Mr W was moved to three different wards during his stay
21. Mr W was initially admitted to ward A. While on this ward, he was diagnosed with hydronephrosis (stretching and swelling of the kidneys due to a build-up of urine inside them) and was transferred to ward B.
22. Mr W was later transferred to ward C for treatment following a review by the urology team who recorded that Mr W’s cancer had spread and was causing an obstruction in his kidney.
23. In response to the complaint, the Trust recognised there was no clear communication with Mr W or the family about why he was moved and has apologised for this and the distress it caused.
24. We have reviewed Mr W’s medical records with our adviser and carefully considered the care he received. In our view, there are no signs that moving Mr W between these wards had any impact on his care, as there are no signs the movements led to any delay in investigations or treatment.
25. This is because the records show Mr W was reviewed quickly by the relevant teams involved in his care. The written handovers, communication and care plans are detailed, and our adviser has confirmed they give enough detail to allow for a smooth handover of care between each ward.
26. We consider this is in line with the GMC’s ‘Good medical practice’ guidance with specific reference to point 15b – promptly provide or arrange suitable advice, investigations or treatment where necessary, and point 35 with regards to working collaboratively with colleagues.
27. For this reason, we have not seen any signs of service failure relating to this part of the complaint. Despite this, we recognise it must have been confusing for Mr W and his family as he was moved between different wards. The confusion was likely made worse by the restrictions in place at the time because of COVID-19, which impacted on visiting and communication. We will address communication during the admission later in this statement.
Mr W’s hearing aids were lost and not replaced
28. In response to the complaint, the Trust has recognised the hearing aids were lost while Mr W was an inpatient. We consider this is a sign of poor service and we have considered what actions were taken when staff were made aware of this. The Trust explained that as soon as the ward manager discovered the hearing aids were missing, they spoke with staff, searched the ward and contacted the X-ray department to see if they had been found.
29. The Trust said mould fittings were taken so Mr W could be given new hearing aids, but they did not arrive before his discharge to the hospice. The audiology department contacted the hospice when they were ready, but was told Mr W had sadly passed away.
30. The Trust apologised the hearing aids were lost and has recognised this would have caused distress for Mr W. It said it has learned from this and now makes sure patient property forms are filled in for each patient to stop property getting lost. Also, the Trust advised that although it does not currently have a lost property policy, it is now in draft format and awaiting approval.
31. As part of our consideration of this part of the complaint, we spoke to the Trust to understand the timeline of events. The Trust advised that the ward asked for ear mould impressions to be made in early January 2022 and Mr W was taken to the audiology department the same day. A right impression was taken and sent to the manufacturer on the next working day. The hearing aid was sent back to the Trust in late January 2022 and the hospice was contacted the following day to arrange delivery.
32. The Trust explained a left impression was not taken as Mr W had a wax occlusion and it would not have been safe to do so. The ward contacted audiology in mid-January 2022 to advise the left ear had cleared. The impression was taken two days later, processed the following day and the hearing aid was sent to the Trust in early February 2022.
33. We asked the Trust what the normal turnaround time would be for replacement hearing aids. While there is no standard turnaround time, a senior clinical scientist looked at other requests processed at the same time and these ranged from 13 to 25 days. The right ear mould turnaround time was 16 days from the date sent to the manufacturer and the left ear mould was 13 days.
34. We also asked the Trust if any consideration was given to speeding up the request. The Trust has confirmed the ear moulds were not sent with a priority sticker on them. It explained that moulds sent with a priority sticker at that time were returned after 13 days, which suggests a possible three days’ time could have been saved for the right ear mould. The team was told by the ward that Mr W was moving to hospice care in mid-January 2022. There was a further note added five days later to say a doctor from the hospice had called, asking that audiology contact them directly when the ear mould was available.
35. We consider the actions taken by the team were in line with the GMC’s ‘Good medical practice’ guidance with regards to 15b – promptly arranging suitable investigations and treatment. We can see the moulds were taken and sent to the manufacturer quickly and were returned in the average turnaround time for that period.
