Decision to admit Mr R to hospital and what action was taken while he was there
21. Ms N told us Mr R had been to the ACU several times before and received blood and platelet transfusions for his medical condition, but on this occasion the doctor wanted to admit him to have an urgent haematology assessment.
22. Ms N said the Trust could have offered an urgent outpatient appointment as there was already a diagnosis, and the transfusions could have been administered as an outpatient too. She also said the Trust admitted Mr R on a Friday, but the haematology assessment did not happen until the Monday. She explained the doctor in the ACU told her they were short staffed and wanted to close, so that was the reason Mr R had to be admitted to hospital, although this conversation was not documented.
23. Ms N was also concerned that nothing was done during the hospital admission, that could not have been done on an outpatient basis.
24. We considered this issue with help from our physician adviser.
25. BMJ guidance states that the immediate goal is to stop bleeding in a patient with a low platelet count. As well as close observation of respiratory and cardiovascular status being required, undertaking a thorough history and physical examination, blood tests and giving platelet transfusions is also recommended.
26. NICE transition standards explain that older people with complex needs have a comprehensive geriatric assessment started on admission to hospital. This helps practitioners to develop long-term plans to manage needs and help people regain their independence sooner and maintain it for longer.
27. When Mr R’s GP referred him to the ACU, as well as having had a low platelet count, he had two episodes of blood in his urine and for the two days prior, he had been drowsy, confused and was not eating or drinking. These were all new symptoms that had not been mentioned on prior attendances at the ACU and indicated he was unwell and deteriorating.
28. Mr R also had low blood pressure. On admission his diastolic reading (pressure in the arteries when the heart rests between beats) was 52 when it should be 60 or more), and this is another indication he was potentially clinically unstable.
29. We therefore think it was necessary for the Trust to admit him to hospital from the ACU on 23 June, due to the symptoms he was displaying that needed further assessment and treatment. And this is in line with BMJ guidance.
30. We recognise that in the time leading up to Mr R’s admission, his platelet count had been dropping since May, and the Trust had not admitted him before. On 23 June, as described above, Mr R had new symptoms which had not been mentioned previously. This combined with his low platelet count, meant there was good reason for the Trust to admit him on this occasion due to his overall deteriorating health.
31. Furthermore, as Mr R’s general condition was deteriorating, he required assessments for nursing care and equipment that he could not receive at home. This links in with NICE transition standards and due to his needs, it was likely he needed more support at home in the form of district nurses/carers and specialist equipment. This is something that takes time to arrange and needs to be assessed. It also cannot be done in a timely manner when someone is an outpatient.
32. Based on what we have seen, we think the Trust’s decision to admit Mr R on 23 June following an assessment at the ACU, was correct. We acknowledge what Ms N has told us about the doctor’s reasoning for admitting Mr R, but we think this was due to the symptoms he displayed (some which were new and indicated his health was deteriorating) which meant he needed closer observations and assessments, as well as safe discharge planning which could only be carried out in a hospital setting.
33. We acknowledge a haematology assessment did not take place until Monday 26 June. We think it is likely Mr R had to wait for this to take place due to it being a weekend where there are often less resources available. However, we can see several other things happened during the first few days of admission that could not have taken place in Mr R’s home, as explained below.
34. Mr R received nursing care and assistance during the hospital admission which he required because of his symptoms and deterioration in his health. This took place every four to six hours and included monitoring of his pulse and blood pressure. This level of nursing care could not have been provided at home or on an outpatient basis.
35. The clinical team also gave Mr R a platelet blood transfusion on the day of his admission and again on 25 June. He required this due to his low platelet count which can cause excessive and serious bleeding. Mr R had already had blood in his urine and, therefore this needed to be done in an inpatient setting, so he could be monitored due to the potential risks of further bleeding.
36. Mr R also required assessments from haematologists, occupational therapists, and palliative care during his admission due to his condition at that time. If he had been at home, these things could not have taken place in a timely manner as an outpatient.
37. On 26 June, Mr R had a palliative care review, this noted he was barely responsive and confused. A discussion was held with his family about theirs and Mr R’s wishes and preferred place of discharge (where someone wants to be at the end of their life).
38. It is noted in the medical records that Mr R’s family confirmed with staff on 27 June, their wish for Mr R to be discharged home. An occupational therapy review (aims to improve a patient’s ability to do everyday tasks) then took place and the assessment identified he needed more equipment at home before he could be safely discharged. This included a stair lift which was planned to be fitted on 30 June when Mr R was discharged.
39. To summarise, the assessment in the ACU on 23 June, identified that Mr R’s condition was deteriorating, and he needed to be admitted to hospital. Whilst an inpatient, Mr R received monitoring, observations, and treatment, that could not have taken place in an outpatient basis, in a timely manner. Healthcare staff also planned for him to go home safely. We think this is in line with the guidelines highlighted under this issue and there is no failing here.
