Care and treatment
• Management of pressure sores
17. Mr S complains there was a lack of concern about and care of his mother’s pressure sores, which the district nursing team had been managing in the community, upon admission and while on the ward.
18. From reviewing Mrs S’s medical records with our nursing adviser, we can see in the admission notes that Mrs S had multiple pressure sores to her sacral area, buttocks and right knee. The records show she was in the care of the district nursing team for care and support.
19. The initial adult nursing assessment shows Mrs S was bedbound and required help with nutrition, eating and drinking, and personal hygiene. She was incontinent and using pads, and she was catheterised upon admission. Our nursing adviser explains taking this step helps to protect the skin in the sacral area.
20. As part of this assessment, staff completed a body map showing Mrs S’s pressure sores, conducted a Braden Scale risk assessment, completed a wound assessment document and took clinical photographs of the sores. Additionally, we can see from the nursing notes that the nurses completed the Skin Surface Keep Moving Incontinence Nutrition & Hydration care plan charts, and regularly repositioned Mrs S. They also nursed Mrs S on an airflow mattress throughout the admission.
21. This is in line with NICE CG179 ‘Pressure ulcers: prevention and management’ with regards to the key recommendations for completing risk assessments, skin assessments and regular repositioning to monitor current pressure sores and manage the risk of more pressure sores developing.
22. We consider the medical records show staff managed Mrs S’s pressure sores appropriately in line with the relevant guidance. For this reason, we will not be taking any further action on this part of the complaint.
• Treatment and end-of-life care
23. Mr S complains a consultant disagreed with his view that Mrs S was not at the end of her life and so did not provide her with appropriate treatment.
24. Mr S tells us he spoke with a doctor who disagreed with his opinion that his mother had improved, and when he asked about the likelihood of ongoing improvement, the doctor appeared to be agitated and told him she did not have ‘a crystal ball’. Mr S considers from this interaction the consultant decided his mother’s fate and crushed his optimism about her symptoms. Mr S feels his mother’s care and treatment contributed to her deterioration.
25. In response to the complaint, the Trust advised the clinical decisions made in Mrs S’s care were based on her condition at the time and not because Mr S had challenged its decisions.
26. The Trust explained a plan was in place upon admission to trial treatment for 24 hours, and to then consider a discussion around palliative care if Mrs S did not improve. The consultants who reviewed Mrs S all agreed she was approaching the end of her life. During a review in early July, Mrs S was noted to be unconscious, and there were signs of cardiovascular shutdown. She had been given a significant volume of fluids, but they had not helped.
27. A plan was put in place to continue with fluids and change antibiotics for a chest infection. At this stage of the admission, the impression was that the treatment had not improved Mrs S’s condition. This, along with her frailty, poor physiological condition and other medical problems meant she was unlikely to survive.
28. We have considered this part of the complaint with our geriatrician adviser. We can see from the records that staff quickly identified upon admission that Mrs S was dehydrated and septic. Staff also identified Mrs A was very frail and at high risk of deterioration. This is in line with NG51 ‘Sepsis: recognition, diagnosis and early management’, which explains a structured set of observations should be used to assess people in a face-to-face setting to calculate their level of risk. Clinicians can also use a National Early Warning Score (NEWS) to assess people with suspected sepsis.
29. Mrs S was appropriately assessed as high risk based on her being over the age of 75, her frailness and her multiple underlying co-morbidities. Observations of Mrs S showed that she had a high NEWS and she met some of the moderate and high-risk criteria in NG51. Because of this, a clinician quickly reviewed and assessed Mrs S and ran additional blood tests. Initially, staff treated Mrs S with intravenous (IV) fluids and antibiotics, which is in line with the guidance set out in NG51 for providing antibiotics urgently where someone presents as high risk.
30. Our adviser explains it was appropriate to hold discussions with Mr S about ceilings of care, the risk of deterioration and the risk of dying because Mrs S was so frail and high risk. NG51 outlines the importance of keeping family members updated on diagnosis, treatment options, prognosis and complications. Having these discussions was also in line with the GMC’s Good Medical Practice with regard to communicating effectively, being considerate to those close to the patient, and being sensitive and responsive in giving them information and support.
31. Understandably, these conversations were likely very difficult for Mr S given his mother’s deterioration. It is evident he was passionate about her care and had cared for her successfully for many years.
32. Mr S also raises concerns that a palliative care plan was not arranged when Mrs S was put on the end-of-life pathway.
33. In response to the complaint, the Trust explained that when staff reviewed Mrs S in early July 2021 they devised a plan to finish the current bag of fluids, give the last dose of antibiotics and stop all blood tests. The records show staff shared this plan with Mr S, and made him aware that Mrs S was now approaching the end of her life.
