23 November 2019
17. Mr E says a doctor sent his wife home with antibiotics for an infection and codeine for her shoulder pain. He believes the doctor did not recognise that his wife was seriously unwell.
18. Good Medical Practice says doctors must provide a good standard of care. This includes carrying out adequate assessments, taking account of the patient’s history and examining them if necessary. Doctors should also arrange timely treatment and appropriate investigations or referrals if needed.
19. The UTI Guideline sets out how doctors should treat women who have a UTI. It explains the preferred choices of antibiotics for different circumstances. The first choice for Mrs E would have been to prescribe nitrofurantoin for three days.
20. The clinical records show Mrs E told a nurse that she had been experiencing urinary symptoms for a week. She said her urine was foul smelling, with increased frequency and a burning sensation. She had been to see her GP who had tested the urine and found no problems. She explained how her symptoms had worsened recently. Mrs E also referred to pain in her right shoulder. The nurse took Mrs E’s observations, which were normal apart from a slightly raised temperature.
21. A doctor then reviewed Mrs E. He noted she had fallen from the toilet on the previous day and hurt her right shoulder. The doctor examined Mrs E and noted her chest was clear. Her shoulder movement was limited because of her pain. The doctor arranged a urine dipstick test and an X-ray of the shoulder. The dipstick test was positive for a UTI so the doctors prescribed a course of antibiotics. This was nitrofurantoin for three days. The X-ray did not highlight any concerns. The doctor was satisfied for Mrs E to leave the Hospital with pain relief.
22. On 24 November 2019 a therapy practitioner from the Hospital called Mrs E to discuss her shoulder injury. Mrs E advised him she did not need any additional support at home.
23. The Emergency Medicine Adviser said there is no evidence of any ‘red flags’ to suggest Mrs E needed to remain in hospital. The doctor assessed Mrs E appropriately, examined her, and arranged the investigations she needed. The Emergency Medicine Adviser said it was good practice for the therapy practitioner to contact Mrs E the next day.
24. We find the doctor on 23 November 2019 followed Good Medical Practice by carrying out an appropriate assessment and arranging for the investigations and treatment Mrs E needed. He also followed the UTI Guideline by prescribing suitable medication.
25. We recognise Mr E considers his wife had an illness that required further hospital treatment. This is not what we have seen. Sadly, Mrs E developed an extremely rare condition over the following days. There was no evidence of that condition during her attendance on 23 November 2019.
Medical treatment from 29 November 2019
26. Mr E believes it took doctors too long to recognise how serious his wife’s health problems were. He says she became so unwell she could not be treated, and doctors denied her critical care. He believes they relied too much on what had been written in the records rather than looking at her appearance or examining her. He also questions whether doctors correctly identified and treated sepsis and wants to know whether early warning scores (NEWS) were recorded. He believes sepsis caused his wife’s death and not pneumonia.
27. The Medical Adviser told us there are no specific treatment guidelines for the complex conditions Mrs E had during her admission to the Hospital. Good Medical Practice would have applied, and we have explained this earlier in the report. The Sepsis Guideline explains how clinicians should recognise and treat sepsis. This includes providing intravenous fluids, antibiotics, monitoring urine output and taking regular physiological observations.
28. The NEWS Guideline refers to the NEWS system. This is a tool to help clinicians easily identify when a patient’s health is deteriorating by recording physiological observations. It involves creating a score based on a patient’s rate of breathing, levels of oxygen in the blood, blood pressure, pulse, temperature, and level of consciousness. High scores should result in clinicians taking urgent or emergency action.
29. When Mrs E first arrived at the Hospital on 29 November 2019, she had various symptoms that prevented doctors from identifying the cause of her illness. She felt generally weak and was struggling to walk. She had not opened her bowels for a week and had swelling and pain around her right shoulder. She had a slightly high temperature, but her other observations appeared normal.
30. Doctors diagnosed an infected shoulder joint and arranged scans and investigations. They also gave Mrs E antibiotics and admitted her to the Hospital. On the next day they diagnosed sepsis in the shoulder joint and suggested she also had a possible infection and her spine and a concern with her liver. They also found a mass in the chest wall, which they suspected to be a collection of pus.
