25. Before we decide if 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 for each aspect of Mr A’s complaint and explained below what we have seen. The first section of this report covers the aspects of the complaint where we have not seen any signs that something went wrong.
Management of clinical condition
26. Mr A says the Trust did not provide appropriate treatment to his mother. He feels this contributed to her death.
27. In its response to the complaint dated 24 September 2020, the Trust says Mrs A arrived at the emergency department by ambulance. On arrival, she was very unwell with an elevated pulse rate, low oxygen saturations, a high breathing rate and a high temperature.
28. The Trust says a doctor made an initial diagnosis of heatstroke or sepsis (an infection of the bloodstream requiring urgent medical attention). The doctor referred Mrs A to the medical team who administered IV antibiotics, IV fluids and oxygen. The medical team explained Mrs A’s condition did not improve, so they referred her to the ITU team. The ITU team conducted a computerised tomography (CT) scan (which uses X-rays and a computer to create detailed images of the inside of the body) and continued with treatment, but Mrs A died.
29. Royal College of Physicians guidance on NEWS2 states early warning scores are a physiological track and trigger system to assess and respond to acute illness. The NEWS2 simple system allocates a score to different physiological measurements, already recorded in routine practice, when patients present to or are being monitored in hospital. These physiological measurements are: • respiration rate (the rate at which a person breathes) • oxygen saturation (blood oxygen levels) • systolic blood pressure • pulse rate • level of consciousness or new confusion • temperature.
30. NEWS2 has four combined score tiers:
• 0-4 (low clinical risk) • 3 in any individual aspect (low-medium clinical risk) • Total score 5-6 (medium clinical risk) • Total score of 7 or more (high clinical risk).
31. The tiers show a total score of seven or more means a patient is at high risk of clinical deterioration. If a patient scores over seven, the critical care team should assess them. This often results in patient transfer to a higher-dependency care area.
32. The UK Sepsis Trust recommends the use of the sepsis screen tool if a patient looks unwell or has a NEWS2 score of 5 or above.
33. This guidance says doctors must identify whether the patient is unwell due to an infection. If they are, the doctor should check for any red flag sign of sepsis, including: • objective evidence of new or altered mental state • systolic blood pressure under 90mmhg • heart rate above 130 beats per minute • respiratory rate above 25 breaths per minute • needs oxygen to keep oxygen saturations above 92%.
34. The guidance states if any red flag sign is present, doctors must start the Sepsis Six, a set of six steps doctors must take within an hour: • ensure a senior clinician attends • start oxygen if blood oxygen levels are less than 92% • obtain IV access and take bloods • give IV antibiotics (maximum dose broad spectrum therapy) • give IV fluids • monitor using NEWS2 • measure urinary output.
Our view
35. Mrs A arrived at hospital at 11.20pm. Notes from the ambulance service show they suspected she had sepsis.
36. At 11.40pm, an emergency department doctor reviewed her and noted her: • respiratory rate • oxygen saturations • heart rate • blood pressure • temperature • level of confusion.
37. The doctor gave a diagnosis of heatstroke and chest sepsis. They calculated her risk score as 8. As per guidance, this meant her condition was at high risk of deteriorating. The doctor referred Mrs A to the medical team for further review. While she waited, staff planned to keep her cool using IV fluids and keep her oxygen levels above 95%. We can see they ordered IV fluids and antibiotics.
38. We can see the doctor provided Mrs A with IV 1.2g co-amoxiclav during the review. This is in line with British National Formulary guidance, which recommends co-amoxiclav for people with respiratory tract infections. It states patients receiving IV treatment should receive 1.2g every eight hours.
39. The medical team accepted Mrs A for review at 12.50am. A consultant from the team reviewed her at 2am. They noted she had: • a 40°C fever • confusion • raised breathing rate.
40. The consultant diagnosed her with a fever and low blood oxygen caused by a chest infection. They planned to continue giving IV fluid, antibiotics, painkillers and oxygen.
41. The consultant discussed Mrs A with the ITU team, who agreed to admit her for review. The consultant reviewed Mrs A again at 3am. She was on four litres of oxygen. The consultant calculated her NEWS score as 11 (which meant her condition was deteriorating) and planned to discuss resuscitation (restarting the heart if it stops) with her. The consultant agreed to continue IV fluids and antibiotics. They recommended staff monitor her observations closely. They also planned to: • increase her oxygen • repeat electrocardiogram (ECG, a heart scan) • test for COVID-19 • run a CT pulmonary angiogram (a scan used to look for blood clots in the lung) to rule out pulmonary embolism (a condition in which a blood clot blocks one of the pulmonary arteries in the lungs).
