The Practice
Chickenpox 27. Mrs G considers the Practice could have diagnosed Mr H with chickenpox on 13 or 20 May 2019 when he had a rash.
28. The GMC Guidance sets out expected standards for all registered medical doctors. Section 15a says doctors must assess the patient’s condition properly, taking account of their history and examining them if necessary.
29. The NICE Chickenpox Guidelines say in most cases diagnosis can be made from the characteristic rash. They describe the rash as small red flat lesions on the scalp, face, trunk, and limbs, which progress over 12 to 14 hours to raised bumps and intensely itchy blisters filled with clear fluid or pus. The guidelines say a history of recent exposure to chickenpox or shingles, or cases in close contacts, may help confirm the diagnosis.
30. Our GP adviser said when reviewing adults with a blistering rash, chickenpox is an uncommon cause. This is because most adults have immunity through having had the virus in childhood. Our GP adviser said it is rare to have chickenpox more than once.
31. When Mr H attended the Practice on 13 May 2019 the GP examined his rash and diagnosed a fungal skin infection. Fungal skin infections are usually characterised by a patchy rash of scaly, itchy skin. Our GP adviser said the chickenpox rash would not usually be confused with a rash from a fungal skin infection.
32. When Mr H returned on 20 May 2019 the GP examined him again and noted the rash looked worse and had spread across more of his torso. The GP thought the rash looked more bacterial. Some bacterial skin infections are characterised by blisters filled with fluid or pus, which can look similar to chickenpox.
33. There is no evidence Mr H reported any recent exposure to chickenpox on 13 or 20 May 2019. There is also no evidence he said he had not had chickenpox before. This means chickenpox was a less likely cause of the rash than fungal or bacterial infection.
34. Mrs G sent us a photograph of Mr H’s rash from 23 May 2019. Our GP adviser confirmed this is a blistering rash that could be chickenpox or a type of bacterial skin infection.
35. Mr H’s hospital records show he initially received treatment for chickenpox. On 9 July 2019 a laboratory test confirmed he did not have the virus, so the treatment stopped. We have seen no clear evidence Mr H ever had a confirmed diagnosis of chickenpox.
36. We have not found any failings in the Practice not diagnosing Mr H with chickenpox in May 2019.
Time taken to advise Mrs G to call 999 37. Mrs G complains the Practice took far too long to advise her to contact 999 after a community nurse asked for a home visit on 4 September 2019. The Practice did not contact her until the following morning, by which point an ambulance had already arrived after she contacted 111.
38. Section 15b of the GMC Guidance says doctors must provide or arrange suitable advice, investigations or treatment quickly where necessary. From the Practice’s complaint response, it is clear there were two areas where things went wrong. The receptionist sent a ‘red flagged’ task to the on-call GP after the community nurse’s call at 12:25pm. The GP did not review the task for six hours.
39. The GP then sent a message to the reception staff at 6.29pm (one minute before the Practice closed) to say Mr H’s family needed to call 999. The reception staff had switched off the computer by this time, so did not see the message until the following morning. They contacted Mrs G at 8.15am.
40. In line with the GMC Guidance, doctors should urgently communicate if someone needs to call 999. As the Practice has recognised, the doctor should ideally pass this message on directly. If reception staff are to pass the message on, the doctor should speak to them rather than sending a message. Sending a message to reception one minute before closing time was not in line with the expected standard.
41. The Practice’s actions led to a significant delay in Mr H’s family being informed they needed to call 999. If the doctor had acted on the red flagged task urgently, it is possible Mr H could have been admitted to hospital on the afternoon of 4 September 2019 rather than the following morning.
42. Mrs G believes the delay contributed to Mr H’s death. We understand why she feels this way. Mr H was very unwell when he arrived at hospital and needed urgent treatment.
43. Our physician adviser explained Mr H had a combination of very serious underlying health problems, and it is likely the treatment and sad outcome would have been the same even if he had gone into hospital on 4 September 2019. We cannot say Mr H would have had an increased chance of survival if he had gone into hospital sooner.
44. We recognise the delay caused significant distress. Mrs G was very worried about Mr H and expected a doctor to come and visit him on 4 September 2019. She then cared for him overnight without any medical advice. She was distressed to be told on the morning of 5 September that she needed to call 999 when this could have happened the previous day.
45. Mrs G has been left in a position where she will always wonder if things would have been different if Mr H had gone into hospital sooner.