31. The Medical Adviser told us that within 24 hours doctors diagnosed Mrs E as having a rare and very complex set of conditions. He said the records show the teams involved in Mrs E’s care made appropriate referrals, took advice, and investigated in a co-ordinated and impressive way to arrive at a clear diagnosis and an agreed treatment plan.
32. On 30 November 2019 doctors identified abnormal blood tests relating to how Mrs E’s liver was working. They investigated this using an ultrasound scan. She also had a comprehensive geriatric assessment. The Medical Adviser told us this is like an MOT for older people.
33. Later that evening doctors noted Mrs E had a weakness towards the left side of her body. A cardiothoracic surgeon reviewed her within 25 minutes. He decided not to proceed with surgery and suggested antibiotics should be tried first. Microbiologists confirmed she was already taking appropriate antibiotics for the infection she had. They said these should continue for four to six weeks. That same day doctors inserted a midline cannula. The Medical Adviser said people usually wait many days for a midline cannula insertion in the NHS.
34. By 5 December 2019 doctors confirmed Mrs E had discitis and a psoas abscess. These were caused by bacteria in her blood. Doctors started an additional antibiotic. The next day an infectious diseases consultant reviewed Mrs E, prescribed a water tablet to try and reduce swelling and referred her to the orthopaedic team to see whether it would be possible to wash out her infected joints.
35. The clinical records from 8 December 2019 show Mrs E was experiencing breathing difficulties. Mr E questioned whether she had a chest infection. Doctors arranged a chest Xray but this did not identify any signs of infection.
36. On 12 December 2019 Mrs E had further scans. This led to a drain being placed into the infected shoulder joint. The scans also suggested pneumonia in both lungs. They did not confirm a blood clot. Doctors gave Mrs E new antibiotics and blood thinning medication. The critical care team also reviewed her.
37. By 20 December 2019 a scan showed the liver abscess had grown and three days later doctors inserted a drain to try and reduce it. Treatment continued over the following days but Mrs E was becoming weaker. By 2 January 2020 doctors recognised she was unlikely to recover from her illness. Two days later she was found to have pneumonia again and end of life care started on 6 January.
38. The Medical Adviser said there is clear evidence of good involvement from multiple different teams all working together in Mrs E’s best interests. Several complications and new findings arose during Mrs E's admission. Doctors consistently focussed on the larger picture and did not focus on individual reviews. Doctors with the appropriate expertise made decisions in a timely manner. They gave Mrs E active treatment and the investigations they requested took place quicker than they would in most hospitals. Doctors acted on test and investigation results quickly, including during the holiday period. The Medical Adviser said the level of care was not only appropriate but very impressive.
39. Mr E questions whether doctors managed his wife’s sepsis appropriately. The Medical Adviser told us sepsis is a life-threatening reaction to an infection. It happens when the immune system overreacts to an infection and starts to damage the body’s own tissues and organs. By this definition Mrs E had sepsis for most of her admission to the Hospital. Initially, doctors were able to control sepsis using antibiotics, but it still took at a considerable toll on her, meaning she lost weight and became much frailer.
40. Mr E also has concerns about whether clinicians recorded early warning scores (NEWS) during his wife’s admission. The clinical records show clinicians recorded NEWS throughout Mrs E’s stay. They show Mrs E usually scored between one and three on the NEWS system. There were a few exceptions when she scored between four and seven, which suggested she needed an urgent medical response.
41. The Medical Adviser said scores of one to three were the result of Mrs E’s known illness. Clinicians would not be expected to have taken action about those scores. A reading of five might indicate an acute deterioration. It should have prompted escalation to a doctor or for a medical review, which happened on most of the occasions. Escalation did not immediately happen on two occasions. However, doctors reviewed Mrs E shortly after the elevated scores and did not consider she needed critical care at that stage.
42. The Medical Adviser did not consider the isolated raised NEWS to be significant. He said it is not uncommon to encounter an isolated ‘high’ NEWS which does not indicate an acute deterioration. It can be caused by an episode of fear or pain which can ‘artificially’ raise the heart rate, or breathing rate, to suggest a more worrying state than is medically true. The records show Mrs E’s NEWS returned to between one and three after these episodes. He said a ‘one off’ high reading is unlikely to have been meaningful.
