Barts Health NHS Trust

7. Ms R complains about the care her late father, Mr R, received on 28 and 29 May 2019, while an inpatient at the Trust. She complains:

• communication on the ward was poor, including: o Mr R was stepped down (disconnected) from a heart monitor without explanation o the nurse did not communicate with Ms R regarding administering morphine or Mr R’s cannula (a metal tube for insertion into the body to draw off fluid or to introduce medication) o the nurse told Ms R and her mother that one of them must leave the ward, even though it had already been agreed they could stay o the nurse used inappropriate language towards Ms R.

• there was too long a gap between the morphine injections that the nurse gave Mr R.

8. Ms R says the Trust’s failings left her feeling helpless. She says Mr R was left in pain, agitated and could not sleep that night, and she is still affected by the memories of this. Complaining to the Patient Advice and Liaison Service (PALS) at the time meant she had less time to spend with her father.

9. Ms R wants the Trust to apologise and offer a payment in recognition of the injustice she suffered.

10. Mr R was an end-of-life cancer patient receiving care at one of the Trust’s hospitals in London.

11. On 28 May 2019, Mr R was moved abruptly from the Coronary Care Unit (CCU) to another ward. The only explanation Mr R’s family were given was that there had been an emergency and he had to be moved immediately. Mr R was disconnected from his heart monitor and his family had to collect his belongings.

12. In the other ward, the nurse told Ms R and her mother only one family member could stay with Mr R, even though Ms R says a nurse in the palliative team had already told them they could stay overnight.

13. Mr R was in pain and had been prescribed regular morphine and morphine as required. On the evening of 28 May, Ms R asked the nurse if she would give morphine to Mr R. She says the nurse did not do this.

14. At 11pm on 28 May, Mr R was agitated and attempted to pull the cannula from his arm. Ms R says the nurse did not attend to him immediately. Ms R says when she asked the nurse for help, the nurse replied ‘I can’t do anything to shut him up’. The Trust disputes the nurse used those words.

15. The nurse attended Mr R at 11.16pm when Mr R’s arm was bleeding around the cannula’s entry point. Ms R says when she told the nurse this had happened, the nurse replied ‘I will come when I want’. She came at 11.30pm and bandaged the cannula. She did not clean the blood on Mr R’s arm or the bedsheets. Ms R says when she returned to the ward later, the cannula had been reinserted.

16. On 29 May, Ms R returned to the hospital to speak to the PALS team. She spoke to the nurse in charge and told her she did not want the nurse to be involved in Mr R’s continuing care on the ward. PALS advised Ms R to make a formal complaint.

17. Sadly, Mr R died shortly after this.

Communication

22. Ms R has complained about issues in communication on the ward. She says Mr R was disconnected from a heart monitor without explanation. She says there was a lack of communication from the nurse about giving morphine and Mr R’s displaced cannula. She says the nurse told Ms R she and her mother could not remain on the ward with Mr R, although this had already been agreed. She also says the nurse spoke to her inappropriately on the ward.

23. This point is about the Trust’s nursing staff’s communication. We have considered this in line with the NMC Code, in particular section 7, which states a nurse must communicate clearly. Section 7.4 specifies a nurse must ‘check people’s understanding from time to time to keep misunderstandings or mistakes to a minimum’.

24. We have considered whether, for each point, the Trust acted in line with the relevant guidance. We have then considered whether communication overall fell so far below the required standard as to represent a failing.

Mr R was stepped down from a heart monitor without explanation

25. Ms R told us Mr R was moved abruptly from the CCU to another ward during a Speech and Language Therapy (SALT) assessment on 28 May 2019. Mr R was disconnected from the heart monitor and his family had to collect his belongings. Staff told the family there had been an emergency and they had to move Mr R immediately. Ms R says no one explained why they were moving her father or where he was being moved to.