42. A consultant from the ITU reviewed Mrs A at 3.20am. They diagnosed her with chest sepsis and cardiac failure. The consultant agreed to continue antibiotics and to admit Mrs A to the ITU for non-invasive ventilation. They also planned to conduct an ECG and cardiac echo (an ultrasound scan used to identify abnormalities in the heart).
43. At 3.40am, staff changed Mrs A’s antibiotics to 500mg clarithromycin via IV. This is in line with British National Formulary guidance, which recommends clarithromycin for people with respiratory tract infections (chest infections). The guidance states patients receiving IV treatment should receive 500mg every 12 hours.
44. We can see doctors prescribed IV antibiotics (co-amoxiclav and clarithromycin) to treat Mrs A’s chest infection. Her records show she received doses in line with British National Formulary recommendations.
45. At 4am, a medical registrar visited Mrs A to discuss applying a DNACPR order. Notes from this indicate she agreed, and the registrar planned to update the team about her DNACPR status.
46. The records show staff monitored Mrs A observations using NEWS2 hourly between 11.20pm and 3.40am. Her NEWS scores were between 8 and 11 during this time. The guidance makes it clear a NEWS score of 5 or more means a patient needs urgent medical attention and the critical care team should become involved.
47. We can see an emergency department doctor initially reviewed Mrs A before referring her to the medical team, who in turn referred her to the ITU. The evidence shows the Trust responded quickly to Mrs A’s NEWS scores and increased her care in line with guidance.
48. As part of our consideration of this complaint, we obtained clinical advice from our adviser who is a consultant physician in acute internal medicine. They diagnose and treat people with sepsis daily.
49. Our adviser said Mrs A was extremely unwell and it became clear that she would not survive when she got to hospital. Her observations and symptoms showed she was unlikely to recover from chest sepsis. Our adviser said many clinicians would have recognised she was unlikely to survive and not offered any treatment other than keeping her comfortable. The Trust staff chose to actively treat her as she had a very small chance of survival.
50. Our adviser reviewed the medical records and noted the Trust treated Mrs A with oxygen, antibiotics, fluids and: • measured serum lactate (a test to check for low blood oxygen) • took blood cultures (a test to check for bacteria in the blood) • monitored urine output.
51. Our adviser explained the Sepsis Trust’s guidance on sepsis screening at acute assessment outlines this treatment. They explained the likelihood of Mrs A surviving was already small, and this decreased throughout her hospital stay. Despite receiving the recommended treatment, she continued to deteriorate and sadly died a few hours after she was admitted.
52. GMC guidance on good medical practice states doctors must provide a good standard of practice and care. If they assess, diagnose or treat patients, they must adequately assess the patient’s conditions and examine them if necessary. The guidance states doctors must: • promptly provide or arrange suitable advice, investigations or treatment where necessary • refer a patient to another practitioner when this serves the patient’s needs • only prescribe drugs or treatment when they are satisfied they serve the patient’s needs • provide effective treatment based on the best available evidence.
53. We believe the evidence shows the Trust assessed Mrs A and provided her with treatment in line with guidance. We are satisfied with the way the Trust responded to her declining health and increased her care. We have seen no sign of failing in this aspect of the complaint.
54. We were sorry to hear of Mrs A’s death and the significant impact this continues to have on her son and the family. We recognise the effect this continues to have on their lives.
55. Mrs A was admitted to hospital towards the beginning of the COVID-19 pandemic. At the time, most hospitals had suspended their visiting policy. We recognise this meant Mrs A’s family could not be with her to provide support.
56. We accept this may have meant they were unaware of how unwell she was. We hope that the information in our statement provides reassurance that Mrs A received the care she should have received.
DNACPR
57. Mr A complains about the Trust’s decision to apply a DNACPR order. He says staff did this without speaking to family or obtaining his mother’s consent.
58. In its response to the complaint dated 10 May 2021, the Trust said staff decided to apply a DNACPR order to maintain Mrs A’s comfort and ensure her treatment did not cause her any unnecessary distress. It said when clinicians decide to apply a DNACPR order, they do so in the patient’s best interests.
59. The Trust explained the patient does not have to consent, but good practice involves the deciding clinician explaining the process to the patient and, if possible, next of kin, so they understand why CPR would not be appropriate.