43. Mr E asked why doctors did not arrange for his wife to have critical care. The Medical Adviser told us there was no specific treatment indicated that required critical care involvement in the earlier part of Mrs E’s admission. Critical care is concerned with the delivery of organ replacement therapy, for example drugs to support the heart or ventilation to support the lungs. At no point did Mrs E need those treatments. The critical care team reviewed Mrs E and noted there was a ‘low threshold for referral to critical care.’ The Medical Adviser considered she did not meet this threshold because the treatment she needed was available on the medical ward.
44. Doctors considered intensive care for Mrs E when they identified hospital acquired pneumonia towards the end of her life. This is because it was likely her lungs would have needed mechanical support. But she was so frail and unwell at that stage that she was not capable of surviving the stress this would have caused her body. At that stage treatment in intensive care would not have increased her chances of recovering from her illness.
45. The Medical Adviser said it was highly likely Mrs E’s initial infection, MSSA possibly in the shoulder joint, spread into her blood stream releasing a large amount of infected material around the body. This then created new abscesses and problems.
46. Mr E believes sepsis caused his wife’s death and not pneumonia. The Medical Adviser told us sepsis was one possible mechanism of death caused by pneumonia. It is also possible that hypoxia, meaning the lungs were not working well enough to provide the oxygen the body needed, was the actual cause of death. The Medical Adviser said the point should be that whatever the mechanism of death was, sadly, it was inevitable following a long illness which did not respond adequately to treatment. Doctors treated the pneumonia appropriately but could not prevent Mrs E from dying. They also gave her the treatment for sepsis, but this was to no avail.
47. We recognise Mr E believes doctors were too slow to recognise the seriousness of his wife’s condition. This is not what we have seen. The records contain frequent and detailed references to physical examinations from a range of different specialist clinicians.
48. We find doctors provided a good standard of care in line with Good Medical Practice. They carried out good assessments and arranged appropriate, and timely, investigations and treatment. They also followed the Sepsis Guideline by providing the recommended treatment for sepsis and the NEWS Guideline by monitoring Mrs E’s physiological observations.
Record keeping
49. Mr E believes the medical records were of poor quality and this meant doctors had difficulty to establishing what was happening. He believes incorrect records prevented his wife from getting the support she needed.
50. Good Medical Practice says doctors must make records that are clear, accurate and legible. They should make records at the same time as the events they are recording or as soon as possible afterwards. Records must include relevant clinical findings, decisions made and actions agreed, information given to patients, drugs prescribed or investigations or other treatments and who is making the record and when.
51. The NMC Code says nurses should make records that are clear, legible, and contemporaneous. They should be dated and signed.
52. The Medical Adviser told us the medical records were extremely easy to review because the standard met the criteria set out in Good Medical Practice. In any admission of significant length, especially one covering two major public holidays, there will always be occasional deviation. He said these were few and far between and the medical records were generally of a good standard.
53. The Nursing Adviser told us the nursing records included intentional rounding charts, food charts, fluid balance charts and narrative records. They also recorded NEWS scores and repositioning charts.
54. In general, the clinical records appear to have been accurate and met the standards required. The exceptions to this were some of the documents relating to nutrition and records following Mrs E’s death, which we will refer to later in this report.
55. We find clinicians generally followed Good Medical Practice and the NMC Code when completing records. We have not seen significant concerns about record keeping by doctors and nurses.
Communication
56. Mr E explained how the lack of any clear diagnosis meant his wife was very distressed. He said doctors reassured them that she seemed to be getting better when this was not the case up to 29 December 2019. He says doctors did not tell them she had sepsis until 2 January 2020.
57. Good Medical Practice says doctors must listen to patients, take account of their views and respond honestly to their questions. It says they must give patients the information they want or need to know. Doctors must be considerate to those close to the patient and be sensitive and responsive in giving them information and support.
58. The clinical records contain extensive notes showing doctors communicated with Mrs E’s family. Mr E also noted this in his diary. Doctors regularly gave Mrs E updates on the investigations that were taking place and why these were happening. They also discussed the diagnoses they made. The records, and the diary, show there were times when Mrs E’s health appeared to be improving and doctors clearly shared this news with her family.