26. In its complaint response, the Trust said Mr R was moved elsewhere in the hospital because of an emergency. Clinical staff decided he was clinically suitable to be ‘stepped down’ (given an intermediate level of care between the intensive care units and the general medical-surgical wards). The Trust apologised for the anxiety and stress the lack of explanation had caused.

27. There is no clinical note for the stepdown. The only reference to the event is in a note a SALT assessor made at 10am on 28 May 2019, which states: ‘During assessment, patient moved to another bay, family appeared distressed/confused. Advised on PALS service if required.’

28. We considered this point in line with NMC guidance. Section 7 of the Code stresses the importance of ensuring actions are understood. Our nursing adviser told us that, while difficult and hurried decisions about ward space must sometimes be made, in line with the Code we would expect staff to explain to the family the reasons for the transfer. We consider this was particularly important, given Mr R was undergoing cardiac monitoring and given Ms R understood disconnecting him from the monitor may have increased the risk of cardiac failure, but the available evidence indicates no one explained why they were moving Mr R.

29. After the stepdown, Ms R spoke to the PALS team, who arranged for the nurse in charge to speak to her. Ms R says the nurse in charge told her she had to decide which patient could be moved and, ‘from her deduction’, Mr R could be moved. Ms R said she told the nurse in charge Mr R had been attached to a heart monitor due to high calcium levels and his heart could stop at any point. The nurse in charge told her that, if this was the case, a doctor would advise and Mr R could be reconnected to a heart monitor.

30. There is no record of this conversation in the Trust’s records. The Trust has accepted Ms R’s account of events in its complaint responses. We have no reason to question Ms R’s recollection of events here.

31. Without questioning the Trust’s belief that Mr R was suitable for stepdown, we feel the meeting with the nurse in charge represented a second opportunity for the Trust to explain to Ms R the clinical justification for Mr R’s transfer, in line with the Code. But the available evidence shows that the Trust did not explain the clinical appropriateness of the stepdown on this occasion, which left Ms R not understanding why her father was disconnected from a heart monitor that she understood was key to his care. This was not in line with the NMC Code.

Issues with giving morphine and managing the cannula

32. Ms R says the nurse did not explain why she did not give morphine to Mr R when asked to. She also says the nurse did not explain why she did not replace Mr R’s cannula when it had become dislodged or clean him when he was covered in blood.

33. The Trust apologised for the nurse’s lack of communication on both occasions. It said the nurse was concerned about giving Mr R too much morphine and felt he was experiencing agitation rather than pain, for which she could not prescribe medicine. Regarding the cannula, the Trust says the nurse was unable to refit the cannula so she bandaged over the cannula and arranged for another nurse to cannulate Mr R’s other arm.

34. The nursing notes from that evening do not contain an account of these events. They do not mention any pain relief given after 10pm, or any issues with the cannula.

35. In line with NMC Code section 7, we would expect to see the Trust had taken steps to make sure Ms R clearly understood what was being done to ensure Mr R’s care and comfort. The available evidence suggests Mr R’s family was not given an explanation for either issue. This was not in line with the NMC Code.

The nurse used inappropriate language towards Ms R

36. Ms R says when she asked the nurse to attend to her distressed father, the nurse said, ‘I can’t do anything to shut him up’.

37. The Trust says the nurse recalls telling Ms R there was nothing she could do to ‘stop [Ms R’s father] from shouting’. By this, it says the nurse: ‘meant … she had assessed [Mr R] previously, when [Ms R] escalated his agitation, and looked to see if there was anything prescribed that could help. [The nurse] found that there was not, and therefore [there was] nothing further she could do. She had bleeped the medical team to come and prescribe something but they could not come to the ward at that time.’

38. In line with NMC Code section 7, we would expect to see the Trust had tried to ensure Ms R understood why the nurse was unable to help her father and what steps were being taken to provide care for him.

39. As an impartial complaints handler, our role is to reach balanced decisions based on the evidence available. This is the only area of the complaint where there is a significant difference between Ms R and the Trust’s accounts of events.