36. Despite this, we recognise how frustrating and confusing it must have been for Mr W during the time he was without his hearing aids. The Trust has apologised the hearing aids were lost and has recognised the impact this had on Mr W. It has also explained how it will improve its service in future to stop this happening again (paragraph 30).
37. We consider the response from the Trust is in line with our Principles with regards to being open and honest when accounting for decisions and actions, saying what they will do to put matters right when things have gone wrong, and putting things right with a remedy that is fair and proportionate.
Access to a phone and tablet
Phone
38. In response to the complaint, the Trust explained ward C was having technical issues with bedside phones. This meant Mr W did not have access to a working phone while he was on the ward. At the time of the response, the Trust advised the issue was ongoing and had been reported to the phone provider so repair work could take place. The Trust has apologised for the inconvenience this caused.
39. We asked the Trust for more information about this and it advised an external company provides the telephones. It says the fault was reported to the company and fixed at a later date but, given the time lapsed, staff cannot remember how long it took to be repaired.
40. The technical issues with the phones appear to be out of the Trust’s control and it seems the Trust took appropriate action to report this to the external provider to have it fixed. We recognise the turnaround time for the repair would be up to the provider and likely out of the Trust’s control.
41. Unfortunately, we do not have extra evidence which would allow us to work out an accurate timeline of how long this went on for. We can see the Trust has apologised for the inconvenience this caused. We consider this is in line with our Principles with regards to being open and honest when accounting for decisions and actions, and putting things right with a remedy that is fair and proportionate.
42. Although we have not found any signs of a service failure, we recognise the absence of a working phone made contact between Mr W and his family more challenging due to the restrictions on visiting at the time. We also understand this was made more difficult by the changes to Mr W’s prognosis, as the family would have preferred to have been able to support him in person.
43. We will address the Trust’s communication with the family later in this statement.
Tablet
44. Mrs O says other wards had tablets and iPads to communicate with families outside the hospital because only one person was allowed to visit. She says the ward her father was on did not, and when one was found, a charger was not provided to continue to use the tablet to communicate with the family.
45. In response to the complaint, the Trust advised there are iPads available on the ward for patients and families to use, and following the family’s concerns, the ward manager had reminded all staff they must offer patients and families the option to use them regularly. The ward manager also explained Mr W had advised staff he did not want to communicate using the iPad because he was struggling to hear. The Trust has recognised this was likely made worse due to him not having his hearing aids and has apologised for this.
46. After reviewing the medical records, and while we do not dispute Mrs O’s recollection of events, we do not have independent supporting evidence to show a service failure took place.
47. However, we can see the Trust has apologised for what happened and has spoken with the relevant staff to make sure they communicate better with families in future. We consider this is in line with our Principles with regards to being open and honest when accounting for decisions and actions, and putting things right with a remedy that is fair and proportionate. For this reason, we will not be taking any further action on this part of the complaint.
Communication of end of life stage
48. Mrs O says her father had several tests while he was in hospital and there was a lack of information from the wards. She says the palliative care nurses told her there was no way her father was at the end of life. They told her he was poorly, but not at the end of life in the latter stage of his hospital stay. But five days later, after being discharged to the hospice, they were told he was at the end of life.
49. In response to the complaint, the Trust explained that when Mr W was admitted, investigations were carried out to work out the cause of his pain. It says it was not until Mr W had several scans that it was identified his cancer had spread.
50. The Trust said this was discussed with Mrs O in early January and it was explained that Mr W’s prognosis was likely to be shortened by these findings. A plan was in place to manage his pain and he was discharged to the hospice for pain management.
51. The Trust explained that when Mr W was re-admitted to the hospital in late January, it was suspected he may have developed hydronephrosis again. The doctor felt that, as Mr W’s cancer was rapidly progressing, it was likely he would continue to develop more problems despite treatment. It said the doctor discussed this with the family and explained Mr W was approaching the end of his life and decided he would return to the hospice for end-of-life care.
52. The Trust has apologised the family were told Mr W was not approaching end-of life-care, to be told shortly after he was. It has recognised this must have been incredibly distressing for the family. The Trust has also recognised that once it was determined Mr W’s cancer had spread, there should have been clearer communication with the family about his prognosis. The Trust has apologised for this.