59. On 2 January 2020 a consultant met Mr E to explain what was happening. They both made a note of the discussion, which differed slightly but the content was broadly similar. The consultant recalled saying there were some signs of improvement in Mrs E’s health but there had been a general deterioration in her condition. He noted referring to Mrs E not having the resilience to be able to deal with any further complications, and while he was optimistic she could recover, she was poorly enough that she could die.
60. The Medical Adviser explained how, up to that point, doctors were hopeful the treatment they were providing would be successful. The Medical Adviser told us it would have been confusing for doctors to provide the family with detailed medical explanations with reference to complex clinical discussions about the causes of Mrs E’s deterioration. He did not consider sepsis needed to be specifically mentioned. Mrs E was likely to have had sepsis for most of her admission. The records referred to possible sepsis in the infected shoulder joint on Mrs E’s admission to the Hospital. When it became clear she was terminally ill, doctors clearly documented appropriate discussions with her family.
61. Mrs E had a complex illness with several different elements. The evidence suggests doctors made appropriate attempts to explain the illness to her and her family. They shared information about investigations, test results and treatments. It was only after the new year that they became aware there was a significant chance Mrs E may not recover. At that point they updated Mr E and his family.
62. We can see how confusing it must have been for Mr E and his family when they were trying to understand what was happening. We find doctors followed Good Medical Practice by providing them with the information they needed to know. The doctors appear to have been sensitive and responsive in their communication.
Nutrition
63. Mr E noted in his diary that his wife was struggling to eat throughout her admission to the Hospital. He says it took too long for the dieticians to attend and this only happened because the family insisted. He recalled a doctor telling him his wife was ‘starving to death.’ He also says nurses failed to complete accurate nutritional assessments. He does not agree with assessments showing his wife was not at risk of malnutrition.
64. Clinicians should have followed the Nutrition Guideline during Mrs E’s hospital admission. This says clinicians should screen all patients when they are admitted to hospital to see whether they are malnourished or at risk of becoming malnourished. They should assess the patient's body mass index (BMI – used to establish whether someone has a healthy weight), the amount of unintentional weight loss over time and whether nutrition has been reduced or is likely to become reduced. The Nutrition Guidelines refer to MUST (Malnutrition Universal Screening Tool).
65. The Nutrition Guideline also explains when clinicians should consider giving people nutrition support. It details what the support should include depending on the patient’s circumstances. It says healthcare professionals who are trained in nutrition should ensure they take account of the risk of refeeding problems when prescribing nutritional support. Refeeding happens when someone has had insufficient nutrition leading to the body processing food in a different way. It can lead to serious health problems and can be fatal. The Nutrition Guideline specifies the measures that need to be introduced to try and prevent refeeding.
66. The BDA Standards explain how dieticians should carry out full assessments of patients before implementing any plans for nutritional support. They say dieticians should consider the evidence to establish the patient’s nutritional status, manage nutritional risk, identify (and prioritise) aspects that require action and provided a considered action plan to meet the patient's needs.
67. MUST is an accepted system of monitoring someone’s nutritional status in line with the Nutrition Guideline. It helps clinicians support people who are malnourished or who are at risk of malnutrition. During Mrs E’s admission to the Hospital nurses calculated her MUST score six times. Each time they recorded a score of zero, which meant they considered she had a low risk of malnutrition. They noted Mrs E gained weight during her stay and that she did not need assistance with feeding. She also needed to be screened weekly, which is what happened.
68. The evidence shows nurses followed the Nutrition Guideline when they completed an initial screening on Mrs E’s admission to the Hospital using MUST. The nurses noted she weighed 78.15kg and had a MUST score of zero. There is no evidence to suggest at that stage that this score was incorrect.
69. The MUST explains staff should complete food charts for any patients who have a score of one or higher. Despite not requiring a food chart, nurses completed them at times during the early part of Mrs E’s admission.
70. On 30 November 2019 a doctor noted Mrs E had a reduced appetite. Mr E recalled a clinician confirming there would be a referral to a dietician. However, he said there was no reference to this again until staff made a referral on 9 December. The clinical records show a doctor asked colleagues to make a dietician review on 9 December. The reason was because of Mrs E’s low albumin levels. Albumin is a protein that carries hormones, vitamins, and minerals throughout the body.
