Failure to recognise and manage Mrs L’s vulnerability
19. Mr L complains the Trust did not recognise and manage Mrs L’s great vulnerability. He says this is because it did not do a written vulnerability assessment, and did not take Mrs L’s medical history into account.
20. In its response, the Trust said it does not have a written vulnerability assessment, but it looks at a patient's medical history and their current health issues when making decisions to move them around wards.
21. We reviewed this issue with help from our advisers.
22. GMC guidelines say doctors must give a good standard of practice and care. If they assess, diagnose or treat patients, they must:
• properly assess the patient’s condition, looking at their history (including their symptoms and psychological, spiritual, social and cultural factors), their views and values; and, where necessary, examine the patient • quickly give or arrange suitable advice, tests or treatment where necessary • and refer a patient to another practitioner when this would be better for the patient.
23. When Mrs L was admitted to the Trust on 9 June, her medical records listed her medical problems, specifically, that she had heart failure, COPD, dementia and atrial fibrillation (irregular heartbeat). The records also showed she was usually very confused and not able to do much at home. The Trust also did a confusion assessment. On 11 June, staff at the Trust filled in a mental capacity assessment form saying Mrs L was not able to make decisions about NIV.
24. This shows from a medical perspective, the Trust understood Mrs L’s health problems, frailty and dementia when she was admitted and looked at them as part of her assessment. This is in line with the GMC guidelines above.
25. We understand this was a worrying time for Mr L, and we hope this gives him some reassurance that staff at the Trust saw Mrs L’s vulnerability and took her medical history into account.
26. We next looked at how the Trust managed Mrs L’s vulnerability while she was an inpatient.
27. Our nursing adviser said the Trust does not need a written vulnerability assessment, and clinicians can find out a patient’s needs through nursing assessments.
28. The NMC code states nursing assessments should cover all aspects of basic care. It says among others, the basics of care include nutrition, hydration, bladder and bowel care, physical handling and making sure that those getting care are kept in clean conditions. It also says nurses use information they got during these assessments to find out what is needed and most important for giving each patient the proper nursing care and support. Nurses work together with people to come up with care plans that take into account their circumstances, characteristics and preferences.
29. We have looked at the Trust’s nursing assessments. The nursing assessment found Mrs L needed help with her hygiene needs. However, the section explaining how this will be managed had not been completed. We therefore cannot say whether the Trust took care of Mrs L’s hygiene needs in line with her preferences.
30. A Waterlow score shows a patient’s likely risk for getting a pressure sore. Mrs L’s Waterlow score is incorrect and incomplete. This is because staff did not score Mrs L’s loss of appetite, her age or single organ failure. They also incorrectly noted down her skin as ‘healthy’ despite finding skin damage. Her Waterlow score should therefore have been 16, not six as documented. A score of 16 puts a patient at a higher risk of further skin damage and would mean staff would need to complete a risk plan. It also means Mrs L should have been checked at least every hour through the day, and every two hours at night.
31. There were intentional rounding charts (charts for recording regular checks nurses in hospitals carry out on patients) for 11 and 12 June, but they did not show how often the nurses did the checks. The evidence shows Mrs L did not get checks as often as she should have.
32. Mrs L should also have had a falls multifactorial risk assessment (completed for all patients aged 65 years and older). This assessment is blank.
33. Therefore, the evidence shows nursing assessments were incorrect or incomplete. This means nursing staff did not plan care with Mrs L’s needs in mind, and this shows they did not manage her vulnerabilities in line with the NMC code. This shows a failing happened.
34. We have thought about whether this had an impact on Mrs L with the help of our nursing adviser. We cannot say whether Mrs L’s needs were fully met due to incorrect or blank assessments, but her comfort may have suffered as a result. We understand this will be distressing for Mr L, especially as he was worried about Mrs L being on her own when he was not able to visit her.
35. Our principles say where maladministration (fault) or poor service has led to injustice or hardship, public organisations should try to put things right in a way that returns the complainant to the position they would have been in otherwise. If that is not possible, the organisation should compensate the complainant properly.
36. A proper range of compensations will include an apology, explanation and acceptance of responsibility.
37. We have looked at the actions the Trust took as a result of Mr L’s complaint.
38. In its complaint response, the Trust accepts staff did not complete the documentation during Mrs L’s admission as well as they should have. It apologised to Mr L for this.
39. The Trust also stated several actions it had taken to make sure these issues will not happen again. This includes talking about the complaint with staff (including the expected standards) and setting up a new accountability handover document that needs to be checked weekly.
40. We think these actions will mean the earlier guidance is met, and will hopefully keep the same events from happening again.
41. We can also see the Trust has made an apology for staff not completing documentation properly, but it has not apologised for not managing Mrs L’s vulnerability as it should have. We talked about this further with the Trust, which agreed to send an apology letter to Mr L about this point.