34. The medical team planned to review Mrs S the next day to ensure this plan was still appropriate, and transferred Mrs S to another ward in the evening. Sadly, she deteriorated quickly before the medical team could provide palliative care.
35. The medical records show Mrs S was on a ‘care of the dying’ patient document. This suggests staff thought upon admission Mrs S was approaching the end of life. The plan was to first trial active treatment to see whether Mrs S responded before deciding if it was in her best interests to continue.
36. Sadly, shortly after the medical team decided to stop active treatment, Mrs S deteriorated. The records show the palliative care team reviewed Mrs S during her admission and considered referring her for a fast-track discharge to a 24-hour care placement to support her needs. As such, this documentation suggests to us plans were in place for Mrs S’s end-of-life care.
37. The clinical team’s actions were in line with NG31 ‘Care of dying adults in the last days of life’, which explains clinicians should assess any changes in signs and symptoms in the person and review any investigation results suggesting a person is entering the last days of life. At this point, any investigations unlikely to affect care in the last few days of life should be avoided to make sure the patient is comfortable.
38. Additionally, the clinical team should monitor the person’s condition at least every 24 hours and update the care plan accordingly. We can see the clinical team had plans to review the care plan the following day, but sadly Mrs S died before clinical staff could conduct this review.
39. We have not identified any signs of poor end-of-life care, and for this reason we will not be taking any further action on this part of the complaint. Despite this, we recognise what a challenging time this was for Mr S, and we understand he wanted his mother to receive the best possible care available.
• Provision of oxygen and management of the airway
40. Mr S considers the nursing team were not treating Mrs S with oxygen effectively. He says staff left the oxygen mask beyond her reach, and he says this was crucial to her care. In response to the complaint, the Trust stated Mrs S was receiving oxygen and was being nursed in a semi-upright position to help her breathing. The Trust has apologised if there was any misunderstanding based on information provided during conversations with the nurse.
41. We have reviewed this part of the complaint with our geriatric adviser. It is important to note that Mrs S was on long-term oxygen therapy before her admission. The records show the aim for Mrs S’s oxygen saturation (Sp02) was 88-92% because of the risk of hypercapnic respiratory failure (where there are abnormally high carbon dioxide levels in the blood). This target was in line with NG51’s guidance on oxygen saturation levels in patients with sepsis.
42. Mrs S’s Sp02 levels fluctuated slightly throughout her admission and mostly ranged between 88% and 100%. There is only one instance when Mrs S’s Sp02 level dropped to 82%, but this was treated quickly with oxygen.
43. We understand this is in line with the BTS guidelines on oxygen prescribing, which state that oxygen saturation and delivery should be recorded on the patient’s monitoring chart, delivery devices and flow rates should be adjusted to keep the saturation in the target range, and prompt clinical assessment is required if oxygen therapy needs to be initiated or increased due to a falling saturation level.
44. Overall, there are signs Mrs S was receiving oxygen as and when required, and staff kept her oxygen saturation levels within the target range for most of her admission.
45. Mr S also raises concerns that his mother was flat on her back, struggling to breathe. He says he alerted a nurse who told him she had a ‘very poorly patient to see’, and other members of staff heard his pleas for help but ignored him. When a nurse did come to check on Mrs S, she said she was fine and there was nothing to worry about.
46. In response to the complaint, the Trust explained Mrs S had some excess secretions in her chest but was not choking. It accepted how distressing the sound must have been, but assured Mr S his mother was settled and her airway was not blocked. The Trust also explained that staff had positioned Mrs S to take pressure off her sore areas, oxygen was provided and she appeared to be comfortable.
47. As NG31 explains, patients in the last days of life may breathe noisily and produce secretions. Healthcare professionals should establish whether this is affecting the dying patient or those important to them, and provide reassurance it is unlikely to cause discomfort despite the noise being distressing.
48. As we have outlined above, there are signs Mrs S’s oxygen treatment was appropriate throughout her admission. This suggests to us her airways were not blocked at any time during her admission. Mrs S’s notes also show she was repositioned regularly in line with CG179, but often changed position herself. As our nursing adviser explained, there is no direct link between Mrs S’s positioning and her period of low oxygen saturation.
49. In line with NG31, reassurance could have been given to Mr S about his mother’s noisy breathing, and we can see the Trust accepted this in its response to the complaint. We consider this is a shortcoming in communication rather than a service failure, so in our view the Trust has responded to this part of the complaint appropriately, in line with our Principles of Good Complaint Handling. For this reason, we will not be taking any further action on this part of the complaint.