46. When we see evidence things have gone wrong and this has affected the person concerned, we consider whether the organisation has done enough to put things right. To help with this we refer to our Principles for Remedy. These say organisations should recognise and apologise when things have gone wrong and put things right in a way that is appropriate given what has happened. It also says organisations should use lessons learned from complaints to make sure the failings do not happen again.
47. The Practice’s response apologised that its systems were not robust and this led to a delay. The response explained why this happened and set out some changes the Practice had made to its ‘red flagged tasks’ protocol to prevent a recurrence.
48. The Practice said reception staff now monitor red flagged tasks to make sure the GP has dealt with them as quickly as necessary. The Practice said if a patient or carer needs to contact emergency services, the clinician should contact them directly or speak to reception face to face. Clinicians must not send tasks to reception after 5:30pm.
49. While these measures go some way to putting things right, we identified areas where the Practice could make further improvements. Our GP adviser said processing home visit requests via the task system is not robust. This is because GPs may not review the task list frequently through the day, and they also receive numerous tasks related to a variety of things. Even if the Practice marks home visits with a red flag, there is no quick way for the GP to identify which red flagged tasks are most important.
50. Our GP adviser said a more robust process is for receptionists to book a home visit slot in the duty doctor’s appointment screen or in a dedicated home visit request screen. This makes sure someone deals with the request quickly. The duty doctor has a list of patients who need a home visit that day. The doctor can quickly sort through the requests and decide what needs to happen to them.
51. We spoke to the Practice about our concerns. The Practice told us it introduced a new home visiting service in October 2022. It now has three bookable home visit appointments per day. The Practice shares the home visiting service with other Practices in the area, so more appointments can become available at 11am if no other practices have used them.
52. The protocol says if there are no home visit appointments available, reception staff should speak to the on-call GP to decide on the best course of action. The protocol specifically says not to send tasks regarding home visit requests.
53. We hope Mrs G is reassured these changes show the Practice has improved the way it works and it is unlikely these events would ever happen again. The Practice now has a robust bookable home visiting service with a clear protocol to make sure there are no delays.
54. As we are satisfied the Practice has now done enough to put things right, we have not made any recommendations to the Practice.
Findings about the Trust
Management of leg and foot wounds 55. Mrs G complains the Trust did not properly treat the leg and feet ulcers Mr H had got during his time in hospital from June to August 2019.
56. In response to Mrs G’s complaint the Trust explained its view that it provided appropriate treatment for Mr H’s legs as soon as issues arose. The Trust noted Mr H often preferred to keep his legs undressed against the staff’s recommendations.
57. The clinical records show Mr H had oedema (swelling caused by excess fluid) in his ankles from when he went into hospital. By 4 July 2019 the oedema had spread to his knees and by 12 July 2019 it had spread to his thighs.
58. Oedema is a symptom of heart failure and a risk factor for venous leg ulcers. These happen when the veins in the legs are not working properly, which leads to high pressure in the veins. This high pressure can damage the skin and lead to ulcers. The Vascular Society for Great Britain and Ireland says it can take up to six months for venous leg ulcers to heal. They also say some venous leg ulcers are resistant to treatment and do not heal.
59. Annex B of the NMC Standards says nurses should observe, assess and optimise the patient’s skin and hygiene status and decide what help they need. It also says nurses should use appropriate products to prevent or manage skin breakdown.
60. Section 4.1 of the NMC Code says nurses must balance the need to act in people’s best interests with the need to respect their right to accept or refuse treatment. This means nursing staff cannot force any care or intervention on patients against their wishes.
61. Section 15 of the GMC Guidance says doctors must adequately assess the patient’s conditions, provide or arrange suitable advice, investigations or treatment as quickly as they are needed and refer to another practitioner when necessary. Section 16 says doctors must take all possible steps to alleviate pain and distress.
62. We find nursing and medical staff acted in line with these standards.
63. The clinical records show nursing staff observed and assessed Mr H’s skin as well as they could. They offered Mr H skin assessments twice per day from when he went into hospital. Mr H sometimes accepted these assessments, but the records say he often declined them. When Mr H declined full skin assessments, nursing staff continued to record what they could see regarding his skin and the care they were offering or giving.
64. Doctors initially focused on treating Mr H’s oedema with diuretics (medication that increases urine production). When Mr H’s oedema worsened doctors tried different doses and types of diuretics. Sadly, Mr H’s oedema did not respond to diuretics.