42. We think the steps the Trust has already taken, along with the further apology it has agreed to make, are enough to put right the impact caused. This is in line with our Principles.
43. We will therefore not be looking into this part of the complaint further.
Failure to consult with Mr L as Mrs’s L carer
44. Mr L is unhappy the Trust did not talk with him about Mrs L’s condition and overall well-being while she was an inpatient.
45. Information-sharing in hospital is up to the multidisciplinary team (MDT – a group of healthcare staff working together to give patients the care and support they need). We therefore looked at this issue with help from our advisers.
46. The NMC code says nurses should give information about and explanations for people’s treatment and care to the people and their families and carers.
47. GMC guidelines state doctors must be considerate to those close to the patient and be sensitive and responsive in giving them information and support.
48. The medical records show during the admission, the nurses and doctors caring for Mrs L either updated Mr L by telephone or during ward rounds. These were daily and included updating him on the plan of care and on Mrs L getting worse.
49. On 11 June, the medical records say staff updated Mr L about the recommended summary plan for emergency care and treatment (ReSPECT - a plan for how to treat and care for patients who cannot make decisions for themselves in case of an emergency) and about the do not attempt cardiopulmonary resuscitation decision (a decision not to try to get a person’s heart or breathing going again if they stop). Staff also made two further calls to him later that day, but he did not answer. This shows staff were trying to contact him to update him about Mrs L’s plan of care.
50. The evidence shows staff updated and talked to Mr L about Mrs L’s care, and this is in line with the relevant guidance. There is no sign of a failing here, and we will therefore not be looking into this part of the complaint further.
Failure to identify, monitor and effectively treat Mrs L’s conditions, including the use of NIV
51. Mr L says they had been managing Mrs L’s health at home, and he does not understand how her condition got so much worse in the short time she was admitted.
52. We looked into how the Trust managed Mrs L’s conditions by looking at her medical records with our advisers.
53. Clinicians use the National Early Warning Score (NEWS) for the first assessment of acute illness and for ongoing monitoring of a patient’s well-being throughout their stay in hospital. By recording NEWS regularly, hospital staff can keep an eye on the patient’s condition to spot early warning signs of a possible worsening of their health and put in place the care they need. If a patient scores three or higher on NEWS, staff should respond urgently, and if the patient scores seven or higher, there should be an emergency response.
54. Throughout Mrs L’s admission, staff kept an eye on her NEWS, and she scored between zero and ten. The main causes of the high NEWS were a high pulse rate, a high respiratory rate (fast breathing) and low oxygen levels. This is consistent with the first diagnosis of pneumonia (infection of one or both of the lungs) and Mrs L’s existing COPD.
55. At each time her NEWS was raised, staff either referred Mrs L to a doctor, or she already had an escalation plan (ReSPECT) in place.
56. In summary, staff completed NEWS properly and in line with the guidance above.
57. BTS guidelines state patients admitted to hospital with suspected community-acquired pneumonia (pneumonia the patient got outside the hospital) should have a chest X-ray done as soon as possible to see whether the diagnosis was right or not.
58. NICE guidance says to treat community-acquired pneumonia with an antibiotic. It also states to reassess adults if symptoms or signs do not get better as they should or worsen quickly or a lot.
59. On 9 June, the Trust admitted Mrs L and diagnosed her with community-acquired pneumonia on the basis of her symptoms and a chest X-ray that showed an infection of the left lung. Clinicians then treated Mrs L with intravenous antibiotics (antibiotics given through the veins).
60. On 11 June, Mrs L had a high NEWS of eight. Doctors diagnosed her with pneumonia, respiratory failure (a condition that makes it difficult to breathe on your own) and fast heart rate. The plan was to keep giving her antibiotics, and, after a talk with the respiratory consultant, doctors decided to start NIV. This started on 11 June at about 10am.
61. Doctors took Mrs L off NIV at 11.15pm, as she was not tolerating it.
62. The diagnosis and treatment of Mrs L’s pneumonia were therefore in line with the guidelines mentioned above.
63. We next looked into the use of NIV.
64. BTS guidelines recommend NIV as treatment for respiratory failure. However, the guidelines state NIV should not be given to patients whose respiratory failure is due to pneumonia, as was the case for Mrs L. Therefore, she should not have had NIV.
65. Further, the medical records state several times that Mrs L had dementia and delirium (confused thinking). The ReSPECT form in place also stated Mrs L should not get NIV due to her dementia and delirium as she would not tolerate it.
66. There is no other treatment in this situation. This is because doctors did not think Mrs L was suitable for an intensive care unit, so keeping her comfortable and giving her oxygen would have been appropriate.
67. It therefore seems that Mrs L got NIV for about 13 hours even though she should not have got it, and this shows there was a failing. We have thought about whether this had any impact on Mrs L with the help of our physician adviser.
