7. Mr D complains that the Trust should not have discharged his mother on 11 October 2020 because she was unable to swallow antibiotics and was too unwell. Mr D also complains the Trust failed to give suitable antibiotics during his mother’s admission from 14 October.
8. Mr D says if she had been treated with suitable antibiotics, she may not have died. He says her avoidable death has caused him to feel depressed and angry.
9. Mr D would like a financial payment and service improvements.
10. Mr D returned from holiday on 11 October 2020 to find his mother confused. Mrs G lived alone but had carers visiting her twice a day and Mr D lived nearby.
11. Mr D took Mrs G to the Trust’s emergency department (ED) at 8pm. She was discharged just before midnight with a suspected urinary tract infection (UTI). She was given a course of antibiotics.
12. Mr D brought Mrs G back to hospital on 14 October. Sadly, she died in hospital later that month.
Antibiotics
17. Mr D said when he took his mother to the ED on 11 October, he told the Trust many times that she could not swallow antibiotics in tablet form. He says he could not have ‘raised the issue more’ than he did. He said she should not have been discharged but instead given IV antibiotics.
18. In its first complaint response the Trust said it could not find any evidence that Mr D said Mrs G needed antibiotics in a different form. It said the doctor looking after Mrs G had no memory of Mr D saying this. It said most of the medication already prescribed to Mrs G was in tablet form.
19. The Trust wrote to Mr D again and it agreed with Mr D that Mrs G ‘struggled to take medication’. It said the records do not provide any further detail around this. It said because Mrs G’s existing medication was in tablet form, it was reasonable to prescribe antibiotics in tablet form. It said IV antibiotics would not routinely be used as a first line treatment for a UTI.
20. When Mr D brought Mrs G to the ED, he told the Trust she ‘had not been taking her normal medication’. We can see the Trust wrote in the records that Mrs G was ‘struggling’ to take her medication.
21. The evidence we saw does not give a clear indication about what was causing Mrs G to have problems with taking her medication. Mr D’s account is that Mrs G was physically unable to swallow. Our adviser said the records do not refer to an underlying problem with Mrs G’s swallowing reflex.
22. Our adviser said they noted information that could have affected Mrs G’s ability to take medication. The records show Mrs G had experienced ‘nausea’ and ‘confusion’ in the days leading up to her admission. During her first ED assessment, the Trust noted Mrs G was ‘not eating much, not drinking as much’ and was ‘more confused than normal’. An ED nurse noted that Mrs G had ‘started to vomit’ after drinking water.
23. We think there is enough evidence to show that Mrs G was experiencing problems with taking her medication, regardless of what was causing the problem.
24. We considered the ED doctor’s actions in line with GMC guidance. This guidance sets out the standards people can expect from their doctor. It tells doctors, ‘you must provide a good standard of practice and care. If you assess, diagnose, or treat patients, you must adequately assess the patient’s conditions, taking account of their history (including the symptoms and psychological, spiritual, social, and cultural factors), their views and values; where necessary, examine the patient.’
25. The records show Mrs G was discharged just before midnight. The ED consultant noted they were discharging Mrs G ‘in the interests of avoiding risks of admission to hospital’. They prescribed Mrs G oral trimethoprim (tablet antibiotics) ‘to go home on’. The records also state that Mr D ‘agreed to watch out for [Mrs G’s] deterioration’ and ‘to make sure she took her [antibiotics].’
26. Although this entry seems to show that Mr D agreed to the discharge and to help Mrs G take her medicine, it does not show the Trust had taken account of Mrs G’s problems with taking medication. We did not see any sign that she was able to swallow her antibiotics before being discharged. The records do not show how Mr D could have made sure Mrs G took her medicine, if she was struggling to take them. If she was physically unable to take them, we imagine Mr D would have been limited in what he could do to help her.
27. Our adviser suggested the Trust could have expected that Mrs G may not manage to take the oral antibiotics because it knew she had been struggling to take her normal medication and had vomited while she was in the ED. They said the Trust should have considered whether it could give Mrs G her antibiotics in a liquid form. They said this would have been easier for her to take.