40. We have no evidence of what was said on this occasion other than the respective accounts of the complainant and the nurse. It has not been possible to reconcile these two accounts. We are not able to say, on the balance of probabilities, exactly what they said on the evening. We accept this will be disappointing for Ms R.

41. But we do not need to know exactly which words were used to decide whether communication was in line with the NMC guidance. This is because, regardless of the precise language used, the evidence indicates no one attempted to reassure Ms R or to explain to her why her father could not be helped. The communication on these occasions was not in line with the NMC Code.

Both family members not allowed to stay

42. Ms R says a nurse in the palliative team told her and her mother they could stay by Mr R’s bedside on the ward overnight. Ms R says the nurse was not aware of this and insisted only one family member remained by his bedside.

43. The Trust has apologised for this. It accepts the agreement was in place and says the nurse should have received a handover explaining this arrangement, but this did not happen. The Trust says that given Mr R was receiving end-of-life care, the nurse should have considered the family’s wishes.

44. We did not see any record of this arrangement in the records the Trust provided. It is possible the agreement was not written down but instead was made verbally during the handover between nursing staff. The nursing note from this period says the patient was received with the family by his bedside, but does not say anyone was asked to leave.

45. NMC Code section 8 instructs nurses to work co-operatively. Point 8.2 states a nurse must maintain effective communication with colleagues. As family members had already arranged to remain on the ward, we would expect to see the Trust had effectively communicated this to the staff members responsible for Mr R’s care.

46. We have also considered the nurse’s communication with Mr R’s family in line with NMC Code section 3.2, which says a nurse must recognise and respond compassionately to the needs of those who are in the last few days and hours of life. We would expect to see issues like this discussed empathetically with Mr R’s family.

47. The available evidence shows that this arrangement was not communicated to the nurse verbally or in writing. The evidence also shows that the nurse missed an opportunity to discuss this with the family sympathetically or to ask other staff on the ward who may have been aware of the agreement. The Trust’s communication on this occasion was not in line with the NMC Code.

Cumulative consideration of communication issues

48. We have considered whether, all together, issues in the Trust’s communication over this two-day period fell so far short of the required standard as to represent a failing.

49. We accept the Trust was extremely busy throughout this period, which will inevitably have affected staff members’ ability to communicate effectively. Also, support was not available on several occasions, for example when the nurse paged for support but was not answered, which would have made things worse. We also accept that, in the context of a highly pressurised environment, it may not always be possible to maintain a high standard of communication. We do not consider that any of these individual occasions represent a failing, given the pressures on the ward.

50. But, as a whole, the evidence shows communication fell below the required standard on numerous occasions. Given the repeated missed opportunities to explain what was being done and why it was being done, we feel that, together, the Trust’s actions fell so far short of the required standard as to represent a failing. We understand how difficult Ms R found her experience on the ward. We have found a failing in the Trust’s actions.

Giving morphine

51. On the evening of 28 May 2019, Mr R had two active prescriptions for morphine: • a regular prescription for 2.5mg of Oramorph (a liquid form of morphine, a drug often used as a pain killer), to be given every 4 hours, with a maximum dose of 10mg per day • a prescription for 2.5mg of morphine sulphate (a medicine to manage pain), to be given pro re nata (PRN, which means ‘as required’), with a maximum dose of 20mg per day.

52. The medicines charts show that the nurse administered 2.5mg morphine PRN at 9.40pm, and 2.5mg morphine regular at 10pm. This was Mr R’s fourth and final regular dose of morphine. He was given a 2.5mg PRN dose at 1.25am, 3 hours 25 minutes later. He was given another 2.5mg PRN dose at 6.09am.

53. Ms R complains there was a period on the evening of 28 May 2019 when her father was left in pain. She says morphine could be given every two hours, but there was a period of 3 hours and 25 minutes when Mr R did not get a dose, which left him in pain and agitated. She says it felt like the nurse had deliberately not given him pain relief.