68. Our physician adviser said NIV can be quite difficult to cope with due to the tight-fitting face mask. Given Mrs L’s dementia and delirium, getting NIV may have been difficult for her, but the medical records do not seem to say it distressed her (until it was removed, when the documents say she was not tolerating it).
69. NIV does not treat the cause of respiratory failure. It can support breathing while the treatment of the underlying conditions starts to work. Therefore, we do not think the use of NIV shortened Mrs L’s life, but it may have been distressing for her to get it. This probably also caused distress to Mr L.
70. We have looked at our Principles again to look at the actions the Trust took about this issue. We did this with the help of our physician adviser.
71. BTS quality standards explain a set of steps clinicians should follow when giving NIV. This includes making sure patients meet the criteria for NIV, and staff who give the treatment have the proper training.
72. In its complaint response, the Trust says since the events, it has now moved delivery of NIV to a dedicated unit (called a respiratory support unit, or RSU). This means it now has specialist nurses to start NIV and challenge inappropriate requests for NIV, and a respiratory doctor to give specialist advice to patients. The Trust also now has a special NIV referral system and escalation process in place.
73. We think the changes the Trust made, including the use of an RSU, mean it is in line with the BTS quality standards for giving NIV, and this should hopefully keep the same situation from happening again.
74. We can see the Trust has made appropriate improvements, but it has not apologised to Mr L for the improper use of NIV and the distress this caused. We talked about this further with the Trust, which agreed it would send an apology letter to Mr L about this.
75. We think the steps the Trust took, along with the further apology, are in line with our Principles and put right this issue of complaint. For these reasons, we will not be looking into this part of the complaint further.
Failure to allow Mr L to help with Mrs L’s care and to visit her before she was dying
76. Mr L complains the Trust did not let him visit Mrs L earlier or help with her care. He says as he was her husband and carer, he could have helped the staff.
77. We looked at the Trust’s internal policy with the help of our physician adviser.
78. The Trust’s internal policy says Mrs L should have had a visiting risk assessment, given that she was in a high-risk area (a COVID-19 ward) and had dementia. The policy also explains exceptions to the normal rules, including compassionate grounds for visiting patients who are getting end-of-life care and visiting for carers to help support patients with dementia.
79. Based on the Trust’s internal policy, it seems Mrs L met the criteria for Mr L to support her care needs due to her dementia and to be with her during the end-of-life care.
80. There is no evidence in the medical records Mrs L had a visiting risk assessment, and staff did not tell Mr L he could visit her earlier during her inpatient stay. We can see this was distressing for Mr L.
81. We thought about what actions the Trust has taken about this issue, using our Principles.
82. The Trust accepts there is no documented risk assessment, and that staff should have done one for Mrs L. It says it should have been flexible and looked into the risks to allow Mr L earlier visiting to see Mrs L. It apologised for the distress and upset this caused Mr L. It also says it has shared the events with medical and nursing teams, and there are now clear recommendations in place, which include allowing compassionate visiting for end-of-life care patients.
83. We can see the Trust has accepted what went wrong and offered its apologies to Mr L. It has also explained the improvements made to its service. In line with our Principles, we think these actions put right what went wrong, and we hope this reassures Mr L that the same events should not happen again. We will therefore not be looking into this part of the complaint further.
Inaccurate recording of the verification and time of Mrs L’s death
84. Mr L is unhappy that the time of Mrs L’s death in the medical records is incorrect.
85. Mr L says staff told him when he got to hospital in mid-June that Mrs L had died that morning, and he went to see her body at around 10am. The Trust’s response says the medical records say Mrs L died at 3pm.
86. Mrs L was admitted during the COVID-19 pandemic. Verifying death guidelines state the process of verifying a death during this period of emergency was to check the identity of the person and record their details. Staff recorded the time of death as the time at which verification criteria (above) had been fulfilled. Our nursing adviser also explained that ward-based nurses cannot verify a patient’s death, and they have to wait for a doctor to do this.
87. There is a nursing record from 7am of the day Mrs L died that states Mrs L ‘died this morning’. There is a further entry from later that day at 3.05pm, where the doctor has verified Mrs L’s death and put the time of death down as 3pm.
88. It seems nursing staff were not able to verify Mrs L’s death when she died and had to wait for a doctor to do this. We understand this delay is upsetting for Mr L.
89. The wait for a doctor probably happened due to extreme clinical pressures during the COVID-19 pandemic. When a doctor was available, they verified Mrs L’s death and recorded it at the time they saw her. This is in line with the verifying death guidelines. We understand this is disappointing for Mr L, and we are sorry to hear of the upset this caused.
90. As the verification of Mrs L’s death was in line with the guidelines above, we will not be looking into this part of the complaint further.
Summary
91. Some things did not happen as they should have with Mrs L’s care. We are sorry to hear of the distress the Trust’s actions caused Mr L at what was certainly a sad and difficult time. We hope the Trust’s further apology gives Mr L closure on his complaint.