The actions of a nurse (Ms K)
15. Ms T complains Ms K took too long to bleep for medical help when her mother was having a seizure. She wants to understand why the nurse waited. She also disputes Ms K’s recollection that she put Mrs T into the recovery position.
16. The NICE CKS explains what clinicians should do when someone is having a seizure. The most important thing is to keep the patient’s airway open and protect them from injury. Clinicians should put the patient in a safe position, such as the recovery position. If the seizure lasts for more than five minutes, they should ask for emergency help, such as from the critical care outreach team.
17. The NEWS Guideline explains how clinicians should examine and treat acutely ill patients. The NEWS is a scoring system that gives a score to various physiological measurements (breathing rate, levels of oxygen in the blood, blood pressure, pulse, level of consciousness and temperature). The resulting score should help the clinician to decide whether further action is needed, and if so, what that should be.
18. The NMC Code sets out the standards nurses should follow. It says they should treat people as individuals and look after their dignity. They must treat people with kindness, respect and compassion. They must ‘deliver the fundamentals of care effectively’.
19. Ms K’s clinical record of the incident in mid-March 2021 is brief. She completed the record at 2.40am the next day. She noted Mrs T’s general condition was stable but poor and she had had a seizure. She noted bleeping the on-call doctor twice without a response. She then noted, ‘fast bleep was done for both outreach and the doctor’.
20. Ms K also noted down Mrs T’s NEWS score at 10.54pm. She noted Mrs T had a score of 11, which meant the clinical risk was high and she needed an urgent or emergency response. But she was not having a seizure at that point. The records do not show any evidence Ms K responded to the high NEWS score.
21. A doctor recorded a review with Mrs T at 11.41pm on the day of the incident. This was in response to Ms K’s ‘fast bleep’. The doctor noted Ms T told her Mrs T had been seizing for less than ten minutes. A later entry said the seizure lasted for 20 minutes. The doctor gave Mrs T an injection of lorazepam (a medicine used to treat anxiety and sleeping problems, or to help patients relax before an operation or other medical treatment), which ended the seizure.
22. During the Trust’s complaint investigation, the manager of ward B met Ms K. Ms K said when she noticed Mrs T was having a seizure, she moved her into the recovery position. The ward manager said once the seizure had been going on for more than five minutes, she should have ‘fast bleeped for help’. Ms K accepted she did not do so, and this fell below the expected standards.
23. Ms T gave us her detailed recollection of the incident, which is different to Ms K’s account. She says Ms K left her mother on her back and was unkind and uncaring. She says Ms K told her she had bleeped a doctor. Ms T says she felt helpless as her mother’s seizure kept going on. She remembers asking Ms K for help again. Ms K bleeped a doctor for the second time. After 20 minutes, Ms T says Ms K finally ‘fast bleeped’ and a doctor came who gave her mother the medication she needed.
24. Ms T’s account of these events seems convincing, and we have no reason to doubt her memories. There is evidence to show Mrs T had a long seizure, lasting for at least five minutes and probably up to 20 minutes. There is no evidence in the records to show Ms K used the recovery position.
25. Our view, based on the evidence, is Ms K did not put Mrs T in the recovery position. Ms K did not look after Mrs T’s dignity or treat her with kindness and compassion. She did not follow the NMC Code. She also fell below the standard expected in the NICE CKS when she did not ask for emergency help once the seizure had been ongoing for five minutes.
26. Ms K also knew before Mrs T’s seizure started that her NEWS score was high. The nursing adviser told us Ms K should have called a doctor to ask for an urgent or emergency response. There is no evidence she did so. She only bleeped a doctor after Ms T let her know of her mother’s seizure. This falls below the NEWS Guideline.
27. The Trust told us Ms K has now retired. After the incident in mid-March 2021, she had further training about how to respond to deteriorating patients. We cannot at this stage explain why Ms K did not follow the relevant standards.
28. We asked the medical adviser about the impact of the delayed response to Mrs T’s seizure. He said it would not have had a great impact on Mrs T’s health. Doctors may have seen Mrs T more quickly and given her the lorazepam sooner. The seizure happened because of the huge burden of Mrs T’s illness and was not the cause of the illness. We also cannot say a doctor would have stopped the seizure from happening if they had reviewed Mrs T because of her raised NEWS score. It was her ongoing illness rather than seizure that caused the high NEWS score.
29. We can understand how upsetting it would have been for Ms T to see her mother’s long seizure and the lack of response from the nurse. Some of the distress would likely not have happened if Ms K had taken quick action when the seizure had lasted longer than five minutes. A doctor is likely to have come more quickly to give an injection to stop the seizure. We have seen no evidence to show the seizure could have been held off completely, so there would always have been some distress. We partly uphold this part of Ms T’s complaint.