54. In the local complaints process meeting, the Trust says the nurse was worried about giving Mr R too much morphine and wanted to give the two doses he had already received time to work. The Trust says she asked a more experienced nurse for advice. In hindsight, the Trust agrees pain relief could have been given earlier, and it says its nurses should feel empowered to administer medication to patients on end-of-life care.

55. The relevant nursing note for this period does not mention morphine being given after 10pm. There is no explanation for why morphine was given at 1.25am or why it was not given earlier. As the Trust has explained, because of how much time has passed since these events, it no longer holds a controlled substances list for the relevant date. Our consideration of this point is based on Ms R’s account of events, the Trust’s investigation and the medicines record.

56. We considered this point in the context of the NMC Code. Section 18 states a nurse must: ‘advise on, prescribe, supply, dispense or administer medicines within the limits of your training and competence, the law, our guidance and other relevant policies, guidance and regulations.’ As morphine had been prescribed and it was within the nurse’s competency to give it, we would expect to see morphine given as prescribed.

57. We discussed the case with our clinical adviser. Ms R said she remembers her mother appearing on the ward at around 11.40pm, when her father appeared to be in pain. She asked a nurse to give him morphine, but this did not happen. As our adviser confirmed, given the last PRN dose had been given at 9.40pm, the next dose could have been given at 11.40pm. This did not happen.

58. We have considered the Trust’s explanation that the nurse was wary of giving too much morphine in a short period. Our adviser told us morphine can affect a patient’s breathing, so we accept why the nurse would be reluctant to give too much of it. But the clinical team decided to prescribe PRN morphine in the patient’s best interests, and NMC guidance requires nurses to give medication as prescribed. We have found that the time gap in giving morphine represents a failing in the Trust’s actions.

Impact

59. We believe the Trust has had an impact on Ms R, which it has not put right.

60. Ms R says the failings left her feeling helpless. She says the memories of her father being left in pain, agitated and being unable to sleep still affect her. She says complaining to PALS reduced how much time she had left with her father.

61. Regarding the failing in communication, we can see that the gaps in understanding caused Ms R to feel helpless. We can also see why Ms R feels that having to complain about Mr R’s care meant she lost time with her father while she pursued the complaint with PALS.

62. We have considered the failing around providing pain relief. In our view, as Mr R’s condition improved after receiving PRN morphine at 1.25am, we can say it is likely an earlier dose of morphine would have had the same effect. On the balance of probabilities, we can say Mr R was left in pain for a period between 11.40pm and 1.25am, which could have been avoided.

63. We can say the Trust’s failings resulted in Ms R experiencing the emotional impact of seeing her father in pain, agitated and unable to sleep.

64. Our Principles for Remedy say that, where poor service or maladministration (fault) has led to injustice or hardship, the organisation responsible should take steps to put things right. This can include an apology, implementing service improvements or offering a payment in recognition of the injustice suffered. We have considered whether the Trust has already taken steps to put right the effects of its failings.

65. The Trust has apologised for the failings. It has also highlighted several areas where it has tried to improve its service. Regarding the nurse, the Trust says it has made the following plan to manage her performance:

• a senior team member is supervising [nurse]’s performance during clinical practice to ensure she is providing the correct standard of care and is communicating appropriately with patients and their relatives • [nurse] will attend the staff nurse training and development days on communication and fundamentals of care • [nurse]’s knowledge and skill will be assessed formally using the Trust’s competency pathway • the ward manager will monitor [nurse]’s performance closely and, if necessary, use the Trust’s disciplinary policy to address it • a summary of this complaint, the investigation and its findings will remain on [ nurse]’s file for six months.

66. The Trust told Ms R the ward was part of a month-long improvement programme involving observation of the staff, scrutiny of their notes and a day when nurses reflect on feedback and complaints. It says one goal of this programme was to establish continuity of care between the CCU and other wards and minimise any disparity in the quality of care each unit provides.