28. Our adviser also suggested it would have been sensible for the Trust to watch Mrs G to see if she managed to take the tablets or not, before it made the decision to discharge her from the ED.
29. We consider the evidence shows that on 11 October the ED doctor did not fully take Mrs G’s symptoms and history into account when they assessed her.
30. We also considered if the Trust should have offered Mrs G support with taking her medication. NICE guideline 67 aims to make sure adults who have social care in the community get support to manage their medication. It covers how support should be ‘planned and delivered’. We think this guideline applies to Mrs G’s situation because she had a package of care at home from care workers.
31. The guideline says, ‘health professionals should provide ongoing advice and support about a person's medicines and check if any changes or extra support may be helpful, for example, by checking if: • the person's medicines regimen can be simplified • the formulation of a medicine can be changed • support can be provided for problems with medicines adherence • a review of the person's medicines may be needed.’
32. Our adviser says if the Trust had checked if Mrs G needed changes or extra support as it should have, it should have considered prescribing a liquid form of her medications. This means it may have prescribed the antibiotics as a liquid. This would have made it easier for Mrs G to take her medication by herself or with support from Mr D or the care workers.
33. We think this is a failing. We look at whether the failing led to an impact later in our report.
Sepsis
34. The NICE guideline on recognition, diagnosis and early management of sepsis sets out that healthcare professionals should consider anyone with a possible infection to be at risk of sepsis. The guideline sets out how healthcare professionals should screen people at risk of sepsis.
35. The guideline says healthcare professionals should, ‘assess people with any suspected infection’ to identify the possible cause of their infection, any factors that increase the risk of sepsis and any sign of ‘clinical concern’, including abnormal behaviour, a high heart rate, or breathing difficulties. It explains patients should be managed and treated for sepsis if they have one or more high-risk criteria.
36. As we know, Mrs G had a suspected UTI when she attended ED on 11 October. So in line with the NICE guideline, the Trust should have considered her to be at risk of sepsis.
37. The NICE guideline says a heart rate of more than 130 beats per minute (bpm) is ‘high risk’ criteria for suspected sepsis. Not long after she arrived in the ED, Mrs G’s heart rate was 133bpm.
38. The records show Mr D told the Trust Mrs G was ‘more confused than normal’. As we know, she had not been taking her usual medication at home. The Trust noted Mrs G was showing signs of ‘mild delirium’ and was ‘pleasantly confused’. Our adviser said this is objective evidence of a ‘new altered mental state’ which, according to the guideline is ‘high risk’ criteria.
39. So, as we have seen, Mrs G had two ‘high risk’ criteria and should have been managed and treated for suspected sepsis.
40. The NICE guideline sets out the steps healthcare professionals should take once they have identified that a person needs to be managed and treated for suspected sepsis. It says a senior clinical decision maker (a doctor or nurse authorised to prescribe antibiotics) should review the patient. It says they should be given antibiotics, fluids and have a blood test, including a lactate measurement (the amount of lactic acid in the blood). The guideline says a lactate measurement can help health professionals identify how a person is responding to treatment.
41. We did not see evidence that the Trust took Mrs G’s lactate measurement. But, the records show it treated her with at least 250ml of ‘infusion fluids’. A doctor reviewed her and prescribed IV antibiotics.
42. The NICE guideline says the next step healthcare professionals should take after treating a patient with fluids is to monitor them in the ED and have their observations taken every 30 minutes. Observations would include heart rate, temperature and respiratory rate.
43. We can see the Trust took Mrs G’s observations at 10.12pm on 11 October. The records show her heart rate had decreased to 110 after she was treated with fluids. According to the guideline, a heart rate between 90 and 130 indicates a person is at ‘moderate to high risk’ of suspected sepsis. These were the last observations the Trust recorded for Mrs G before she was discharged at 11.43pm.
44. Overall, this evidence shows us the Trust discharged Mrs G when she was still at ‘moderate to high risk’ of sepsis.
45. The Trust said it wanted to avoid admitting Mrs G because of the COVID-19 pandemic. We can understand why the Trust would have wanted to avoid putting patients at risk unnecessarily. But, we do not think the measures in place at the time support its decision.