65. By 16 July 2019 Mr H’s legs had started to leak fluid. From this time there are numerous references to nurses offering to dress his legs, in line with the NMC Standards. The first documented instance of Mr H allowing staff to dress his legs is on 25 July 2019. By this time the skin had already started to break down.
66. Throughout the records there are several references to Mr H removing the dressings from his legs and declining nurses’ offers to re-dress them. Staff respected his wishes in line with the NMC Code.
67. On 27 July 2019 nursing staff documented Mr H now had an ulcer. They referred him to the Central Treatment Suite (CTS) for specialist tissue viability nurses to review him. This is in line with the NICE Venous Leg Ulcer Guidelines. These say staff with expertise in wound management should be involved in cleaning and dressing the ulcer.
68. Staff in CTS reviewed Mr H on 29 July 2019. They acted in line with the NICE Venous Leg Ulcer Guidelines by completing a detailed wound assessment, dressing the wounds and offering to bandage his legs to provide compression therapy.
69. From 30 July 2019 there are some documented instances when Mr H allowed staff to dress his wounds and apply compression therapy in line with CTS recommendations. The records show most of the time Mr H preferred to care for his legs himself and did not want staff to help him.
70. The records show Mr H sometimes followed the nurses’ advice about caring for his legs and used the products they provided. Mr H often found the dressings painful, so did not want to keep them on. There are several documented instances where he left his wounds undressed or covered them with incontinence sheets or wet paper towels, against the nurses’ advice. There are also references to Mr H touching and picking at his wounds and using non-medical skincare products.
71. We recognise this was a difficult situation for nursing staff to manage. They had to balance the need to give good wound care against Mr H’s right to refuse care and treatment. We are satisfied nursing staff did all they could to care for Mr H’s skin appropriately. When Mr H did not want the nurses to help, they gave appropriate advice and products to allow him to look after his skin himself.
72. By 1 August 2019 it was apparent Mr H’s leg wounds were getting worse. Doctors acted in line with the GMC Guidance by referring Mr H to the dermatologists (specialist skin doctors). They also asked for swabs of Mr H’s wounds to check if there was any infection.
73. The dermatologists advised specialist lotion, ointment, dressings and elevation of Mr H’s feet. They also recommended wound photographs, antibiotics dependent on the wound swab results and an ultrasound doppler (a test that checks blood flow through the legs) to decide if compression therapy was appropriate. The doctors followed these recommendations.
74. On 3 August doctors prescribed an antibiotic, co-amoxiclav, to Mr H. This is an appropriate antibiotic for infected leg ulcers as set out in the BNF.
75. On 5 August the laboratory informed ward staff it had rejected Mr H’s leg swabs. Doctors asked for new swabs the same day. These swabs were reported as showing no significant growth. This shows they were not infected.
76. On 6 August Mr H had an ultrasound doppler. This showed evidence of reduced blood flow to his legs. The NICE Venous Leg Ulcer Guidelines say in this scenario compression therapy should be avoided and patients should be referred for a specialist vascular assessment.
77. Doctors arranged for a CT angiogram (a scan to check for evidence of disease in the arteries which may be restricting blood flow) the same day. They sent the results to the vascular team (part of another Trust) and asked them to review Mr H.
78. The vascular team said there was no significant change from Mr H’s previous CT angiogram. They thought Mr H’s ulcers were likely a consequence of his heart failure. They arranged to review Mr H in CTS on 13 August 2019. This review did not take place as Mr H left the ward for 90 minutes when the porters came to collect him.
79. On 7 August 2019 staff noted there was green discharge coming from Mr H’s leg wounds. The doctor queried whether this was a sign of bacterial infection, so arranged for more wound swabs. They prescribed another antibiotic, gentamicin. This is an appropriate antibiotic for infected leg ulcers as set out in the BNF.
80. The following day the laboratory reported the swabs were positive for a type of bacteria called pseudomonas aeruginosa. These bacteria can cause serious infections and are resistant to many antibiotics. The laboratory gave no advice on antibiotics. Doctors continued to prescribe gentamicin and co-amoxiclav. The BNF confirms gentamicin is an appropriate antibiotic for treating pseudomonas aeruginosa infections.
81. On 9 August 2019 a doctor noted Mr H’s wounds had worsened again. They were concerned he may have necrotising fasciitis (a life-threatening bacterial infection that causes soft tissue to die). Treatment usually involves antibiotics and surgery. Doctors acted in line with the GMC Guidance by referring Mr H to the surgeons.
