3. Ms C complains staff at the Trust delayed diagnosing her father’s COVID-19 illness and to start treatment during his admission in December 2020 . She says when they started treatment, staff did not provide the right type of treatment for his illness.
4. Ms C says the delay and problems with Mr C’s treatment meant he did not survive his illness.
5. Ms C wants the Trust to improve its service, apologise and make a payment to her.
6. Mr C attended the Trust’s emergency department (ED) one evening in late December 2020. Staff admitted him to hospital and did a COVID-19 test. This test confirmed Mr C had COVID-19.
7. Staff started Mr C on oxygen therapy three days later. They also started corticosteroid (steroids) and antiviral medications.
8. Sadly, Mr C’s condition deteriorated and he died the next day. The Trust’s medical examiner noted COVID-19 pneumonia as the main cause of his death.
The Trust’s diagnosis of COVID-19
12. Ms C told us:
• staff did not consider Mr C’s dementia and difficulty speaking English or allow her into hospital to translate his medical history to staff to help make a diagnosis • staff delayed doing a CT scan and CT angiogram when they admitted Mr C to hospital • staff delayed doing blood and urine tests.
13. The Trust said it complied with national guidance about restricting visitors to hospital to reduce the spread of COVID-19. It said staff spoke to Ms C on the phone to get Mr C’s medical history and details of the medication he had been taking at home.
14. The Trust said staff did a COVID-19 test while Mr C was still in the ED. Laboratory staff reported the positive result. The Trust said staff immediately moved Mr C to a ward where they treated COVID-19 patients.
15. We saw staff acted in line with relevant guidelines when diagnosing Mr C and we cannot see any delay in his diagnosing.
16. Section 15 of Good Medical Practice says if doctors assess, diagnose or treat patients they 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 • promptly provide or arrange suitable advice, investigations, or treatment where necessary.’
17. Mr C’s medical records show staff noted he did not speak English and he had dementia. Staff called Ms C, who they noted was his main carer, to get a history of his symptoms.
18. Staff recorded Ms C told them Mr C had a weeklong history of a dry cough, fever and shortness of breath. She also said he had been wheezy and more laboured in his breathing.
19. She also told staff Mr C had been experiencing haematuria (blood in his urine) and dysuria (pain passing urine) for a week. He had a history of ongoing urinary tract infections (UTIs). She said his GP had given him a course of coamoxiclav (antibiotics). Ms C told staff this treatment did not work and his temperature increased.
20. Also, in their first assessment in the ED, staff recorded this kind of information. The paramedics who brought Mr C to hospital passed on this information, which they got from Mr C’s family while in his home.
21. Our physician said because staff could get information about Mr C, including by phone from Ms C, this gave staff an appropriate patient history to inform their assessment.
22. We cannot see staff needed to allow Ms C into hospital to help make a diagnosis.
23. As noted in his records, staff examined Mr C in the ED. Through their examinations staff noted he had abdominal pain and a fever. They also did blood tests which our physician said showed abnormal liver function. Staff also noted he had a history of gallstones.
24. To rule out the possibility of gallstones, staff asked surgeons to review Mr C, which they did later in the evening. Staff also did a COVID-19 test to check their suspicion of this illness.
25. From Mr C’s records, we can see laboratory staff confirmed the result of his test and it is noted in his records. We saw staff acted on this because his records confirm he was moved to another ward.
26. Our physician said there are no specific guidelines or targets for how quickly staff should have confirmed any suspicion they had about COVID-19. They added this often depends on a hospital’s laboratory facilities.
27. At this time the NHS was experiencing the second surge of COVID-19 cases and this put pressure on trusts. But, our physician said the reporting of Mr C’s test result was not delayed. Staff needed the result of his test to confirm a diagnosis of COVID19. Our physician could see no delay in reaching the diagnosis or in the steps taken to do this.
28. We appreciate Ms C said staff did not do tests quickly, like the CT scans. Our physician said staff did the investigations they needed to diagnose Mr C’s COVID19. We cannot see that it needed to do other tests or scans.
29. We recognise Ms C wanted and expected staff to diagnose her father’s COVID-19 as soon as possible. We hope our review helps assure her staff did so quickly and there was not a delay. We appreciate Ms C also has concerns about Mr C’s treatment. We go on to address these concerns below.
The Trust’s treatment of Mr C’s COVID-19
30. Ms C told us:
• staff did not do the blood tests they should have to monitor his condition • staff delayed giving Mr C medicines doctors prescribed, including delays giving him corticosteroids and antiviral drugs • staff did not give him enough oxygen or refer him to the intensive treatment unit (ITU) for oxygen support when his oxygen levels dropped • staff gave him co-amoxiclav for his infection despite her telling them he was resistant to these antibiotics • staff did not give him intravenous (IV) paracetamol • staff removed his IV drip.
31. The Trust said it gave Mr C appropriate treatments and staff continued to review his medications after diagnosing his COVID-19. It said staff monitored his oxygen levels. When these dropped, staff started corticosteroids (dexamethasone), antiviral medication (remdesivir) and oxygen therapy.
32. We saw staff acted in line with relevant guidelines when treating Mr C.
33. Our physician said staff needed to consider specific COVID-19 treatments and nonspecific COVID-19 treatments in Mr C’s case. We start our review on this with the COVID19 specific treatments, which include corticosteroids and antiviral medications. Then we consider non-specific treatments our physician identified, starting with oxygen therapy.
34. Our physician said staff should have followed the Corticosteroid Guidance and they did. This guidance says staff should not give a patient dexamethasone if they had nonsevere COVID19. But, staff may use dexamethasone if the patient had suspected or confirmed COVID-19 and they needed oxygen therapy.