71. There is no record of the referral that clinicians made to the dieticians on 9 November 2019. But we can see that the doctor who first noted the referral and the dietician who later attended, both considered this was mainly about low albumin levels. The Dietician Adviser told us concerns about albumin levels would not normally prompt a referral to dieticians.
72. A food chart from 30 November showed Mrs E ate most of her lunch and half of her evening meal. Charts up to 3 December continued to show she ate most of the food provided.
73. On 4 December 2019 a nurse completed a second MUST chart. Again, this suggested Mrs E’s score was zero. The nurse recorded Mrs E’s weight as 83kg, which was a significant increase from the previous week. The Nursing Adviser told us nurses should have considered whether Mrs E’s oedema (excess fluid collecting in the body’s cavities or tissues) could have been masking any weight loss. The Trust has recognised this limited the effectiveness of its MUST assessments. It meant clinicians did not know whether Mrs E met the criteria for nutritional support. However, other evidence indicates she is unlikely to have needed additional support at that stage.
74. From 4 December 2019 onwards nurses appear to have completed food charts intermittently. There is no evidence they were needed at that stage. There are several references in other records referring to Mrs E eating. The food charts that were completed also include references to her being able to eat full meals at times. The further MUST assessments showed no indication Mrs E was losing weight.
75. The Nursing Adviser said the food charts were generally well kept and indicated times when Mrs E refused meals and what was offered as an alternative. They said other nursing records helped to provide a clear picture of Mrs E’s diet.
76. The Medical Adviser said there is ample evidence in the clinical records that Mrs E was eating full meals. This changed by the end of December 2019.
77. We recognise Mr E’s diary repeatedly refers to his wife not eating for many days. But we have seen several entries in the clinical records, made by various clinicians, which suggest Mrs E did not need additional nutritional support before the first dietician review. We are persuaded the clinical records, although at times incomplete, are accurate in this respect.
78. There is no evidence to suggest Mrs E needed nutritional support until just before Christmas 2019. There was no requirement for food charts before then. This means we cannot say there were any failings in this respect. Our view is the nurses followed the Nutrition Guideline for the first three weeks of Mrs E’s admission to the Hospital.
79. The clinical records show a dietician reviewed Mrs E on 20 December 2019. They noted she was eating full meals on the ward and was also taking dietary supplements. The dietician recommended continuing with an oral diet with encouragement and snacks. They said weight should be monitored and the ward team should request a further dietician review if needed.
80. The Dietician Adviser noted it appeared to have taken eleven days for a dietician to attend following the request. They said such a lengthy delay is unusual and unacceptable. We cannot be certain the dieticians were responsible for the delay because the document containing the referral is missing. The Trust has accepted in its complaint responses that there was a delay. There are no specific guidelines about how quickly such referrals should be processed. This means we cannot conclude the delay amounted to a failing.
81. The Dietician Adviser also reviewed the dietician’s assessment of Mrs E’s nutritional status on 20 December 2019. They said, the BDA Standards say a dietetic assessment should include, but is not limited to:
• Anthropometry (which is a detailed review of weight change, BMI and nutritional requirements) • Biochemistry (a review of recent test results) • Clinical (the patient’s clinical history, current clinical status, urine and bowel output) • Diet (a review of dietary intake, including a review of calorie, protein and fluid intake) • Environmental, behavioural and social (the patient’s knowledge, beliefs, social and economic status affecting oral intake).
82. The Dietician Adviser said the review on 20 December 2019 did not meet this standard. The dietician noted Mrs E’s weight had increased by 3.1kg in two weeks. This is a rapid increase in weight. The dietician should have noted this and established it was likely due to Mrs E’s oedema. The dietician also decided to stop nutritional supplements Mrs E was then taking without providing any justification for the decision.
83. The Medical Adviser said the first dietetic review seemed to dismiss the referral on the basis it was made because of decreased albumin levels and Mrs E’s weight had increased. Clinically, he said this was unwise. Mrs E’s weight gain was almost certainly due to fluid retention and not a true increase in her body mass. The Medical Adviser said the low albumin was due to Mrs E’s deep-seated infection and was not an indication of malnutrition.