60. The Trust said Mrs A’s DNACPR status did not prevent her from having active treatment. It said it ensured she was not subjected to a resuscitation process that the clinician felt she would not survive.
61. The NHS guidance ‘Do not attempt cardiopulmonary resuscitation (DNACPR) decisions’ explains the purpose of CPR is to get a person’s breathing and heart going again. The actions used in CPR, such as chest compressions, can cause bruising, break ribs and puncture lungs.
62. The NHS guidance explains only a small percentage of people make a full recovery, even if their heart or breathing can be restarted. CPR can cause permanent heart or brain damage. For this reason, DNACPR forms are written (rather than a verbal agreement being made), which means people do not receive a treatment that may prolong or cause suffering at the end of their life.
63. The GMC guidance ‘Treatment and care towards end of life: good practice in decision making’ states CPR often has a low success rate and can cause internal damage. If CPR is not successful in restarting the heart or breathing, the patient may die in an undignified and traumatic manner.
64. The guidance states if a patient is admitted to hospital acutely unwell and at risk of cardiac or respiratory arrest, clinicians should make a judgement about CPR as soon as possible, considering: • the benefits and risks of CPR • whether further treatment will be needed because of any potential damage CPR may cause.
65. The guidance states if clinicians assess such treatment is unlikely to be clinically appropriate, they may decide not to attempt CPR.
66. BMA, Resuscitation Council (UK) and RCN guidance ‘Decisions relating to CPR (cardiopulmonary resuscitation)’ states a decision not to attempt CPR applies only to CPR. Clinicians should continue to provide all other appropriate care and treatment for the patient.
Our view
67. Mrs A’s records show staff were considering a DNACPR order within two hours of admission. A consultant tried to discuss this with Mrs A during a review at 2am, but Mrs A was unable to have a conversation at that time.
68. A medical registrar discussed resuscitation with Mrs A again at 4am. Their notes state: ‘She understood what is going on, has a clear mind and she is not keen on active resuscitation as she thinks it is too much for her. She is agreeable to DNACPR. Informed other team members about DNACPR status.’
69. The NHS guidance explains the chances of CPR working are lower if the person’s lungs, heart or other organs are struggling to work before CPR is needed. Mrs A was admitted to hospital at 11.20pm with suspected sepsis. She was receiving oxygen therapy as her oxygen saturations were low on room air.
70. Her NEWS score was 8 upon arrival to hospital, which meant she was at high risk of clinical deterioration. This rose to 11 despite treatment with antibiotics, fluids and oxygen. By 4am, she had a diagnosis of sepsis and heart failure. She was also receiving non-invasive ventilation.
71. Our adviser explained Mrs A was extremely unwell throughout her admission. They said her clinical condition meant CPR would not have been successful. They explained they would not expect clinicians to offer CPR.
72. The guidance makes it clear decisions around CPR should be based on the person’s overall clinical condition. We can see the doctor who completed the DNACPR paperwork stated the reason for applying it was ‘frailty and comorbidity (pre-existing medical conditions)’. The evidence suggests Mrs A was not likely to survive a CPR attempt. We believe there are no signs of failing in the clinician’s decision to apply a DNACPR order.
73. Mr A tells us the Trust applied a DNACPR order without his mother’s consent. We accept Mr A remains unhappy with the Trust’s decision to apply a DNACPR order. He feels staff should have spoken to family before doing so.
74. GMC guidance states doctors must offer the patient opportunities to discuss whether they should attempt CPR in the event of a future cardiac or respiratory arrest. Doctors must approach this sensitively and should not force a discussion or information onto the patient if they do not want it. But, if patients are prepared to talk about it, doctors must provide them with accurate information about the burdens, risks and likely clinical outcome.
75. Our adviser said the decision of whether to offer resuscitation is a medical decision and rests with the treating medical team. It is not a family’s decision and there is no requirement for clinicians to obtain ‘permission’.
76. Our adviser explained clinicians involve patient’s families in discussions around DNACPR to understand the patient’s wishes. Our adviser said it was not necessary for clinicians to obtain family input on the DNACPR decision, as Mrs A clearly stated she did not want to be resuscitated.
77. We understand Mr A disagrees with the decision to apply a DNACPR order. The evidence shows it was clinically appropriate not to attempt CPR, and the Trust acted in line with the relevant guidance when making this decision.
78. We recognise Mr A feels clinicians should have discussed the DNACPR order with family before applying it, but nothing in the guidance stipulates clinicians must involve families in these discussions.