35. Staff confirmed Mr C had COVID-19 and his medication charts show staff gave him dexamethasone.
36. But, this was when staff needed to start oxygen therapy to maintain his oxygen levels. Our physician said staff monitored his blood oxygen levels. They said these tests showed a drop in these levels and prompted his need for oxygen support.
37. Mr C matched the factors indicating staff should give him dexamethasone at that time. This means staff started appropriate corticosteroid treatment when the Corticosteroid Guidance said they should have.
38. Our physician said NHS organisations did not have formal guidance available during Mr C’s admission about antiviral medications like remdesivir. At this stage of the pandemic, studies based on trials like the Remdesivir Study were the only resource available.
39. Our physician said the Remdesivir Study showed the drug reduced the time it took for COVID-19 patients to recover from the illness. But the NHS did not get formal guidance on if or how staff should use the drug until March 2021 (the NICE Guideline 191).
40. Mr C’s medication charts show staff started remdesivir at the same time they started dexamethasone. Given the Remdesivir Study suggested this medication might help him recover, our physician said this was in line with the study.
41. Having carefully considered the evidence and advice, we can see staff provided corticosteroids and antiviral medications at the time the guidelines in place recommended it.
42. Moving on to non-specific COVID-19 treatments, the Oxygen Guidance says staff should monitor a patient’s blood gas test results. If their blood oxygen saturation levels fall below 94%, staff should start a patient on oxygen therapy. They should give oxygen at 15 litres per minute through a mask, or they can provide a smaller amount if this maintains their target oxygen saturation levels.
43. Mr C’s records show staff monitored his oxygen saturation levels. Up until a set time, their tests show he maintained his levels at 94% or above on room air.
44. Then the tests staff did showed his levels dropped below this threshold. Our physician said the oxygen staff then gave Mr C was in line with the Oxygen Guidance. His records show they gave him oxygen at a rate of 15 litres per minute through an oxygen mask.
45. We can see staff started Mr C on oxygen in line with the Oxygen Guidance at the right time.
46. We consider staff made decisions on whether to provide more intensive oxygen treatment for Mr C appropriately too.
47. His records show staff noted the oxygen they gave him did not help him reach the oxygen saturation levels staff hoped to achieve. So they considered escalation in his care. This included use of continuous positive airway pressure (CPAP) therapy.
48. Staff can use a CPAP machine to pump air into a mask a patient wears over their mouth or nose. The pressure the machine creates can improve a patient’s breathing and it helps to stop their airways narrowing.
49. Staff noted Mr C’s diagnosis of COVID-19 and how this had developed. This included observations about his oxygen levels and the results of CT scans that showed he had extensive pneumonia linked to his illness. Through their examinations, staff noted Mr C’s oxygen saturations improved when he had his oxygen mask on. But, he did not tolerate the mask and kept removing it. This meant his oxygen levels fell.
50. Through consideration of these factors, staff decided, mainly because Mr C did not tolerate his existing oxygen therapy, not to escalate his treatment further. This included starting CPAP therapy.
51. Our physician said at the time of Mr C’s admission clinicians did not know if oxygen therapies like CPAP were effective in treating respiratory failure associated with COVID-19. Clinical trials to assess its effectiveness were ongoing at the time.
52. They added the observations staff made about Mr C not tolerating a simple oxygen mask suggested he would not tolerate more intensive therapies like CPAP. They said staff would need to fit a tight-fitting face mask with high pressure air continuously blowing through it. Our physician said staff made an appropriate decision not to escalate Mr C’s care further, which included commencing CPAP therapy.
53. Having considered the above, we can see staff decided on the level to which they escalated Mr C’s oxygen therapy in line with the relevant guidance.
54. We cannot see a failing with the level of care staff provided for Mr C’s falling oxygen levels. Staff decided on what to do in line with Good Medical Practice.
55. Our physician said Mr C did not need additional or different antibiotics to the coamoxiclav he was already taking. They added antibiotics do not work against COVID-19 because it is a virus rather than an illness caused by bacteria.
56. Mr C’s medication charts show staff continued his course of co-amoxiclav to treat the UTI staff suspected. We saw the assessments staff did noted Mr C’s history of UTIs. This was supported by information staff gathered on the history of his symptoms. Through their observations, staff also noted his high temperature and his continuing haematuria (blood in the urine) and dysuria (pain when passing urine).
57. As the clinical evidence staff gathered supported Mr C needed antibiotics to treat a possible UTI, our physician said the plan was in line with Good Medical Practice. We also note the BNF Guidance recommends using coamoxiclav to treat UTIs.
58. Having considered all this, we cannot see failings in the antibiotics the Trust gave Mr C. We cannot see staff should have given him additional or different antibiotics to treat his COVID-19.
59. We appreciate Ms C thinks there were other failings in treatment. For example, staff removing Mr C’s IV drip and the use of paracetamol.
60. Our physician said the rest of Mr C’s treatments were supportive ones rather than treatments for his COVID-19 associated lung failure. We agreed with Ms C that the focus of our work would be on whether Mr C received the right treatment for his COVID-19.
61. Sadly, treatment did not prevent Mr C’s death. We recognise this was enormously distressing for Ms C and her family. We are sorry to hear how difficult Ms C and her family have found Mr C’s death.
62. We hope our review helps assure her that staff treated Mr C’s COVID-19 in line with relevant guidelines. We hope we have clearly explained the reasons why in this statement.
1. We are sorry Ms C had such a difficult time when her father, Mr C, was a patient at Milton Keynes University Hospital NHS Foundation Trust (the Trust). We recognise she found what happened very distressing and she is concerned about the Trust’s standard of care.
2. We carefully considered her concerns. Having done so, we saw the Trust acted in line with guidelines. We cannot see delays in staff diagnosing Mr C’s illness or failings in the treatment they gave him. This means we have decided not to consider Ms C’s complaint further.