84. By 23 December 2019 doctors were concerned about Mrs E’s nutrition and recommended that a feeding tube should be used. Mrs E told a doctor she was ‘not keen’ on having a feeding tube. We will refer in more detail to issues relating to feeding tubes later in this report.
85. The same dietician reviewed Mrs E again on 24 December 2019. They had been asked by her family to attend and said she had not eaten for three or four days. Mrs E told the dietician she had eaten half of her breakfast and a small amount or lunch. She had taken almost a full protein shake and felt she could manage more of those. The dietician advised her to eat more food. They also noted Mrs E did not want to have a feeding tube.
86. The Dietician Adviser was concerned about the dietician review on 24 December 2019. They said it did not meet the criteria set out in the BDA Standards. In addition, the records show Mrs E had been continuing to take dietary supplements despite previous instructions. The record of the assessment does not contain a detailed review of anthropometry, biochemistry or the clinical picture. There was no detailed dietary review or any reference to the previous plan. The dietician recommended an increase in dietary supplements without calculating Mrs E’s nutritional requirements.
87. The Dietician Adviser noted there was no appropriate review of Mrs E’s refeeding risk on 24 December 2019. The dietician should have considered weight changes, BMI, oral intake, and refeeding electrolytes (an analysis of body salts to see whether there are signs of refeeding). There is no evidence they did so. The dietician did not follow the Nutrition Guideline.
88. On 26 December 2019 a doctor noted Mrs E had eaten a full meal for breakfast. By the next day Mrs E was not eating and a doctor recommended she should have a feeding tube.
89. On 27 December 2019 the dietician reviewed Mrs E for the third time. They agreed with the plan to use a feeding tube. They also recommended an oral diet and food charts. A doctor inserted the feeding tube later that day.
90. The Dietician Adviser said the records of this dietician review includes the first reference to a calculation of Mrs E’s nutritional requirements, which should have happened a week earlier. However, the details of the calculation were not documented. Again, there was no reference to refeeding risk or a review of weight, biochemistry, clinical information, or consideration of the reasons for poor oral intake.
91. A different dietician reviewed Mrs E again on 30 December 2019. They were unable to locate any food charts and reiterated these needed to be completed. The final dietician review took place on 2 January 2020. The dietician noted Mrs E was eating a minimal amount of food, but the feeding tube was then in place. They made changes to nutritional supplements and planned to continue with the feeding tube and monitoring. The Dietician Adviser was satisfied the final two dietician reviews met the required standards.
92. In summary, we find there were errors in the way staff at the Hospital managed Mrs E’s nutrition. These were:
• MUST assessments did not take account of Mrs E’s oedema on her apparent weight gain • food charts were sometimes incomplete, or not completed, and there was no clear plan about whether they should have been used • dietician reviews were not carried out to the required standard meaning nutritional management was inconsistent.
93. We find clinicians did not follow the Nutrition Guideline or the BDA Standards. This was a failing and we asked our clinical advisers what impact this could have had on Mrs E.
94. The Dietician Adviser said the failings in nutrition management would not have had a significant effect on Mrs E’s prognosis. Dieticians could have made different plans, for example if nurses had recognised her oedema could have been masking weight loss, they could have arranged nutritional support at an earlier stage. But Mrs E was already acutely unwell and improved support with nutrition would not have resolved this. It is common when people are acutely unwell that their oral intake decreases. The plans the dieticians implemented were mostly safe and appropriate for the clinical situation.
95. The Medical Adviser said Mrs E had an overwhelming infection that would have been an enormous drain on her body. Sadly, her health gradually worsened because of her illness and not because of failings in nutrition. Mrs E clearly was frail towards the end of her life and was not getting enough nutrition. But we cannot see this was a result of any failings by clinicians.
96. We can see how appropriate nutritional support would likely have been a comfort to Mr E and his family, who clearly identified some of the failings we have seen. Dieticians may have been able to provide education and support about what to expect in terms of nutrition as Mrs E became more unwell.
97. We recognise Mr E considers his wife could have survived her illness if doctors had supported her. This is not what we have seen. We cannot say, even on the balance of probabilities, better management of nutrition would have led to Mrs E’s survival. We do, though, consider the failings were distressing for Mr E and his family to experience and they could have been avoided. This is an injustice to Mr E.
