 109 of the GMC guidance ‘Meeting patient’s nutrition and hydration needs’ says:
‘All patients are entitled to food and drink of adequate quantity and quality and to the help they need to eat and drink. Malnutrition and dehydration can be both a cause and consequence of ill health, so maintaining a healthy level of nutrition and hydration can help to prevent or treat illness and symptoms and improve treatment outcomes for patients. You must keep the nutrition and hydration status of your patients under review. You should be satisfied that nutrition and hydration are being provided in a way that meets your patients’ needs, and that if necessary patients are being given adequate help to enable them to eat and drink’.
46. It was therefore in line with GMC guidance for Mr U to have been offered food and drink before starting BIPAP.
47. Mrs U says this led to Mr U’s deterioration, which we have carefully considered.
48. There is no evidence not eating led to Mr U’s deterioration or death. This is because we can see his deterioration was the result of pneumonia and MND.
49. However, we understand Mrs U and the family felt distress at knowing Mr U did not eat or drink between arriving at A&E and starting BIPAP.
50. We consider the Trust’s decision to apologise is in line with our Principles for Remedy. We think this partially makes up for the distress Mrs U felt. We have made further recommendations below.
51. Based on the evidence we have seen, we partly uphold this part of the complaint.
Issue four: concerns about the family not being kept informed Issue five: concerns about a delay in the Trust inviting the family to the hospital when Mr U deteriorated
52. Mrs U raises concerns the family was not kept informed about Mr U’s deterioration. She also says there was a delay in the Trust inviting the family to the hospital when Mr U’s health got worse. She says this delay meant they arrived after Mr U had died.
53. We have considered these concerns together as the events are connected.
54. The Trust says ‘there was some deterioration in Mr U’s condition at 10.10pm. Even at this point, the staff treating him did not consider his condition was such that his life was imminently threatened. The policy on visitors in the emergency department as it was in January, is extremely regrettable and we apologise wholeheartedly for the fact Mr U’s family was not given the opportunity to spend time with him before what became his final hours’.
55. We understand Mrs U disputes the Trust’s position on the time her husband’s health deteriorated. She says this began some time before 11.00pm.
56. We have reviewed the NICE guidance. Section 1.1, ‘recognising when a person may be in the last days’, says:
‘Assess for changes in signs and symptoms in the person and review any investigation results that have already been reported that may suggest a person is entering the last days of life. These changes include the following:
• signs such as agitation, Cheyne–Stokes breathing [a specific breathing pattern], deterioration in level of consciousness, mottled skin, noisy respiratory secretions and progressive weight loss • symptoms such as increasing fatigue and loss of appetite • functional observations such as changes in communication, deteriorating mobility or performance status, or social withdrawal.’
57. Having carefully reviewed Mr U’s records, we have seen no evidence he suffered with these signs before 11.00pm.
58. The nursing note at 10.10pm says Mr U had a NEWS score of five and the plan was to transfer him to the ventilation ward once this became possible.
59. The observation charts confirm that Mr U’s NEWS scores were stable from 5.20am to 10.10pm. The NEWS score went up to 11 at 11.00pm and the nursing notes document at 12.10am that Mr U had a sudden deterioration in resuscitation when his oxygen saturations dropped and he became unresponsive.
60. In summary, there is no sign Mr U was at the end of his life before 11.00pm when his health got worse. His observation charts and NEWS scores suggest that he was stable before this.
61. Our adviser explains there are no national guidelines that detail when a patient’s family should be contacted if the patient’s health gets worse. However, paragraph 33 of the GMC guidance ‘Domain 3: Communication partnership and teamwork’ says:
‘You must be considerate to those close to the patient and be sensitive and responsive in giving them information and support’.
62. Our adviser also explains in practice professionals attempt to contact the next of kin as soon as is practicably possible but the staff’s first priority is to deliver urgent patient care, which in this case included trying to resuscitate Mr U.
63. We found no evidence of delays in the family being contacted after Mr U got worse or that the Trust did not keep the family informed of Mr U’s worsening health.
64. We therefore do not uphold this part of the complaint.
Issue six: concerns the family was not involved in the DNACPR process
65. Mrs U complains the Trust did not involve or inform the family in decisions it took for Mr U’s DNACPR.
66. The Trust says:
‘When [Mr U’s] condition had deteriorated, a medical decision was taken, at that time, that whilst treatment would continue, if he was to suffer a cardiorespiratory arrest, then at that point, further treatment would be futile. DNAR decisions should be discussed with the patient’s family, if the patient lacks capacity. [Mr U] suffered the dramatic deterioration in his condition (which was not anticipated an hour earlier) there was no time for discussion with his family to take place. This was [a] less than ideal situation for [Mr U’s] family and the Trust can see how this will have caused distress and offers its apologies’.
67. From the records we understand CPR started when Mr U had a cardiac arrest and then stopped on the advice of the medical registrar because it was futile. Therefore, Mr U did not have a formal DNACPR in place at any point.
68. The GMC guidance ‘Discussions about whether to attempt CPR’ says ‘decisions made in advance about whether CPR should be attempted should be based on the circumstances of the individual patient and take into account their wishes and preferences’.
69. The guidance goes on to discuss CPR in the event of an emergency. Paragraph 145 says:
‘Emergencies can arise when there is no time to access all relevant information about the patient’s condition and the likely outcome of CPR; when no previous DNACPR decision is in place; and when it is not possible to find out the patient’s views. In these circumstances, CPR should be attempted, unless, in your clinical judgement, it will not be successful in restarting the patient’s breathing and circulation’.
70. It is good practice to discuss DNACPR options with the patient and family, but given how quickly Mr U deteriorated there was not an opportunity to do this.
71. The Trust acted in line with paragraph 145 of the guidance by attempting the CPR based on clinical judgment.
72. We can appreciate the distress Mrs U says she has suffered by not being involved in the DNACPR decisions.
73. We find no failings. Given it was an emergency there was no time to have such discussions.
74. Paragraph 138 of the GMC guidance says: ‘If, after discussion, you still consider that CPR would not be clinically appropriate, there is no obligation to provide it in the circumstances envisaged’. Therefore, the final decision on whether to attempt CPR is in the patient’s best interests remains with the medical professional.
75. We do not uphold this part of the complaint.
Issue seven: concerns about the delays in the Trust telling Mrs U about Mr U’s cardiac arrest
76. Mrs U says following Mr U’s death she was not given appropriate information. She complains the professionals told her Mr U had died from a cardiac arrest, but the cause of death on his death certificate is pneumonia. She complains she was not told about this on the night of his death.
77. The Trust says:
‘a cardiac arrest means the heart stops beating. All deaths, irrespective of the underlying cause involve a cardiac arrest. A cardiac arrest is not itself a cause of death in this instance. A cardiac arrest cannot be used as a cause of death on a death certificate. Because of the difficulties ascertaining the exact cause of someone’s death, the regulations state the doctor puts the most likely cause of someone’s death, in [Mr U’s] death it was pneumonia’.
78. We have received clinical advice in relation to this.
79. The adviser explains there is no national guidance on what information should be shared with the family following a patient’s death. However, as detailed above, paragraph 33 of the GMC guidance ‘Domain 3: Communication partnership and teamwork’ says professionals ‘should be considerate to those close to the patient and be sensitive and responsive in giving them information and support’.
80. Although we agree the Trust did not provide incorrect information when explaining Mr U had died of cardiac arrest, it was appropriate to be more specific. It would therefore have been in line with the GMC guidance for the Trust to provide specific information about the cause of death.
81. We consider this to have caused Mrs U distress. We have detailed actions for the Trust to take below.