46. In March 2020, NHS England and NHS Improvement issued advice to all NHS Trusts in preparation for the large numbers of people expected to need hospitalisation in the coming months due to COVID-19. Trusts were asked to urgently discharge all hospital inpatients who were ‘medically fit to leave’. NHS England and NHS Improvement advised ‘emergency admissions and other clinically urgent care should continue unaffected’.
47. We think the Trust should not have discharged Mrs G when it did. The evidence shows she was at moderate to high risk of sepsis and although she had treatment for this, the Trust did not follow the NICE guideline to continue to monitor her in the ED or to take her observations every 30 minutes. Added to this, the Trust’s decision to discharge Mrs G partly because of the risk of her getting COVID-19 was not supported by NHS England and NHS Improvement measures in place at the time.
48. We have seen a failing for this part of Mr D’s complaint. Had the Trust acted in line with the NICE guideline, Mrs G would have stayed in hospital until she was no longer at moderate to high risk of sepsis. We cannot know when this would have been.
Impact
49. Mr D told us Mrs G deteriorated after she was discharged on 11 October. He explained once she was back home, she was not taking her antibiotics. He said he called Mrs G’s GP who told him to ‘get an ambulance immediately’ as she could ‘go into kidney or liver failure’. This must have been very worrying for Mr D.
50. Mr D took Mrs G back to hospital on 14 October. The records state Mrs G had a ‘partially treated’ UTI, ‘difficulty swallowing, and a general deterioration’. The records show Mrs G’s daughter in law reported Mrs G was ‘confused’, had been vomiting over ‘the past couple of days’ and was ‘bringing her tablets back up’.
51. Our adviser said that Mrs G does not seem to have got better or worse between her discharge and her readmission on 14 October. They highlighted that Mrs G was given a National Early Warning Score (NEWS) of ‘1’ at discharge and ‘2’ at readmission on 14 October. NEWS is a simple scoring system where scores are given to specific physiological measurements (breathing rate, levels of oxygen in the blood, blood pressure, pulse, consciousness and temperature).
52. The higher the score, the further a patient’s physiological measurement is from the normal range. While these physiological measurements do not give the full picture of a person’s health, they give clinicians an accurate way of identifying and assessing people who are at risk of becoming acutely unwell.
53. As we know, Mrs G had a heart rate of 110 bpm when she was discharged. This is above the normal range of 51 to 90 beats per minute. When readmitted, Mrs G’s heart rate was closer to the normal range, but her temperature had dropped from 36oc to 35.6oc, slightly below the normal range between 36oc and 38oc.
54. Overall, the main difference between Mrs G’s physiological condition between 11 and 14 October is a less rapid heart rate and a slightly lower temperature. We do not think this is significant enough to show she had become more ill during that time.
55. Our adviser told us it is possible that Mrs G’s condition may have improved if she had stayed in hospital, but also that it is impossible to know whether there was a clinical impact on Mrs G being discharged. We cannot say Mrs G’s discharge on 11 Oct led to her sad death.
56. Our adviser noted Mrs G deteriorated very quickly and suddenly on the day before she died. Although we can see she was unwell when she was readmitted on 14 October, our adviser could see no evidence of Mrs G showing signs of sepsis until over a week later.
57. In summary, we cannot rule out that Mrs G may have had a better chance of recovery from her UTI without the failings we found. But, taking account of our clinical advice we cannot say this is likely or that she would not have had to go back to hospital. We can only say that the failings did not cause Mrs G to become more unwell between 11 and 14 October.
58. We recognise this will leave Mr D with some uncertainty about what the failing may have meant and we are sorry for the distress this will likely cause him.
59. We asked the Trust to take action to address the impact on Mr D. We understand we cannot change what he has been through, but we hope our recommendations will assure him that his complaint will result in improvements in care.
Admission between 14 and 22 October
60. Mr D says Mrs G should have been given IV antibiotics when she returned to hospital on 14 October. He says he phoned the ward to tell staff Mrs G was unable to swallow antibiotics in tablet form, but staff ignored him.