98. We partly uphold this aspect of Mr E's complaint. We can see the Trust has recognised some of the failings and has acted. We will consider the Trust’s actions in response to the failings later in this report.
Feeding tube
99. Mr E believes his wife should have been offered a feeding tube much earlier in her admission to the Hospital. He said it took 20 days for one to be requested and then it was not used for several days.
100. The Nutrition Guideline refers to when a feeding tube (known as enteral or Nasogastric feeding) should be used. It says healthcare professionals should consider a feeding tube if a patient is not taking in enough nutrition orally. It should not be used when a patient is able to eat adequately.
101. The BDA Standards say all plans and aims of dietary support should be patient centred.
102. The Dietician Adviser told us decisions about feeding tubes are usually made by doctors, with advice from other healthcare professionals. It is not usual practice to use a feeding tube when a patient is able and willing to eat and drink. Clinicians will offer oral nutritional support first, with extra snacks or nourishing fluids.
103. The clinical records, and Mr E’s diary, show a doctor first mentioned using a feeding tube to assist Mrs E on 23 December 2019. A dietician also referred to this when reviewing Mrs E the next day. On both occasions Mrs E told the clinicians she did not want a feeding tube. Mr E told us his wife was too distressed on these occasions and needed time to recover from procedures that had recently taken place.
104. The Dietician Adviser said it would not have been patient centred for clinicians to start a feeding tube when Mrs E did not want this to happen.
105. By 27 December 2019 clinicians had again spoken with Mrs E about starting a feeding tube. This time she agreed to having a feeding tube and it was positioned later that day. On 30 December staff could not check whether it was safe to continue using the feeding tube, because they could not test any aspirate from the tube (this means they could not check a sample of stomach contents). This meant they had to stop feeding and they provided oral supplements instead. On 1 January doctors confirmed it was safe to resume tube feeding even though they still could not to test any aspirate.
106. Records show the tube provided nutrition to Mrs E until 2 January 2020 when it was pulled out. It was replaced the same day and continued until 6 January. At that point doctors had decided not to provide active treatment for Mrs E and withdrew the tube because it was causing her distress.
107. We have already mentioned earlier in this report how there were no significant concerns about Mrs E’s nutrition until 23 December 2019. Clinicians therefore followed the Nutrition Guidelines when they did not consider a feeding tube up to that point. They were also right not to insist on inserting the tube on 23 December when Mrs E said she was ‘not keen.’ The dietician followed the BDA Standards in this respect.
108. Clinicians were also right not to continue providing nutrition using the feeding tube when there were concerns about safety. They made appropriate attempts to try and ensure the tube was not causing harm when they were unable to test any aspirate.
109. We find the clinicians followed the relevant standards relating to the use of feeding tubes. There is no evidence of any failings relating to how clinicians managed this aspect of Mrs E’s care.
Midline cannula
110. Mr E says a doctor fitted a midline cannula incorrectly. He believes the doctor was not competent to do this and wants us to explain whether the doctor was qualified to carry out the procedure. Mr E has contrasted how a clinician first fitted a cannula with how this was later replaced.
111. The Medical Adviser told us there are no specific standards relating to how doctors should use a cannula. They said it is particularly difficult to site a cannula for a patient with sepsis throughout the body and generalised body swelling. Good Medical Practice would have applied in terms of providing a good standard of care. It also says doctors must recognise and work within the limits of their competence. If a doctor cannot carry out a procedure they would be expected to consult with colleagues.
112. The clinical records show Mrs E’s midline cannula fell out on the morning of 31 December 2019. A doctor replaced this the same afternoon using ultrasound guidance at Mrs E's bedside. He secured the cannula using sutures. The doctor checked the line was working and noted no immediate complications. There is limited information in the records about this incident. The Trust has recognised its record keeping should have been better in this respect. Mr E’s diary and the clinical records both refer to Mrs E bleeding from the site of the midline cannula over the following day. Doctors assessed the site and provided new dressings. On 1 January 2020 a doctor flushed the line and by the next day records show it was working correctly with no bleeding. There is no suggestion the line needed to be replaced again.