82. A surgeon reviewed Mr H later that day. They said there was no evidence of necrotising fasciitis, but Mr H appeared to have severe cellulitis (infection of the inner layers of skin). The surgeon recommended staff contact microbiology for advice. They did this. Microbiology advised a different antibiotic, flucloxacillin, and very careful wound care. Flucloxacillin is an appropriate antibiotic for cellulitis as set out in the BNF.
83. The medical notes show Mr H’s leg wounds improved over the next few days. On 13 August 2019 a doctor noted the redness had improved and covered a smaller area, and there was no fluid leaking from the wounds. The doctor spoke to microbiology, and they confirmed Mr H could step down to oral antibiotics.
84. On 18 August doctors noted Mr H’s right leg looked worse. They referred Mr H back to CTS for specialist wound dressings. On 20 August doctors noted Mr H’s leg wounds had worsened and there was yellow/green discharge again. Doctors acted in line with the GMC Guidance by arranging wound swabs.
85. The laboratory reported the wound swabs were positive for a type of bacteria called myroides sp. These are environmental bacterial organisms that rarely cause disease in humans. When they do cause infection, they are highly resistant to many antibiotics.
86. The laboratory report said myroides sp may represent colonisation rather than infection. Colonisation happens when bacteria grow on body sites exposed to the environment, without causing infection. For example, a wound may provide warm and moist conditions where bacteria will grow without causing harm. The laboratory did not provide any advice on antibiotics, so doctors continued with flucloxacillin to treat cellulitis.
87. At this time doctors focused their efforts on controlling Mr H’s pain, as his leg wounds were deteriorating despite all previous efforts at treatment. They referred Mr H to the pain team, which is in line with the GMC Guidance. The pain team started a trial of methadone (a strong opiate painkiller). The records show this gave Mr H some relief.
88. On 27 August a doctor noted there was no redness to the skin on Mr H’s legs and the ulcers were leaking clear fluid. This shows there was no skin infection.
89. On 29 August a dermatologist reviewed Mr H and noted he now had a pressure sore on his heel. They recommended Mr H sleep in bed rather than the chair as he usually did. They also recommended he elevate his legs and use pressure-relieving equipment and specialist dressings. The dermatologist recommended Mr H take a three-month course of doxycycline, an antibiotic. This is an appropriate antibiotic for infected leg ulcers as set out in the BNF.
90. We recognise Mr H’s serious leg wounds caused great distress and pain and contributed to his death, as the coroner said. The evidence shows staff gave appropriate care to manage Mr H’s skin and wounds.
Discharge 91. Mrs G complains the Trust discharged Mr H inappropriately on 31 August 2019. She complains the Trust did not carry out home assessments or provide a care plan, even though Mr H could not walk unaided or get to the toilet.
92. The Trust’s complaint response explained Mr H could move around on his own on the ward and only used a wheelchair when he left the ward. The Trust recognised it could have referred him to physiotherapy before it discharged him, but staff did not consider this was necessary. The Trust apologised for the stress and worry it caused by not doing so.
93. In considering what should have happened, we referred to the Trust’s Discharge Policy. This says all patients should have a planned and safe discharge from hospital, and those who need community care should have appropriate arrangements put in place before discharge.
94. The Trust’s Discharge Policy says nursing staff should speak to the patient and carer or next of kin to understand their usual abilities with activities of daily living and home circumstances. The policy says staff will refer the patient to an occupational therapist or physiotherapy if they can do less than they could before they were ill.
95. There are several references to discharge planning in Mr H’s records. The evidence shows the doctors decided when to discharge him based on his changing condition. Plans to discharge Mr H in mid-July, late July and mid-August did not go ahead because Mr H’s condition changed.
96. On 14 August 2019 there is a documented conversation between a nurse, Mr H and Mrs G’s daughter, Miss G, about discharge planning. It is recorded Miss G told the nurse they were keen to get Mr H home as soon as medically possible, and they had discussed moving a bed downstairs in the short term. The nurse documented Mr H was happy with this plan.
97. From this conversation it is clear Mr H’s abilities had changed from before he went into hospital, as he could no longer manage stairs. In line with the Trust’s Discharge Policy, staff should have referred Mr H to occupational therapy or physiotherapy.
98. The clinical records show the therapy team could not review Mr H prior to discharge because of staff leave. We have considered whether discharging Mr H without a physiotherapy or occupational therapy review falls so below the expected standard we would consider it to be a failing in the service provided.