• Communication with the district nursing team and mental health team
50. We have reviewed this part of the complaint with our geriatric adviser. We have reviewed the daily records from Mrs S’s care, and we can see there was considerable communication between the teams involved. The adviser explained there was more communication than you would normally expect for an acute admission, especially with the community team who would normally only become involved at the time of discharge planning or for obtaining background information.
51. The community team shared information with the Trust about Mrs S’s background and their concerns, and the mental health team also shared information and offered support for Mr S. Additionally, the palliative care team reviewed Mrs S to prescribe anticipatory medicine to ensure she was comfortable.
52. There are signs this level of communication was appropriate and in line with the GMC’s Good Medical Practice guidance with regards to quickly providing or arranging suitable advice where necessary and referring patients to other practitioners when needed. This also shows a collaborative approach to Mrs S’s care, with examples of effective communication, in line with the GMC’s Good Medical Practice guidance.
• Prescription of midazolam and management of schizophrenia
53. Mr S considers Mrs S’s schizophrenia was overlooked. He says this played a big part in her symptoms, but two consultants ignored it. He says the mental health team were not informed of the admission or involved in her care. Mr S tells us staff stopped giving Mrs S olanzapine, and told him she would be given midazolam if she became agitated.
54. The Trust explained staff prescribed midazolam to relieve Mrs S’s anxiety and agitation while she had difficulty swallowing tablets. It also stated midazolam is used to settle patients who are approaching the end of their life.
55. We sought advice from our geriatrician adviser when reviewing this part of the complaint. Before admission, we understand Mrs S had been eating and drinking less. She was unable to take oral medication effectively, including olanzapine. In this scenario, we understand it would be appropriate to prescribe an alternative medication that can be injected.
56. There are signs these decisions were in line with NG31. As NG71 explains, where it is recognised a patient is at the end of life, their medications should be reviewed, and those not providing any symptomatic benefit or possibly causing harm should not be given. The guidance says a trial of benzodiazepine medication can be used to manage anxiety and agitation in patients at the end of life. According to the British National Formulary, midazolam falls into this category.
57. The purpose of prescribing midazolam was to relieve anxiety and agitation, and was appropriate in this case as the benefits of the medication far outweighed any risks of taking it. Our adviser has also confirmed there is a small risk of respiratory depression associated with midazolam, but this is a caution rather than a contraindication, and therefore it would not be inappropriate to prescribe midazolam despite Mrs S’s medical history.
58. Our adviser also believes there are no signs the mental health team should have given its input, as the focus was on treating the presenting issue of infection. But the records show the psychiatric liaison team and Mrs S’s community psychiatric nurse were aware of both Mrs S’s admission and symptoms. This shows a collaborative approach to Mrs S’s care, with examples of effective communication, in line with the GMC’s Good Medical Practice guidance.
59. Based on the evidence we have considered, we have not identified any signs of a service failure in relation to the prescription of midazolam or the management of Mrs S’s mental health.
• Misuse of a tourniquet and congealed substance around Mrs S’s nose
60. We will address these two parts of the complaint together.
61. Mr S tells us he noticed his mother’s arm had swollen ‘like a balloon’. When he raised this with staff, they discovered a tourniquet tightly wrapped around her upper arm. He says the tourniquet was removed and thrown onto the table, and no further action was taken.
62. In response to the complaint, the Trust explained neither Mrs S’s medical records nor the Trust’s electronic reporting system contain any notes about the tourniquet. The Trust stated an electronic incident form should be submitted if a tourniquet is left in place after a blood sample has been taken. The Trust apologised Mr S’s concerns were not reported and advised it would feed this back to the team.
63. We have reviewed Mrs S’s medical records and do not see any evidence of this incident being recorded.
64. Similarly, Mr S says he visited his mother on 5 July 2021 and had to clean a residue from around her nose that looked like Fortisip. He says there was a substantial amount around her nostrils, which could have proved to be significantly dangerous.
65. In response to the complaint, the Trust explained the records show Mrs S was receiving regular mouth care consisting of a solution on a sponge to ensure her lips and mouth were kept moist. It stated there is no entry in her records to suggest she had been given anything like Fortisip to drink that may have caused these symptoms.
66. We have reviewed Mrs S’s medical records and nursing notes and find signs regular mouth care was performed. This is in line with the NMC’s Code of Practice with regards to delivering the fundamentals of care effectively.
67. We have also reviewed the prescription charts. While Fortisip was prescribed, the notes indicate it was not given during the admission. This was likely because of Mrs S’s level of consciousness and the risk of aspiration, which is documented throughout the consultant’s entries in the records.