79. Our adviser explained families can help communicate patient’s wishes if they are unable to communicate themselves, but the evidence suggests Mrs A was able to communicate. It is clear she did not want to be resuscitated and agreed to DNACPR. We are satisfied the Trust involved Mrs A in decisions around CPR. For these reasons, there are no signs of failing in this part of the complaint.
Communication
80. Mr A complains about the Trust’s communication while his mother was in hospital. He says the Trust provided no update on his mother’s care until he called. He explains this meant he did not know what was happening and was unprepared for her death.
81. In its response to the complaint dated 24 September 2020, the Trust said staff called Mr A on his mobile number at 3.30am and several times following this on the day his mother died. It said a junior doctor also tried to call him but was unsuccessful in contacting him.
82. GMC guidance on good medical practice states doctors must be considerate to those close to the patient and be sensitive and responsive in giving them information and support.
83. GMC guidance on treatment and care towards end of life states doctors should acknowledge the role of people close to the patient. Doctors should ensure they respect the feelings of those close to the patient and meet their needs for support.
84. The guidance explains those close to a patient may want information about the patient’s diagnosis and about the progression of the condition to help them provide care and recognise and respond to changes in the patient’s condition.
85. Mrs A’s medical records show that doctors looking after her included updating family as part of her care plan. We can see this in notes from her initial review in the emergency department and in the medical team’s review at 3am.
86. We can see doctors tried to contact Mr A on several occasions on the day his mother died, but they were unable to reach him.
87. At 2am, a member of the medical team reviewed Mrs A and saw her respiration was poor. The notes state: ‘contact NOK – called son no answer’.
88. At 3.30am, a medical registrar attempted to call Mr A. The notes state: ‘unable to get contact. Plan – try again later.’
89. We reviewed Mrs A’s medical records and can see they do note a mobile number for Mr A. We compared this against our records and can confirm we have the same number on file.
90. Mrs A was in hospital only for about six hours before she died. During this time, staff tried to contact her family when the medical team reviewed her and when the ITU team took over her care. We consider it likely staff would have updated Mr A if the calls had been successful.
91. Mrs A was admitted to hospital in August 2020, during the COVID-19 pandemic. This was a period of immense pressure for the NHS. The ideal situation would have been for Mr A to have received updates, but we accept this was not possible in this instance.
92. Mr A tells us he checked with his phone provider and could not see the Trust had attempted to contact him. He feels the Trust’s statement that staff tried to reach him is inaccurate.
93. We recognise Mr A does not agree the Trust tried to contact him before his mother’s death, and we do not discount his version of events. But, when someone complains to us about events that the other party disputes, our role is to gather evidence and reach a view about what is more likely to have happened.
94. The evidence shows staff planned to update Mr A and made several attempts to do so. We consider it likely Mr A would have been updated in line with guidance had the calls been successful.
95. It is clear Mrs A’s health was deteriorating rapidly during the admission and she needed increasing levels of care. COVID-19 restrictions meant family members were unable to visit. We accept this meant Mr A could not see how unwell his mother was and so was not prepared for her death. We do not underestimate how distressing this was for Mr A.
96. We accept that the Trust’s communication did not meet Mr A expectations, but we consider the Trust made reasonable attempts to contact him. Sadly, Mrs A died within an hour of the Trust’s last attempt. We have seen no sign of failings in this aspect of the complaint.
Complaints handling
97. Mr A also complains about the way the Trust handled the complaint. He says the Trust repeatedly delayed its response and provided ‘vague’ and contradictory information.
98. NHS Complaints Regulations 2009 state organisations should accept complaints within three working days of receipt. Organisations should provide the complainant with an explanation of how it will handle the complaint and a timeframe in which it hopes to complete its investigation.
99. Organisations should send a report as soon as possible after the investigation is complete. The report explains how it has considered the complaint and the conclusions reached. If the organisation does not send a complaint response within six months of receipt, it must notify the complainant and explain why.
100. Our Principles of Good Complaint Handling state organisations should deal with complaints in line with published service standards where appropriate. Organisations should respond flexibly to the circumstances of the case. This means considering how the organisation may need to adjust its normal approach to handling a complaint in the particular circumstances.
101. Mr A’s aunt complained to the Trust in August 2020. We can see the Trust responded the following day to acknowledge the complaint. It then responded to the complaint on 24 September 2020. The COVID-19 pandemic had begun six months before this. Most NHS organisations paused work on all complaints around this time.