Pneumonia
40. Ms N complained that a few days into Mr R’s first admission, she thought he was developing a chest infection (she says he had a temperature, marks on his arms and was coughing, as well as coughing up mucus) and, although she and her son supported the DNAR, they wanted every other appropriate treatment administered if and when required. She said staff ignored this and there was a failure to carry out tests and administer appropriate antibiotics to Mr R.
41. We reviewed Mr R’s medical records with help from our geriatrician adviser.
42. NICE last days of life guidance covers the clinical care of adults who are dying during the last two to three days of life. It refers to steps to be taken to identify if someone is entering the last days of their life.
43. The guidance goes onto explain that members of the clinical team should assess for changes in signs and symptoms in the person and review any investigation results that may suggest a person is entering the last days of life. These changes include, but are not limited to:
• signs such as agitation, deterioration in level of consciousness, mottled skin, noisy respiratory secretions, symptoms such as increasing fatigue and loss of appetite, and changes in communication, deteriorating mobility or social withdrawal.
44. On 26 June, there is a clear entry in Mr R’s medical records that the clinical team treating him believed his death was imminent at that stage. In particular, a palliative care assessment was carried out that noted Mr R’s symptoms. At this stage he was barely responsive, drowsy, confused and had difficulty swallowing, which met the criteria above, and indicated he was significantly unwell and appeared to be in the terminal phase of his life.
45. At this point, the clinical team decided there was no further treatment options available and undertaking further tests had little value.
46. The NICE last days of life guidance goes on to explain that when it is recognised a person is entering the last days of life, their medications should be reviewed. It also says after discussion and agreement with the dying person and those important to them (as appropriate), the clinical team should stop any previously prescribed medicines that are not providing symptomatic benefit or may cause harm.
47. GMC guidance on treatment and care towards the end of life also explains the most challenging decisions in this area are generally about withdrawing or not starting a treatment when it has the potential to prolong the patient’s life. This may involve treatments such as antibiotics for life-threatening infection, ‘artificial’ nutrition and hydration and mechanical ventilation (helps a person to breathe when they are unable to on their own).
48. It goes on to say the benefits of a treatment that may prolong life, improve a patient’s condition or manage their symptoms, must be weighed against the burdens and risks for that patient, before a view can be reached about whether it could be in their interests.
49. In light of the assessment of Mr R’s presentation on 26 June, the decision to stop active treatment was consistent with the guidance highlighted above.
50. NICE last days of life guidance also recommends healthcare professionals be aware that improvement in signs and symptoms or functional observations, could indicate a person may be stabilising or recovering. It also says they should monitor a person for further changes at least every 24 hours and update the person’s care plan.
51. GMC good medical practice states doctors must adequately assess a patient’s condition, taking account of their history (including the symptoms and psychological, spiritual, social and cultural factors), their views and values and where necessary, examine the patient.
52. GMC guidance also states doctors must seek advice, or a second opinion from a colleague with relevant experience if there is a serious difference of opinion between them and the patient. Or, between the healthcare team and those close to the patient who lacks capacity, about the preferred option for a patient’s treatment and care.
53. On 28 June there were signs Mr R’s condition was stabilising. A further palliative care assessment carried out on that day noted Mr R did not appear to be imminently dying. There was a discussion with his family on this date that they were concerned about his temperature and a possible infection. We understand this was a worrying time for Ms N and her family.
54. The medical records show that at this time, Mr R had a raised temperature, and this was recorded as 37.7ºC (normal body temperature is approximately 37ºC).
55. A junior doctor reviewed Mr R after the updated palliative care assessment and decided he did not need antibiotics. However, as the updated palliative care assessment indicated a change in Mr R’s condition and that he was not imminently dying, this should have prompted some further action at that stage, in line with the NICE last days of life guidance above.
56. Apart from the junior doctor examining Mr R’s arms, there was no other examination that took place. Because of the concern (from Mr R’s family), about an infection and cough, more of a physical assessment and examination should have taken place to determine what may have been causing this. We also think a second, more senior opinion should have been obtained.
57. GMC guidance explains that as part of the doctor’s assessment, they should also take into account the patient’s views to identify options for investigating, treating or managing the patient’s condition.
58. We cannot see there was any consideration of Mr R’s views. There is no evidence he did not lack capacity at that time and a continuing healthcare assessment (an assessment of someone’s care needs) on 27 June did not indicate any issues with capacity or cognition. Therefore, there should also have been a discussion with Mr R about his wishes.
59. The evidence we have seen indicates it was appropriate for a further review of Mr R’s condition to be carried out and recorded when there was a change in his symptoms on 28 June.
60. However, we cannot see the doctor’s assessment carried out on 28 June, took into account the updated palliative care assessment, or the need to review the care plan. This meant the doctor did not thoroughly investigate Mr R’s symptoms, did not consider his views, and there was a missed opportunity to obtain a second, more senior opinion. These things should have happened in line with the NICE and GMC guidelines highlighted above. As they did not, this means a failing in Mr R’s care occurred.