68. Having looked through the medical records, we see no signs that an incident such as the one described by Mr S were recorded.
69. We do not dispute Mr S’s recollection of events, and we recognise these were very distressing events for Mr S, which caused him concern about the impact this may have had on Mrs S and her care.
70. Unfortunately, we were not present at the time to know what happened, and we accept a tourniquet could have been left around Mrs S’s arm, and there may have been a build-up of some sort around Mrs S’s nostrils.
71. We have no independent supporting evidence indicating there was a service failure. But, in response to the complaint, we can see the Trust apologised staff did not report Mr S’s concerns, and it has assured Mr S it will report this to the team. The Trust also reviewed Mrs S’s mouth care and whether staff gave her Fortisip during the admission.
72. We consider the Trust’s actions to be in line with the Parliamentary and Health Service Ombudsman’s Principles of Good Complaint Handling, with specific regard to being open and accountable, acting fairly and proportionately, and seeking continuous improvement. For this reason, we will not be taking any further action on this part of the complaint.
Communication
• Staff saying they would contact the police to remove Mr S from the ward
73. Mr S complains about the attitude of various members of staff who were caring for Mrs S. Mr S also recalls overhearing staff saying they would call the police about his behaviour. He tells us most staff were cold and abrupt with him and did not show any sympathy. Mr S says he was afraid to raise concerns about his mother’s care, as he feared he would be reported to security.
74. In the complaint responses, the Trust has reassured Mr S no judgement was made about Mrs S’s condition when she arrived at hospital. The care and treatment plan was based on her needs at the time, and it was clear to all involved Mr S had been her main carer for several years and was dedicated to her health and well-being.
75. The Trust explained security are often called to visit wards when staff feel they are unable to manage a patient or family member’s behaviour. The Trust has a zero-tolerance approach to physical and verbal aggression towards staff. The Trust also accepts staff should not use security as a threat but emphasises security are there to protect staff and visitors.
76. The deputy ward matron has apologised Mr S felt she was abrupt and rude. The clinical team involved in Mrs S’s care has also apologised Mr S did not feel their responses were caring and compassionate. The medical and nursing teams were aware of the many years of care and devotion Mr S had given his mother and knew this was a difficult time for him. The Trust has explained its aim was to provide him with honest and accurate information to allow him to come to terms with the severity of Mrs S’s condition. The Trust also explained staff felt Mr S responded to them angrily and aggressively, which made difficult conversations more challenging.
77. The NHS takes a zero-tolerance approach to any forms of discrimination, bullying or violence, and criticises inappropriate behaviour against its staff (NHS People Promise 2021).
78. With regards to staff attitudes, we recognise the ways in which people say things are open to interpretation, so each person involved in the same conversation can come away with a different perception of its contents and what happened. One person’s perception of what someone said does not invalidate another person’s opposing perception of the same comment.
79. We do not dispute Mr S’s recollection of these comments, and we recognise how distressing it must have been to be spoken to in this way at what was such a difficult time for him. Unfortunately, we were not present at the time to independently know what, and how, things were said. But we do accept comments may have been made in a manner or tone Mr S perceived as cold and abrupt.
80. We have no independent supporting evidence suggesting there was a service failure. But, in response to the complaint, we can see the Trust has provided apologies from the staff involved in caring for Mrs S who had interacted with Mr S. This shows us the Trust shared Mr S’s complaint with the staff involved, so they could reflect on their experience. We consider this to be in line with our principles, with specific regard to being open and accountable, and seeking continuous improvement.
81. With regards to staff warning Mr S that they would call security or the police, the Trust has accepted that staff should not use security as a threat. But, taking the NHS People Promise into consideration, we consider it appropriate to advise Mr S he may be removed from premises if his behaviour makes staff concerned for their safety. For this reason, we will not be taking any further action on this part of the complaint.
• No involvement of Mr S in decision-making
82. The GMC’s Good Medical Practice guidance states doctors must be considerate to those close to the patient and be sensitive and responsive in giving them information and support. One of the key principles of the GMC’s guidance on decision-making and consent is that the choice of treatment or care for patients who lack capacity must be of overall benefit to them, and decisions should be made in consultation with those who are close to them. Doctors should consider the views of those close to the patient about what the patient would want and aim to agree with them.
83. The Trust’s responses to the complaint detail some of the meetings and interactions Mr S had with the staff involved in Mrs S’s care, including where staff informed Mr S of the plan for his mother’s care. In our view, the medical records show Mr S was involved in decisions made about his mother’s care and that he had regular communication with the team caring for his mother.