53. We have considered this part of the complaint with our adviser. As per the Trust’s response, and as shown in the medical records early in January 2022, the family were told the CT scan results showed Mr W’s cancer had spread, and the next day they were informed this had likely shortened Mr W’s prognosis. Our adviser explained that when Mr W was discharged from hospital later in January, his blood tests show his kidney function was improving and his nephrostomy appeared to be working. So, there are signs it would not have been appropriate to say he was at the end of life at that point, because there were no signs he would deteriorate as quickly as he did.
54. Our adviser explained the prognosis for any cancer can be difficult to predict and at this point of Mr W’s care, it was not clear how aggressive his cancer was. It was only on his admission to A&E from the hospice for the second time, that it became clear he would be more suitable for palliative care.
55. Overall, we consider there are signs the communication with the family about Mr W’s prognosis was in line with the GMC’s ‘Good medical practice’ with regards to point 33 and being considerate to those close to the patient and being sensitive and responsive in giving them information and support, and point 31 with regards to responding honestly to questions from patients and their families. For this reason, we will not be taking any further action on this part of the complaint.
Poor communication about what was happening during Mr W’s stay
56. Mrs O says when she was allowed 45 minutes to see Mr W, he would tell her he was having a scan but never knew anything. Mrs O says she asked about the scans but was told there was nobody available to speak to her or read the results. She felt there was no co-ordination among staff and this led to the family not getting up-to-date information on Mr W’s condition. The family felt there was no teamwork regarding Mr W’s care and no urgency to update the family.
57. In response to the complaint, the Trust says it is documented on several occasions that medical staff had conversations with the family to update them about Mr W’s condition, tests results and care. It has given the following examples:
22 December 2021 – Mrs O had a discussion with medical staff while on the ward. They advised a CT scan was booked for the following day. Mrs O asked to be updated by telephone about the results.
23 December 2021 – Mr W had his CT scan and Mrs O was updated about the scan results and the plan moving forward.
29 December 2021 – Mrs O had a phone call with a member of the medical team. She was updated on the care plan, following the CT scan findings.
6 January 2022 – Mrs O had a phone call with the care of the elderly consultant and she was updated about Mr W’s condition and the main issues he was experiencing.
10 January 2022 – Further phone call with the care of the elderly consultant where an update was given on Mr W’s condition. During the conversation, Mrs O said she did not want her father to be told about cancer changes unless a family member was there. The consultant explained if a patient has mental capacity, they have to give them results if they wish to know.
11 January 2022 – Mrs O spoke with the urology consultant and discussed Mr W’s prostate cancer and the management plan.
58. The Trust has apologised the family felt there was no urgency to update them about Mr W’s condition. It has recognised how upsetting this must have been for them and it is especially hard when visiting is restricted.
59. We have also found extra examples in the records:
20 December 2021 – Phone discussion with Mrs O to advise awaiting report from the latest CT scan before the urology team could decide on next steps. Also discussed pain control and awaiting an MRI scan report.
7 January 2022 – Meeting with Mrs O at the ward door to update on latest pain review. Also discussed missing hearing aid with the ward sister.
14 January 2022 – Discussion with Mr W’s son to explain Mr W had been discussed in a meeting and a decision made for ongoing review by the on-call urology team, consideration of systemic treatment via outpatients and ongoing treatment.
60. Overall, we consider there are signs the team contacted the family when there had been significant changes in Mr W’s condition and prognosis. This was made more difficult by the restrictions in place at the time because of COVID-19, which meant most of the communication was by phone. Despite this, the family were kept up to date throughout Mr W’s stay.
61. This is in line with the GMC’s ‘Good medical practice’ with regards to point 33 and being considerate to those close to the patient and being sensitive and responsive in giving them information and support. For this reason, we have not found any signs of service failure relating to this part of the complaint.
Mr W was told of the development of his cancer without a family member or nurse there for emotional support
62. In response to the complaint, the Trust explained that in late December 2021, after Mr W’s CT scan results showed his hydronephrosis was likely caused by cancer, the doctor shared this information with Mr W and the plan for treatment. It explained because Mr W had mental capacity, they had to give him updates.