Medication
30. Ms T says her mother had a seizure before her admission to the Trust. She then had another seizure when she first got there. Ms T wants to know why doctors did not give her mother antiseizure medication she could have taken when needed.
31. The NICE Guideline has since been replaced, but the replacement guidelines make the same recommendations. They set out the treatment doctors should give in different cases. They explain that doctors should first use intravenous (medicine given directly into the vein) lorazepam. If seizures go on for a long time, they should use maintenance treatments such as levetiracetam (a medicine used to treat epilepsy).
32. The clinical records show Mrs T had a short seizure, lasting for around one minute, on 9 March 2021. Doctors gave her injections of lorazepam and levetiracetam. The medical adviser told us the most likely cause of a seizure are a stroke, sepsis (a high fever can cause seizures in older people), issues with metabolism (the chemical reactions by which the body makes food and oxygen into energy and gets rid of waste products) or advanced dementia.
33. Doctors did not do anything to keep Mrs T from having seizures after the first episode at the Trust. The medical adviser told us this was appropriate. Doctors should only think about giving treatment if the patient has ongoing seizures (known as status epilepticus) or repeated separate seizures. There was no evidence of these problems at that stage. Doctors followed the NICE Guideline when they gave Mrs T a single dose of medication.
34. The day before she died, Mrs T had a second, long seizure, lasting for up to 20 minutes. Again, doctors treated this effectively with lorazepam. Afterwards, they gave Mrs T maintenance treatment of levetiracetam. Again, doctors followed the NICE Guideline.
35. We think the doctors caring for Mrs T followed the NICE Guideline when they gave her anti-seizure medication. There was no need for them to prescribe regular medication before the day Mrs T had the second seizure. We do not uphold this issue.
Meningoencephalitis
36. Ms T says the clinical records from the evening of the day of the second seizure show doctors thought her mother probably had meningoencephalitis. They then gave her medication. She asks why nobody made this diagnosis in the three days before.
37. The GMC’s Good Medical Practice says doctors must give a good standard of care. This includes doing proper assessments, thinking about the patient’s history and examining them if necessary. Doctors should also set up timely treatment and investigations or referrals if needed.
38. Mrs T first came to the Trust with suspected sepsis or a possible stroke. Doctors in the emergency department reviewed her, looking at her complex medical history. They noted down their findings and examined her. They arranged scans. They made a first diagnosis of stroke and respiratory failure.
39. Over the following two days, doctors could not reach a clear diagnosis for Mrs T. Several doctors looked at her and noted her history and symptoms. They noted a rise in troponin levels (a protein in the body), which would usually point to a heart attack, but Mrs T did not have other signs of a heart attack. The doctors then did various blood tests and scans to try to find the cause of the problem.
40. Doctors first talked about a possible diagnosis of meningoencephalitis on the morning of the day of the second seizure. By then, they thought a stroke was unlikely, based on the test results. They also noted signs of aspiration pneumonia (an infection of the lungs or large airways caused by food or liquid being breathed in) and worsening COPD.
41. On the same day, a doctor tried to do a lumbar puncture (a procedure in which a needle is inserted between the bones in the lower spine) to see whether there were signs of infection in the central nervous system. This was unsuccessful, and the doctor could not get enough fluid for analysis. The plan was to do another puncture with anaesthetic the next day, but Mrs T was too unwell by that stage. In the meantime, doctors thought meningoencephalitis was a likely cause of some of Mrs T’s symptoms.
42. The medical adviser told us meningoencephalitis was a possible diagnosis, but doctors could not confirm it during Mrs T’s admission to the Trust. Despite this, they treated her for meningoencephalitis with intravenous antibiotics and anti-viral medication. The medical adviser said this treatment was right. Mrs T was too unwell for a lumbar puncture or an MRI scan (a scan that uses strong magnetic fields and radio waves to get detailed images of the inside of the body), which may have helped to confirm a diagnosis. Neither of these would have changed how clinicians treated Mrs T.
43. The clinical records show doctors did proper assessments when trying to find the cause of Mrs T’s problems. They gave her the treatment she needed and arranged tests to help them make a diagnosis.
44. The medical adviser told us Mrs T was very unwell. She had many existing health problems, and her symptoms were complicated. Doctors made a range of working diagnoses. He said they managed Mrs T properly and he did not think anything could have been done differently that would have led to her surviving her illness.
45. We think the doctors followed Good Medical Practice when caring for and treating Mrs T. They did not diagnose meningoencephalitis during her admission, so there was nothing more they could have done.