61. The NICE guideline on antimicrobial (antibiotic) prescribing for lower UTIs sets out the choices of treatment. The guideline says the first choice of treatment for women includes the antibiotic trimethoprim. The recommended dosage is 200mg twice a day for three days. It does not recommend that this drug should be given intravenously.
62. We can see the Trust prescribed trimethoprim on 14 October. It kept a record of every time Mrs G took this medication. This chart shows Mrs G took all the doses of trimethoprim between the evening of 14 October and her final dose days later.
63. We know Mr D was concerned Mrs G could not take her medication, but we have seen no evidence to suggest she missed a dose. We can see the Trust was helping Mrs G to take the medication by crushing it into a yoghurt.
64. Mrs G was next treated with antibiotics when she became more unwell with signs of sepsis over a week from the readmission. As we have seen earlier on in our report, the NICE guideline on the management of suspected sepsis says a patient should be treated with IV antibiotics within one hour of ‘assessment’.
65. The Trust assessed Mrs G as having suspected sepsis at 4.12am. We can see from her medication chart that she was given a dose of IV antibiotics (tazocin and metronidazole) at 4.20am and two further doses that day. Our adviser said by treating Mrs G with these antibiotics, the Trust acted in line with the NICE guideline.
66. Overall, we have seen that the Trust treated Mrs G with IV antibiotics when she needed them. We recognise how worried Mr D was about the treatment Mrs G had in the days leading to her sad death. We hope we have helped assure him that the Trust acted within the guidelines and there is no evidence of a failing for this part of the complaint.
1. We thank Mr D for bringing his complaint to us. We recognise how important the complaint is to him and the effort he has made to share his experience with us. We would like to offer our sincere condolences to Mr D for his sad loss.
2. Through our work, we have seen that North Tees and Hartlepool NHS Foundation Trust (the Trust) did not act in line with relevant guidance when it discharged Mr D’s mother, Mrs G, on 11 October 2020. We consider the Trust should have offered support to Mr D and Mrs G to help her take the antibiotics it prescribed.
3. We have also seen the Trust should not have discharged Mrs G when it did on 11 October. The evidence we have seen shows Mrs G was still at a moderate to high risk of sepsis (a life-threatening reaction to an infection). We do not think the Trust’s explanation that it discharged her partly because of the risk of COVID-19 to be in line with measures in place at the time.
4. We do not think the failings led to Mrs G’s sad death later that month. Even with the benefit of our clinical advice, we have not been able to say with any certainty how Mrs G was affected by the failings. Based on the evidence we have seen, we can only conclude that the failings did not cause Mrs G to become more unwell between 11 and 14 October. We are sincerely sorry for the uncertainty this will leave Mr D with.
5. We think the Trust gave Mrs G intravenous (IV means medicine given directly into the veins) antibiotics in line with relevant guidelines between 14 October and her sad death.
6. We partly uphold Mr D’s complaint. We asked the Trust to make service improvements and to pay Mr D £500 in recognition of the uncertainty he is left with.
67. In considering our recommendations, we have referred to our ‘Principles for Remedy’. These state that where poor service or maladministration (fault) has led to injustice or hardship, the organisation responsible should take steps to put things right.
68. Our Principles say organisations should look for continuous improvement and should use the lessons learnt from complaints to make sure they do not repeat maladministration or poor service. In line with this, we recommend the Trust should review the learning it will take from our findings and write to us and to Mr D to explain what actions it will take to address the failings we found. It should do this within 12 weeks of the date of this report.
69. The Trust should send us evidence it has complied with our recommendations. It should also send a copy of our final report and its action plan to the Care Quality Commission (CQC) and NHS Improvement.
70. Our Principles state that organisations should put things right and if possible, return the person affected to the position they would have been in if the poor service had not happened. If that is not possible, they should compensate them appropriately.
71. To decide on a level of financial payment, we review similar cases where the person has experienced similar injustice, along with our severity of injustice scale. After this review, we have asked the Trust to pay Mr D £500 in recognition that he will never know for sure how Mrs G was affected by the circumstances of her discharge on 11 October. It should make this payment within four weeks of the date of this report.