102. Mr A’s aunt returned to the Trust with outstanding concerns. It is not clear from the records when this was, but it is clear the local complaints process was ongoing. We can see on 11 January 2021 the Trust wrote to her to explain it had paused work on all complaints due to the ongoing COVID-19 pandemic. It reassured her it would contact her when work resumed.
103. The Trust responded again to the complaint on 10 May 2021. It asked Mr A’s aunt to return if she had any outstanding concerns.
104. Mr A’s aunt had a call with the Trust on 14 June 2021 in which she discussed her outstanding concerns. Following this, the Trust sent another letter on 28 June accepting she remained unhappy with its response. The letter states: ‘you were offered the opportunity to attend a local resolution meeting to discuss your concerns, however you did not feel this would be beneficial and therefore declined. You advised that you have raised your complaint to the Parliamentary and Health Service Ombudsman.’
105. Despite having contacted us, Mr A and his aunt went on to attend the local complaints process meeting with the Trust in September 2021. Notes from the meeting show staff discussed all concerns raised in the complaint and provided reassurance that the Trust had taken action to prevent the same events being repeated. We recognise the Trust made an additional attempt to provide reassurances to Mrs A’ family even after the local complaints process was complete.
106. It is not clear from Mr A’s account of events what he feels was contradictory in the Trust’s responses, but we are satisfied the Trust’s responses reflect what we have seen in our consideration of the complaint.
107. We recognise waiting for a response caused frustration to Mr A and his aunt. We accept there was a delay between the Trust’s first and second response, but we consider this delay was understandable due to the impact the COVID-19 pandemic had on complaints handling across the NHS. We can see the Trust provided its responses within the timeframes given in the NHS complaints regulations, so we believe its complaints handling was in line with our principles.
108. It also continued to engage with Mr A and his aunt after the local complaints process was complete. We have seen no sign of failing in this part of the complaint.
Bereavement support
109. On arrival at hospital, Mr A tells us staff took him and his aunt to a room full of dirty PPE where staff ‘coldly’ informed them Mrs A had died. He says staff provided a bereavement booklet and ushered them out of the room.
110. The Trust accepted staff took Mr A and his aunt to this room to tell them Mrs A had died. It apologised and said it is not usual practice for staff to break bad news to relatives in an unsuitable area.
111. It explained the room had been a relatives’ room before the COVID-19 pandemic, but staff had repurposed it to store PPE.
112. Our principles of good administration states organisations should communicate effectively, using clear language that people can understand and that is appropriate to them and their circumstances. They should treat people with sensitivity, bearing in mind their individual needs.
Our view
113. We reviewed Mrs A’s records and were unable to see any entries describing the specific room staff took her family to or what staff said. But the Trust and Mr A’s accounts of events make it clear the support staff could have offered Mr A and his aunt better support. The evidence shows staff did not offer the required level of sensitivity and mistakenly took Mr A and his aunt to an unsuitable room.
114. We consider the Trust did not act in line with our principles when Mr A and his aunt attended hospital in August 2020.
115. In bringing this complaint to us, Mr A would like the Trust to accept it provided poor care and treatment to his mother. Our work has indicated the Trust provided care and treatment in line with guidance. Mr A would also like the Trust to accept it provided poor service to Mrs A’s family.
116. Our Principles for Remedy say organisations should quickly accept and put right cases of poor service that have led to injustice. They should return the complainant to the position they would have been in if the poor service had not happened.
117. When we identify a sign of failing, we consider whether this had an impact on the complainant. We accept the Trust’s actions caused Mr A and his aunt additional distress at an already distressing time.
118. We can see the Trust’s response to the complaint apologises for the effect its staff’s actions had on Mr A and his aunt. It accepted staff delivered the news of Mrs A’s death in an unsuitable room. It said it has told emergency department staff of this mistake and improved signage on the room. It said staff have been reminded of the room changes to prevent this from happening again.
119. We accept the significant impact Mrs A death had on her family and how this continues to affect their lives. We do not dismiss how distressing the events complained about were for Mr A and his aunt. We accept staff’s actions caused them additional distress.
120. In line with our severity of injustice scale, we consider the Trust has done enough by apologising and making improvements to its service to remedy the distress it caused and prevent this from happening again.
121. We will not be continuing our consideration of Mr A’s complaint. We recognise this may be disappointing to Mr A and his aunt, but we hope the contents of our statement reassure them Mrs A received clinically