67. We are pleased to see that the Trust has already offered an apology and has made service improvements, which are remedies in line with our guidance. Ms R approached us partly to obtain an apology from the Trust but, having reviewed the work the Trust has already completed, we are satisfied this has already taken place in line with our principles.

68. But Ms R also approached us to secure a payment from the Trust in recognition of the injustice suffered. While we accept that the Trust has taken steps to put right the complaint in line with our principles, the Trust has not offered a payment in recognition of the injustice suffered. We have found that, in this respect, the injustice for both parts of the complaint remain unremedied.

69. We have upheld both parts of the complaint.

1. We have carefully considered Ms R’s complaint about the care and treatment her father, Mr R, received from Barts Health NHS Trust (the Trust). We are grateful to Ms R for bringing this complaint to our attention and we appreciate she has been through a very difficult time.

2. Based on the evidence we have considered, we have found failings in the way the Trust gave Mr R pain relief. We have also found failings in the way the Trust communicated with Ms R.

3. We understand the Trust’s delay in administering morphine to Mr R has left Ms R with distressing memories of her father while he was on end-of-life care, and these continue to affect her and cause ongoing distress.

4. Based on the above, we have upheld this complaint. This is because we have found an unremedied injustice in the Trust’s delay in giving Mr R morphine and its lack of communication with Ms R.

5. As we are upholding this complaint, we recommend the Trust write to Ms R and pay her £500 compensation within one month of the date of this report.

6. We feel level three of our severity of injustice (SOI) scale is the most appropriate level for this injustice, as it recognises the ongoing nature of Ms R’s distress, linked to the bereavement of her father. We have accepted this failing did not directly affect Mr R’s ongoing medical treatment or cause discomfort to Mr R himself. For this reason, we consider it to be a low level three injustice.

Payment in recognition of the injustice suffered

70. In considering our recommendations, we have referred to our principles. Our principles state that public organisations should put things right and, if possible, return the person affected to the position they would have been in if the poor service had not happened. If that is not possible, they should compensate them appropriately.

71. To decide on a level of payment in recognition of the injustice suffered, we review similar cases where the person has experienced similar injustice on our SOI scale.

72. We reviewed cases where the person had experienced a similar injustice to ensure that any recommendations we make are consistent with our previous work. We found that cases with similar circumstances had resulted in recommended payments of around £500. We used this to guide our thinking.

73. We proceeded to consider the complaint in the context of our SOI scale. This defines a level 2 injustice relating to bereavement as cases involving relatively minor failings not causing significant pain or suffering to the deceased or distress to the person affected or other family members at the time.

74. The SOI scale defines a level 3 injustice relating to bereavement as cases where there were failures in care causing moderate distress or discomfort to the patient and/or adding to the family’s bereavement after the patient’s death.

75. A level 2 bereavement injustice makes no allowance for emotional impacts on the patient’s family after the patient’s death, whereas a level 3 injustice includes cases where the impact has added to the family’s bereavement.

76. As Ms R has stressed, because the failings happened while her father was on end-of-life care, the failings still affect her memories. A level 3 injustice recognises the ongoing nature of the injustice, linked to the bereavement. But we must also accept that these failings did not have an impact on Mr R’s ongoing medical treatment, or directly cause distress or discomfort to Mr R for more than a week. Overall, we consider it to be a level 3 injustice.

77. We also consider that the delay in administering morphine represents a level 3 injustice. Ms R has told us the memories of her father suffering pain while on end-of-life care still affect her. Given the ongoing nature of the impact, which is now linked to Ms R’s bereavement, we consider the most appropriate level for this on our SOI scale to be level 3. But, given the relatively short duration of the period in question, we consider this to be a low level 3 injustice.

78. In recognition of the injustice Ms R has suffered, we recommend the Trust pay her £500 within one month of the date of our final report.

79. This concludes our report.