84. We have identified the following entries within the records that show this:
• 3 July, 10.35am, 11.42am – discussions with Mr S regarding Mrs S’s history over the previous week to understand deterioration. Mr S advised he wanted the team to do the bare minimum and discharge Mrs S • 3 July, 7.35pm – discussion with Mr S about Mrs S’s presentation and current situation. Mr S was aware she was significantly unwell. Reassured about treatment plan, and it is noted he was happy with the management plan. Mr S was asked if he would like to be updated overnight if Mrs S deteriorated but advised he did not due to anxiety of waiting for a phone call and risk of driving dangerously if bad news was told over the phone • 3 July, 9pm – Mr S called to inform staff he would like to be informed if there is a change or deterioration in Mrs S’s treatment or presentation • 4 July, 11.30am – phone call from Mr S regarding management of Mrs S’s pressure sores • 4 July, 3.44pm – discussion with Mr S providing an update on Mrs S’s condition and likely prognosis. Explained the treatment plan. It is noted Mr S agreed with this • [X] July, 11.24am – call from Mr S. He was updated on Mrs S’s treatment and ongoing deterioration. He asked for treatment to continue as he felt she could improve. Mr S was advised two consultants had agreed on the same plan and treatment would now stop.
85. In conclusion, we consider there are signs staff kept Mr S updated about Mrs S’s treatment plans and her condition. There are signs staff considered his views when making decisions, and the relevant consultants explained these decisions to him. This is in line with the GMC’s Good Medical Practice guidance, and its guidance on decision-making and consent. For these reasons, we have not identified any signs of service failure, and will not be taking any further action on this part of the complaint.
• Staff not contacting Mr S in time to be present when Mrs S died
86. Mr S says staff did not call him in time to be with Mrs S when she died. In response to the complaint, the Trust stated nursing staff had spoken to Mr S and explained that Mrs S was comfortable, settled and oxygen was available. The Trust explained staff observed that Mrs S’s breathing was slowing down and she was becoming pale. Staff felt she was approaching the end of her life.
87. The nursing staff contacted Mr S to inform him, but unfortunately Mrs S died around ten minutes after this conversation. The Trust apologised Mr S was unable to be present with Mrs S when she died.
88. NG 31 explains it is often difficult to be certain when a person is dying or going to die. Family and others important to the patient should be given accurate information about the prognosis and the uncertainty of when someone may die. Staff should also advise how they will manage care.
89. We are sincerely sorry to learn Mr S was unable to be with his mother when she died. We recognise this was extremely distressing for Mr S. We understand he had devoted many years to caring for her and ensuring she was comfortable.
90. From Mrs S’s admission on 3 July, we can see Mr S was informed Mrs S was likely approaching the end of her life and would likely not survive. He was also involved in various discussions about her care, treatment and management plan should she continue to deteriorate.
91. We understand it is difficult to be certain precisely when a person is going to die. People deteriorate differently and at varying speeds. This can make it difficult for healthcare professionals to know when to contact families of loved ones. Unfortunately, it appears this is what has happened on this occasion, and we do not consider this a service failure.
92. The Trust has accepted Mr S’s concerns in its response and has apologised he was unable to be with Mrs S when she died. We consider this response is proportionate and in line with our principles, with specific regard to being open and accountable. For this reason, we will not be taking any further action on this part of the complaint.
• Contradictory information given about visiting times
93. Mr S says, upon Mrs S’s admission, staff told him he could visit any time because of her critical condition. He explains he visited twice each day. Mr S says on one occasion a nurse told him to leave because his being in the building was breaking COVID-19 restrictions, but he had been told over the phone he could visit his mother any time.
94. In response to the complaint, the Trust has apologised Mr S received conflicting information around visiting and has accepted this has caused him significant distress. The Trust has accepted the lack of clarity around visiting hours contributed to Mr S’s anxiety and the need to see his mother. The Trust has explained it has since conducted a review of visiting arrangements to ensure all families can agree a clear visiting plan.
95. Doctors and nurses have a responsibility to communicate clearly and effectively (NMC The Code, GMC Good Medical Practice). In the responses to the complaint, we can see the Trust has accepted staff gave Mr S conflicting information about visiting times, which would suggest there were shortcomings in the provision of information to Mr S.
96. We recognise this must have been confusing and distressing for Mr S given the circumstances. We can see the Trust has accepted its communication fell below the expected standards, it has accepted the additional distress caused to Mr S and has made improvements to its service. We consider the Trust’s response to this part of the complaint is proportionate and in line with our principles with regards to being open and accountable, and seeking continuous improvement. For this reason, we will not be taking any further action on this part of the complaint.