Complaint handling
46. Ms T says the Trust did not give proper answers to her first complaint. She says it then refused to answer some further questions she had.
47. Our Principles of Good Complaint Handling explain how public organisations should deal with complaints. It says they should be ‘open and accountable’, which includes giving evidence-based explanations and reasons for decisions. It says they should act ‘fairly and proportionately’, which includes making sure they look into complaints thoroughly and fairly and make decisions that are fitting and fair. It also says organisations should look for ‘continuous improvement’, which includes using lessons learned from complaints to improve their services.
48. Ms T first complained to the Trust on 26 April 2021. She wrote a detailed account of her experience during her mother’s admission to the Trust. She then listed six specific questions.
49. On 15 July 2021, the Trust sent its first response to Ms T. It responded to each of the six specific questions. It also commented on three of the general issues Ms T referred to in her detailed account. For the most part, we can see the Trust’s responses were appropriate and based on the available evidence. But the Trust did not give a proper answer to one of the numbered questions.
50. Ms T wanted to know why Ms K had not used a ‘fast bleep’ during her mother’s long seizure on the day before her death. The Trust replied by explaining what had happened and what should have happened. It accepted Ms K should have used a ‘fast bleep’, and what happened fell below the expected standards. The Trust talked to Ms K but did not explain why she delayed looking for medical help.
51. The Trust’s failure to fully answer the question about Ms K was not ideal. But when looking at the first response as a whole, we can see it largely gave evidence-based explanations and reasons for decisions. In general, the Trust’s first response showed it had looked into the complaint thoroughly and fairly.
52. Ms T was unhappy with the Trust’s first response and sent a detailed letter to the Trust on 21 July 2021. This contained a number of questions. Some of these repeated issues the Trust had already responded to. Others asked further questions following on from the Trust’s response. Ms T also asked a series of new questions that had not been part of her first complaint, and which her review of her mother’s clinical records prompted.
53. On 9 August 2021, the Trust replied to Ms T by email. It thought it had already answered Ms T’s complaint and had nothing to add. The Trust failed to see that Ms T had raised several fair questions about the Trust’s first response. She also asked further questions that were not part of her first complaint. The Trust did not act ‘fairly and proportionately’ when it decided not to look into the new issues or answer Ms T’s questions about its first response.
54. Ms T then got in touch with us. We noted the Trust had not responded to the new issues in Ms T’s second complaint. The Trust agreed to write a further response to questions in two specific areas, about medication for seizures and treatment of patients on the COVID-19 shielding list.
55. The Trust sent its last response on 8 August 2022. It answered Ms T’s questions about the two new issues, giving evidence-based explanations and reasons for decisions.
56. We can see how the Trust’s refusal to answer Ms T’s questions after its first complaint response has left her with unanswered questions. We can see how this added to her distress at a time when she was grieving. We can also see the Trust has answered most of her main concerns. It is not possible now to find out why people did or did not act in a certain way because of the time that has passed. Also, many of the clinicians involved in the complaint will no longer be working for the Trust or will have different roles. It would be very difficult for the Trust to answer Ms T’s unanswered questions now. We do not think it would be fair to ask the Trust to respond to the unanswered questions at this stage.
57. Ms T also says she is not sure the Trust has taken proper action to make sure staff have learned from her complaint.
58. In the Trust’s first response, it explained how it had acted after Ms T’s complaint. It said it had:
· spoken to one of its nurses about unprofessional behaviour · fed back Ms T’s concerns about attitude of staff to the team on ward B · arranged refresher training for Ms K and the team on ward B about how to get more care for patients when needed · fed back Ms T’s concerns about a doctor not being empathetic when breaking bad news and updating families · and made sure the complaint would be talked about at a ward daily meeting and a governance meeting to make sure learning was spread throughout the Trust.
59. In our view, the actions the Trust has taken are enough to show it has used the lessons learned from Ms T’s complaint to improve its services. Ms T believes the action should be stronger, including reporting some staff to the NMC. We understand her strong feelings about these issues. We cannot recommend the Trust take disciplinary action. We have seen further failings by Ms K the Trust has not accepted. But, when looking at the complaint responses as a whole, we think the Trust has sought ‘continuous improvement’.
60. In summary, we think the Trust’s first and third responses showed it was being ‘open and accountable’ and it acted ‘fairly and proportionately’. But this was not the case with the response to Ms T’s second complaint. The Trust’s not answering Ms T’s questions about its first response and about further concerns she had found after reading her mother’s clinical records was unfair. We also think the Trust has sought ‘continuous improvement’ by showing that it learned from the complaint.
61. We partly uphold this issue. This is because we can see how failings in complaint handling led to an injustice to Ms T.