61. As a thorough assessment of Mr R’s symptoms was not carried out, we do not know what would have been found. We therefore do not know if Mr R could have been diagnosed with pneumonia earlier and if treatment should have been offered. We have considered the impact from the failing in more detail below.
Impact
62. As explained above, we think there was a lack of assessment carried out on 28 June, when there was a change in Mr R’s symptoms. No second opinion was obtained or consideration of his views taken at that point. We considered if there was any potential impact from this with help from our geriatrician adviser.
63. Ms N has explained to us the Trust discharged Mr R on 30 June and readmitted him on 5 July. She says at the start of the second admission he was given IV antibiotics for a chest infection and sepsis. She says this shows he should have been treated for this sooner during the first admission, when the symptoms first started.
64. We acknowledge what Ms N has told us, and the symptoms she observed during Mr R’s first admission.
65. Unfortunately, we do not know what the doctor would have found if a proper assessment had been carried out on 28 June, and so we are unable to say if Mr R had pneumonia during the first admission.
66. Our geriatrician adviser explained that if someone is diagnosed with a condition a few days later, this does not always mean the condition was present sooner or that it would have been diagnosed any earlier. Deterioration can occur over a few days, and different symptoms can present themselves.
67. We can see that the ambulance records prior to the second admission show Mr R’s oxygen levels were 95% and then 98% (a normal oxygen level is between 96% and 99%). This does not indicate they were low, and throughout the admission there is no evidence of Mr R having a low oxygen level or requiring oxygen.
68. We think that if Mr R had been dying of pneumonia during the second admission, we would expect to see some degree of respiratory failure (which would lead to low oxygen levels). Records show his breathing was fast, and he had a temperature, but this alone is not diagnostic of pneumonia. He had also been vomiting blood, which is also not a usual feature of pneumonia.
69. The main symptoms Mr R displayed during the second admission were nausea, vomiting and bleeding from his stomach. These are not the usual symptoms of pneumonia.
70. The lack of a full assessment and no senior opinion sought, means we cannot say if treatment should have been given during the first admission, or if anything would have been done differently in Mr R’s care.
71. Despite this, we have considered what may have happened if antibiotics had been given earlier. Mr R was very poorly with cancer and a low platelet count. During the first admission there were also indications he was nearing the end of his life.
72. Therefore, even if he had been given antibiotics, and responded to them, he had a very short life expectancy and was already in the end stage of his life. It is therefore unlikely that antibiotics would have made any difference to his prognosis or life expectancy. We recognise it was a difficult and upsetting time for Ms N.
73. We think that overall, the failing has caused Ms N distress and leaves her with uncertainty about whether Mr R had pneumonia during the first admission, and if the clinical team could have done anything differently in his care.
74. We next looked at what the Trust has already done in relation to the failing.
75. Our NHS complaint standards say that organisations should give fair and accountable responses that take action to ensure any learning is identified and used to improve services.
76. Within its complaint response, the Trust explained that since 2017 it has worked hard to improve its care for patients who are at the end of their life. It has reviewed its end-of- life documentation and its practice now is to complete the anticipated last days of life care plan, with the patient and their family.
77. It has also introduced treatment escalation plans for all patients with a DNAR. The Trust said this encourages the clinical team to discuss the treatment plan for the patient and provides a clear plan of what the patient will receive.
78. We are satisfied the actions taken by the Trust address the failing we have identified, to improve its end of life care of patients. This is because patients and their families will be involved in their treatment plans and the clinical team will be prompted to discuss plans in place.
79. However, we do think there is more the Trust can do to show that the clinical team have taken steps to reflect on decisions they make at the end of a patient’s life, and to ensure NICE last days of life, and GMC guidance highlighted above, are met.
80. We also think the Trust should acknowledge and apologise for the failing we have identified, and the impact this has had on Ms N. We have made some recommendations below to address this.
81. Ms N highlighted similarities with a complaint we previously investigated about the Trust and upheld. We have taken this into account.
82. We recognise Ms N’s worry that similar issues were raised about the Trust. In that complaint we made a recommendation for the Trust to make service improvements and we were satisfied it complied with this in 2018.
83. We acknowledge the circumstances of that investigation are similar to this one. The events in that complaint took place a few months after Mr R’s inpatient stay, and the Trust took steps after the event, to improve its service in relation to the failing we found. We therefore do not consider there are any systemic issues that we need to address further, and we will not be repeating the recommendations we previously made.
84. In this complaint, we have made a recommendation for the Trust to show learning and reflection has taken place by the clinical team, to prevent the failing we identified from happening again. Along with the service improvements already made, we hope this provides reassurances to Ms N that steps will be taken to review what happened, so it does not happen again.