63. The Trust has recognised how important support from a family member can be during conversations like this, but notes it was restricted on involving family members because of visiting restrictions at that time.
64. Our adviser explained that due to the seriousness of the situation, and the circumstances of Mr W needing an operation as soon as possible, it was appropriate not to delay this conversation.
65. There are no entries from this day to suggest Mr W was confused at the time the information was shared with him. There is also no evidence of a formal assessment of Mr W’s mental capacity in the records, so we would begin with the assumption he had mental capacity in line with the Mental Capacity Act 2005.
66. In normal circumstances, it is considered a more sensitive approach to have someone with the patient when giving bad news: Patient UK – ‘Breaking bad news’. However, due to the visiting restrictions in place at the time, this was not possible.
67. Despite this, we consider the Trust could have considered having the family present via video call to give support, but we can also see Mrs O was contacted less than an hour after the conversation with Mr W, to explain the situation to her. This is in line with the GMC’s ‘Good medical practice’ with regards to point 33 and being considerate to those close to the patient and being sensitive and responsive in giving them information and support. For these reasons, we have not found any signs of service failure.
Mr W was given false information while he was experiencing delirium which made his distress worse
68. Mrs O explains she was told she could contact her father on another patient’s phone as Mr W did not have one by his bedside. She rang the phone because she could not get through to the ward. The conversation was distressing for her as Mr W was suffering from delirium and was upset with her. The sister came on the phone and apologised she had to hear Mr W in that condition.
69. Mrs O says the family should not have been put in this position. She says the sister had told Mr W she was going to collect him in an attempt to calm him down. But this upset Mr W even more when he asked Mrs O and she did not know about this.
70. In response to the complaint, the Trust has apologised this was able to happen. The ward manager explained they have since spoken to all staff on the ward about the duty of candour, and to make sure staff are always managing patient and family expectations.
71. After reviewing the medical records, and while we do not dispute Mrs O’s recollection of events, we do not have independent supporting evidence to show a service failure took place.
72. However, we can see the Trust has apologised for what happened and has spoken with the relevant staff to make sure they communicate better with families in future. We consider this is in line with our Principles with regards to being open and honest when accounting for decisions and actions, and putting things right with a remedy that is fair and proportionate. For this reason, we will not be taking any further action on this part of the complaint.
Several attempts were made to catheterise Mr W before a specialist was called to help
73. Mrs O says during the admission there was a problem with Mr W’s catheter. Four medical staff tried to replace this before calling for a specialist who came to insert it. She says this was painful and distressing for Mr W.
74. In response to the complaint, the Trust has explained that registered nurses are trained to insert catheters. The ward manager confirmed patients are catheterised on the ward as needed, but where it is difficult to do so, it is escalated to a specialist nurse. The Trust has apologised if the family felt a specialist should have been contacted sooner and for any distress this caused.
75. After discussing this with our clinical adviser, in our view there are no signs a specialist should have been contacted sooner to insert the catheter. The process followed the normal hierarchy of staff. The first attempt was made by a junior doctor and a nurse practitioner. They then contacted a senior doctor and the request was then escalated to a specialist urology registrar who was successful in inserting the catheter.
76. Our adviser explained it is often more difficult to catheterise patients with the type of cancer Mr W had and this was further complicated by Mr W’s spinal condition, which made positioning him more difficult.
77. For these reasons we consider the actions taken by the Trust are in line with the GMC’s ‘Good medical practice’ guidance with regards to point 15c – referring patients onto other practitioners when this serves the patient’s needs, point 16d – consulting colleagues where appropriate, and point 35 – working collaboratively with colleagues. As such, we have not found any signs of service failure relating to this part of the complaint.
Mr W was discharged from hospital too early
78. Mrs O says her father was admitted to A&E within 12 hours of his discharge to the hospice. She is concerned this discharge was too early.
79. In response to the complaint, the Trust explained that the day after Mr W was discharged to the hospice for pain management, he went to A&E because of concerns about haematuria (blood in his urine) from his catheter and his nephrostomy (a thin plastic tube used to drain urine from the kidney).