99. The clinical records show from 18 August Mr H was walking around the ward and going to the toilet without any mobility aids. The clinical records document he was independent with all his activities of daily living and personal hygiene.
100. The records show Mr H and his family were keen for him to be discharged and they had a plan to look after him downstairs. There is no evidence Mr H’s family expressed any concerns about how they would manage at home.
101. We find the decision to discharge Mr H without a physiotherapy or occupational therapy assessment was not a serious failing. Although the Trust’s Discharge Policy says the assessment should have happened, it is likely this would have delayed his discharge without any changes to the arrangements, given his independence on the ward.
102. We understand Mr H was unable to move around or use the toilet at home. We recognise this loss of independence was distressing and led to Mr H’s family taking time off work. We have seen no evidence staff could have predicted the difficulties Mr H had at home.
103. The records show the Trust made appropriate arrangements for Mr H to have pressure-relieving equipment and specialist footwear delivered to his home. It is recorded Mr H told staff he was happy to go home before the equipment was delivered.
104. The Trust referred Mr H to community nurses for ongoing wound care after discharge. Mr H was independently dressing his wounds and usually did not want staff to help him, so it was appropriate for him to continue this at home with oversight from community nurses.
105. Our cardiology adviser said Mr H was at high risk of re-admission due to his multiple health problems. Keeping Mr H in hospital for longer would not have changed his high risk of re-admission. Our cardiology adviser also noted delaying Mr H’s discharge would have increased his risk of infection and further loss of mobility.
106. We have not found any serious failings in Mr H’s discharge. Sadly, he was not able to be independent at home, but it is unlikely the Trust could have done anything to change this.
Information given on discharge 107. Mrs G complains the Trust did not give the family instructions about Mr H’s care or medication when it discharged him. The Trust did not address this concern in the complaint responses, but during a local resolution meeting it apologised staff did not go through the medication with Mr H’s family before he left the ward.
108. The National Discharge Summary Standards say discharge summaries should clearly state who is expected to take responsibility for any follow-up care. They should also include a full and accurate record of all medications that are prescribed on discharge. This should include the dose, route of administration and timings if necessary. The summary should explain the reasons for any changes from the medication that was prescribed on admission.
109. Mr H’s discharge summary was detailed and set out clear actions for his GP on blood tests, nutritional supplements and a rash that needed reviewing. It also confirmed the community nurses were going to come and dress his legs. The summary also set out how the Trust was going to follow up on iron infusions and outpatient cardiology appointments. We find no key information was missing about Mr H’s care needs.
110. Mr H’s discharge summary listed the 19 drugs he was prescribed on discharge, the dosage and how and when they should be taken. This was a significant increase from the medications he was prescribed on admission. We understand the family wanted to be sure about the instructions for administering and handling methadone, as this is a controlled drug.
111. Although the Trust gave enough information in the discharge summary for Mr H’s family to be able to give him the right medication at the right time, it would have been good practice for nursing staff to talk the family through this. The NMC Standards say nurses should identify the need for a range of alternative communication techniques and provide information and explanation to people, families and carers about their treatment and care.
112. We find the Trust did not communicate Mr H’s medication needs to his family in the way it should have. Nursing staff should have recognised the importance of talking to the family as he was taking lots of new medication, including a controlled drug.
113. The discharge summary explained the reason for most of the new medication that had been started during M H’s time in hospital. However, it did not clearly explain why Calci-D, Gaviscon Advance and mupirocin had been started.
114. We recognise the absence of this information caused Mr H’s family some additional inconvenience at an already difficult time. To identify what these three medications were, they had to read the patient information leaflets included in the packaging. They would not have needed to do this if all relevant information had been included on the discharge summary, or if staff had spoken to the family before Mr H was discharged.
115. We note the Trust has provided an appropriate apology to Mrs G, but it has not explained any steps it has taken to stop these events happening again. Therefore, we have made recommendations to the Trust. These are set out in paragraphs 136 to 140.
Fluids 116. Mrs G complains the Trust gave Mr H fluids inappropriately when he went back into hospital on 5 September. She believes this contributed to his death.
117. During the local resolution meeting the Trust explained staff gave Mr H fluids to help stabilise his kidneys, which septicaemia (blood poisoning) had destabilised. The Trust recognised the fluids affected Mr H’s heart but did not say staff did anything wrong.
118. Mr H’s clinical records show he had acute kidney injury (AKI) and suspected sepsis. These are both serious and potentially life-threatening conditions that need quick treatment.
