12. Before we decide if we should carry out 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. If we can see signs the organisation has got something wrong and that this had a negative impact, we then look at what steps the organisation has taken to put things right.
Going to the toilet unaccompanied and without oxygen
13. Ms A says staff should not have allowed her father to go to the toilet unaccompanied and without his oxygen. In its response to her complaint, the Trust says Mr B was able to mobilise (move) independently and staff do not normally accompany independent patients to the bathroom.
14. Mr B’s medical records show he was able to mobilise independently. Physiotherapists had seen him several times and encouraged him to walk and remain active around the ward. On the day of Mr B’s death, the physiotherapist had assessed him at 11.30am and noted he was independently mobile with a stick.
15. NMC’s guidance says staff should ‘treat people as individuals and uphold their dignity’. Our adviser says privacy and dignity are given to patients for things like going to the toilet, especially if they can mobilise independently. The physiotherapists had encouraged Mr B to mobilise around the ward as much as he could. We cannot see any reason why staff should have accompanied him when he needed to use the toilet, especially as he was independently mobile.
16. In regard to the oxygen, we can see Mr B had difficulty breathing and COPD. NICE guidance says oxygen saturations between 88% and 92% must be maintained for COPD patients. The information recorded in Mr B’s medical records note these levels were maintained.
17. On the day of Mr B’s death, the physiotherapist saw him at 11.30am and noted, ‘20 mins [minutes] following activity patient sats [saturations] 84% so was put on 02 therapy [given extra oxygen].’ While 84% is slightly below the 88% limit, our adviser says it is common for COPD patients’ oxygen levels to fall if they exert themselves. When this happens, they need to pace themselves and rest until their breathing returns to normal. We see no signs Mr B had any further drops in oxygen levels which would have required him to take his oxygen with him to go to the toilet that afternoon.
18. We appreciate Ms A’s concerns that someone should have been with her father when he needed to go to the toilet. We understand how upsetting it is for her to know he died alone in the bathroom. From the information we have seen, there are no signs that someone should have accompanied Mr B to the bathroom or that he needed to take the oxygen with him.
Communication about DNACPR
19. Ms A says the Trust put a DNACPR order in place for her father without discussing this with her first. She says her father was profoundly deaf and she had lasting power of attorney for his affairs.
20. On the morning after Mr B’s admittance to hospital, a doctor noted in his records:
Attempted to discuss DNAR/TEP [Treatment Escalation Plan – a discussion of the treatment people want if they become very sick while in hospital] with patient. Used whiteboard as he is hard of hearing. Asked patient what his thoughts are on resuscitation and what he would like us to do if his heart stopped. He said ‘restart it’… given patient’s advanced age CPR would be unlikely to be successful and is very traumatic. I am unsure if he understood this.
Later that morning, the consultant reviewed Mr B and noted, ‘DNAR discussed with patient... he wishes to update [Ms A] about it.’
21. The consultant then completed the DNACPR form and noted Mr B agreed with the decision.
22. The first discussion about DNACPR suggests Mr B did not really understand what the doctor was saying to him. However, the second discussion with the consultant suggests Mr B did understand. We know Mr B was profoundly deaf and used a whiteboard to communicate with staff so this may have added to the difficulty in explaining and understanding decisions. But there are no signs Mr B lacked the mental capacity to make these decisions.
23. GMC guidance on CPR says:
Decisions made in advance about whether CPR should be attempted must be based on the circumstances of the individual patient and take into account their wishes and preferences… it should also involve discussions with those close to the patient.
24. It appears the Trust did not communicate this decision with Ms A as it should have done.
25. Our adviser says the final decision on a DNACPR order lies with the medical team. Even if the staff had contacted Ms A to discuss the decision and she had disagreed with it, the medical team’s final decision would still stand. Mr B was an elderly patient with COPD and our adviser agrees there was no reasonable chance of survival following CPR.
26. While we are satisfied the lack of communication did not have a clinical impact on Mr B, we recognise the emotional impact it has had on Ms A. She says had the Trust discussed the DNACPR decision with her first, she would have been better informed and could have prepared herself for the event. Better communication would have also met her father’s wish for her to be informed.
27. In its responses to Ms A’s complaint, the Trust explains in normal circumstances, when visiting is permitted, there would be a face-to-face discussion with the patient’s family. As Mr B’s admission was during the COVID-19 pandemic, there were issues concerning effective and timely communication. The Trust recognises the importance of effective communication and apologises this was not Ms A’s experience.
28. We can see the Trust accepts that medical staff should have contacted Ms A about the DNACPR order. It also gives an account of the situation at the time to provide an explanation of how communication was affected by COVID-19. We think this explanation is reasonable and there are no signs of systemic (system-wide) issues. The communication issues were more likely to be associated with the situation at that time. The Trust also apologises that it did not action Mr B’s request and contact Ms A.
29. Taking this into consideration, we are satisfied the Trust has already taken steps to put things right. This is in line with our Principles of Remedy, which say ‘an appropriate range of remedies will include: an apology, explanation and acknowledgement of responsibility’. We consider the Trust’s steps to put things right are appropriate and we can add nothing further to this aspect of Ms A’s complaint.
Communication about Mr B’s death
30. Ms A says the Trust lied to her about the circumstances surrounding her father’s death. She says the Trust told her that her father had died peacefully and she only found out he had died on the toilet when the medical examiner called her. In its response to her complaint, the Trust explains that staff make a judgement call on how much detail is required when communicating with the patient’s family. Staff did not share with her the descriptive information about her father being on the toilet to protect his dignity and his relatives’ memories of him.
31. GMC guidance on good medical practice in communication says doctors should be considerate to a patient’s family. Similarly, NMC guidance on communication says nurses should be respectful, kind, compassionate and honest. Our adviser says the staff member who found Mr B made a clinical observation he had died peacefully as there were no signs to suggest otherwise (Mr B remained seated and there were no visible signs of distress or suffering). We can see the staff member made a judgement call not to share the details of Mr B being found on the toilet when he died, and we consider this is in line with GMC and NMC guidance on effective communication.
32. We empathise with Ms A and can appreciate how distressing it must have been for her when she later found out where her father died. We appreciate, with the benefit of hindsight, she wished the Trust had shared this information with her at the time. We see no signs the Trust lied to her as the staff member who found Mr B made a clinical judgement about her father dying peacefully. We appreciate the Trust did not share the specific details about Mr B being on the toilet but we consider this was done in the best interests of all involved and in line with guidance on effective communication.
33. We are very sorry to hear the circumstances of Ms A’s complaint and can see how distressing the loss of her father has been for her. We appreciate this was a difficult time for Ms A and we thank her for sharing details of her experience with us. We hope this statement provides reassurance we have considered the information carefully.