80. The Trust says it is recorded Mrs O had a discussion with a consultant in A&E who reassured her that her father’s catheter and nephrostomy were draining, and the haematuria was known. There were no changes following his discharge the previous day.
81. The family were informed that if Mr W’s catheter and nephrostomy were draining there were no concerns. However, they were told if Mr W became hemodynamically unwell (unstable blood pressure and heart rate) or there were any problems with the draining, urology should be contacted. Otherwise, hospice care was appropriate in the first instance. Discharge back to the hospice was agreed, and the Trust considers there was no change from the discharge planning from the previous day and so no concerns about the discharge.
82. Mr W was re-admitted to A&E two days later with a worsening acute kidney injury, inflammatory markers and he was more unwell. It was found there was a blockage around the kidney given Mr W's severe acute kidney injury and he had developed hydronephrosis again. The clinicians believed this was indicative of his rapidly progressive cancer and explained to the family he was approaching end of life. Mr W was then discharged to the hospice for palliative care the next day.
83. We have reviewed Mr W’s discharge from hospital with our adviser, and we consider there are no signs it was not appropriate to discharge Mr W to the hospice. His blood results showed his kidney function was improving and his nephrostomy was draining well. He had some haematuria, but this was to be expected due to his condition, recent treatment and the medication he was taking.
84. The focus of his care at this time was pain control and so there are signs it was appropriate to discharge him to the hospice for this focused care. This is in line with the GMC’s ‘Good medical practice’ guidance with regards to point 15b – promptly referring or arranging suitable treatment, and point 16c – taking all steps to alleviate pain and distress whether or not a cure may be possible. As such, we have not found any signs of service failure relating to this part of the complaint.
Long delays for medical attention
85. Mrs O says her father was crying out due to bleeding from the penis. She says it was decided he needed fluids, so a saline solution was attached to the cannula put in by the hospice. She says her father’s arm became extremely swollen, and her father waited two hours for a comfortable bed and had to lie on a hard plastic trolley. She says she asked four people before a bed was brought in.
86. Mrs O says her father was so distressed she rang the switchboard and asked for the sister to come to A&E. She came to them and told them her father’s swollen arm would reduce. The sister also called for the on-call urologist to see Mr W.
87. In response to the complaint, the Trust has apologised there was a delay in Mr W being given a comfortable bed when he was brought to A&E, and Mrs O had to contact the switchboard for someone to go and assess him. It explained it had high levels of patients attending the department for treatment at that time and this impacted on waiting times.
88. The first time, Mr W attended A&E from the hospice, he arrived at 6.01am, he was reviewed at 7.25am and was discharged back to the hospice with advice for ongoing care. This is within the four-hour waiting time target set out in the ‘Handbook to the NHS Constitution’. However, we do recognise this was a significantly distressing experience for Mr W due to the pain he was in and the wait for a bed. We were sorry to learn he had this experience.
89. The second time Mr W attended A&E (two days later) he arrived at 1.51am, his observations were taken at 2.03am and he had bloods taken at 2.17am. Mr W was then seen by a trainee doctor at 3.37am and a plan was put into place for treatment with IV antibiotics for a suspected urine infection. It became clear his kidney function was worsening and the urology senior doctor was called to see him at 4.30am. This is within the four-hour waiting time target set out in the ‘Handbook to the NHS Constitution’.
90. During this review, the senior doctor had a discussion with Mrs O in which they explained Mr W’s blood results showed an acute kidney injury and a suspected blockage around the kidney. They had a discussion that it was felt Mr W was approaching the end of life, and an agreement was made for rapid discharge back to the hospice to focus on comfort and dignity.
91. We consider there are signs that on both occasions it seems Mr W received fast medical attention and was assessed and treated appropriately. This is in line with the GMC’s ‘Good medical practice’ guidance with regards to 15a – adequately assessing the patient’s conditions, taking account of their history and examining them where necessary, and 15b - promptly providing or arranging suitable advice, investigations or treatment where necessary.
92. Despite this, we do not wish to detract from Mr W and Mrs O’s experience and the distress they faced because of this. We recognise it was a difficult time for them. We hope the information in this statement gives some reassurance to Mrs O about her father’s care.