119. AKI is often caused by reduced blood flow to the kidneys. If it is not treated, abnormal levels of salts and chemicals can build up in the body, which can affect the other organs. Section 4 of the National AKI Guidelines recommends clinicians should optimise blood flow using appropriate fluid therapy as set out in the NICE IV Fluid Guidelines
120. Section 1.2 of the NICE IV Fluid Guidelines sets out six clinical signs patients may need urgent fluid resuscitation. The clinical records show Mr H had four of these signs: his systolic blood pressure (the pressure in your arteries when your heart beats) was below 100 mmHg, his heart rate was over 90 beats per minute, his hands were cold and he had a national early warning score (NEWS) of five. NEWS is a tool for assessing clinical deterioration based on the patient’s vital signs. A score of five shows the patient may be at risk of serious deterioration.
121. The NICE Sepsis Guidelines set out several criteria that help clinicians identify people who are at risk of death or severe illness from sepsis. Mr H met two high-risk criteria: his systolic blood pressure was 90 mmHg and he had not passed urine in two days (the NICE Sepsis Guidelines say not passing urine for 18 hours is a high-risk criterion).
122. The NICE Sepsis guidelines say if a patient has one or more high-risk criteria staff should do blood tests immediately. It says if the blood lactate level is between 2mmol/L and 4mmol/L staff should give intravenous fluids without delay. Mr H’s blood lactate level was 2.2mmol/L, so he met the criterion for intravenous fluids.
123. Due to his history of heart failure and oedema, Mr H was at risk of complications if he had too much fluid. Our physician adviser said it is a difficult balancing act to treat patients with AKI, sepsis and low blood pressure when they also have heart failure.
124. We can see staff considered the risks and prescribed the fluids to be given slowly. The Trust prescribed the first litre of fluids over six hours and the second litre over 12 hours. Our physician adviser said this was appropriately cautious given both the NICE IV Fluid Guidelines and the NICE Sepsis Guidelines recommend 500ml be given over 15 minutes.
125. Shortly after starting the second litre of fluids, Mr H deteriorated. The Trust did an ultrasound of Mr H’s chest and from this they diagnosed pulmonary oedema (fluid on the lungs). The Trust stopped the IV fluids at this point and gave him a diuretic to try and reduce the fluids that had accumulated in his body.
126. Sadly, Mr H continued to deteriorate and died in early September. We cannot say this was linked to any failings in the administration of fluids. If the Trust had not given Mr H any IV fluids it is likely he would still have died as he would not have been receiving treatment for AKI and sepsis.
Monitoring 127. Mrs G complains staff did not monitor Mr H in the hours before he died. Due to this she does not know what time he died or whether his death was dignified.
128. The ‘intentional rounding’ documents in the clinical records show staff checked on Mr H every two hours up to midnight in the night when he died. It is documented he was awake and comfortable up to 10pm and asleep in a chair at midnight. There is no further documentation until a doctor verified Mr H’s death at 5.10am.
129. In the local resolution meeting Mrs G said a member of staff called her in the middle of the night to say Mr H had taken a turn for the worse. When she arrived, he had already died and staff had laid his body out. Mrs G was unsure of the exact time she arrived, but said it was around 3am.
130. It is clear a member of staff monitored Mr H at some point between midnight and 2:30am, as they called Mrs G and said he was deteriorating. It is likely a member of staff checked on Mr H around 2am to complete the intentional rounding checks.
131. It is also clear a member of staff checked on Mr H again, before Mrs G arrived at around 3am. When she arrived, staff already knew he had died and had laid his body out.
132. On the basis that staff checked on Mr H around 2am and again before Mrs G arrived at the hospital around 3am, we find they monitored Mr H appropriately. However, we have concerns about the standard of record keeping.
133. Section 10 of the NMC Code says nurses should keep clear and accurate records relevant to their practice. Staff should have documented what they saw when they checked on Mr H after midnight and realised he had deteriorated. They should also have documented when they realised he had died.
134. This failure in record keeping means Mrs G will never know what happened when Mr H died. She will never know whether he had a dignified and comfortable death. She will also never know what time he died, which is important to her. It is not right that Mrs G will never have the information she needs to help her come to terms with Mr H’s death. This has added to her distress.
135. During the local resolution meeting Mrs G told the Trust her concerns about the lack of records of the night Mr H died. The Trust did not recognise the poor record keeping or take any action to put things right. Therefore, we have made some recommendations for how the Trust can put things right.