113. The Medical Adviser told us it is not unusual for people to have to wait days or even weeks before a midline can be replaced. Not all doctors are able to insert a midline cannula. A wait of only a few hours without the line in place would not be considered poor practice because there is often a wait for a doctor with the relevant experience to attend. Despite the lack of clear documentation relating to the incident the Medical Adviser said the timing of the replacement does not suggest there were any failings in this respect. The evidence suggests the doctor followed Good Medical Practice.
114. The Trust confirmed the doctor who inserted the second midline cannula was appropriately qualified to carry out the procedure. We have no reason to question that. It has accepted Mrs E’s experience was different the second time. It also explained how, since the incident, procedures at the Hospital have changed with a dedicated team tasked with inserting a midline cannula when needed.
115. We find there is no evidence the doctor who fitted the second midline cannula fell below the relevant standards when doing so.
Care after Mrs E died
116. Mr E recalled that he and other family members remained in the room with his wife for over four hours following her death. When a doctor later attended, he appeared shocked that the correct procedure had not been followed. Mr E believes the nurse did not follow the appropriate steps after his wife died. He says the nurse did not immediately inform a doctor.
117. The NMC Code says nurses must treat people with kindness, respect, and compassion. It also says they must work co-operatively with colleagues.
118. The Verification Policy says nurses can ‘confirm or verify life extinct’ as long as there is a local protocol in place to support this. It says the nurse carrying out the verification must notify a doctor of the patient's death, preferably by secure email. They are only required to contact a doctor for verification if there is any doubt the patient has died.
119. The Verification Policy also explains the examination the nurse must carry out to verify death. It says the registered nurse needs to complete a Verification of Death form in the clinical notes.
120. There are very limited clinical records about what happened following Mrs E’s death. These show Mrs E died around 5.50am and say the nurse contacted a doctor. The Trust said in complaint responses that the nurse gave the family a bereavement pack and disconnected the syringe driver that was being used to provide Mrs E with end of life medication. The nurse did not complete the specific form included in the Verification Policy. Mr E also says he did not receive a bereavement pack.
121. A junior doctor noted he saw the patient on the ward after her death, with the consultant. They noted the time of death was 6am and completed this record on the following day beneath a signature from a consultant.
122. Mr E’s diary contains a detailed account of events. He recalled Mrs E’s son found a nurse who returned to see Mrs E. Shortly after this the nurse felt Mrs E’s pulse for a few seconds and confirmed she had died. Mr E said he and two other family members then remained alone in the room until after 10am.
123. Mr E recalled meeting the consultant in a corridor at 10am on 7 January 2020. He told the consultant his wife had died. A few minutes after this meeting the consultant, and a ward sister, entered the room apologising that he had not known Mrs E had died. In the absence of any other clear, or contemporaneous records about Mrs E’s death, we consider Mr E’s account to be credible.
124. There is no requirement for doctors to have to attend a patient to verify their death when that is expected. The Verification Policy is clear that a nurse can verify that a patient has died. There is a requirement for nurses to contact a doctor. The Trust suggests a nurse informed doctors that Mrs E had died by sending an email to a central system. It also considers the nurse gave the family a bereavement pack.
125. We find the attending nurse did not follow the Verification Policy when she did not complete the required form. The clinical records do not contain sufficient detail about how the nurse confirmed Mrs E died or how she notified a doctor about it. It does not show she completed all the tasks required when a patient dies. We consider it more likely than not that the nurse did not provide the family with a bereavement pack. We are persuaded by Mr E’s account, which he completed at the time of events. The nurse did not follow the Verification Policy.
126. We are also concerned about the amount of time Mr E and his family were left alone once the nurse who verified his wife’s death had left the room. The Nursing Adviser said it is inappropriate to leave a family for such a long time without support. Nurses should allow the family to have as long as they wish, within reason, and should check on them periodically.
127. The Trust has accepted it was wrong for clinicians to leave the family alone with Mrs E for so long after she died. We agree with this. We consider nurses did not treat Mrs E’s family with compassion and kindness and did not follow the NMC Code.
128. In summary, we find staff at the Hospital fell below the relevant standards (the Verification Policy and NMC Code) following Mrs E’s death.
129. We can see how Mr E and his family were distressed because of their experience after his wife died at a time when they were grieving. They were left uncertain about what was happening and why. This could have been avoided. We consider this is a significant injustice to them and we uphold this aspect of Mr E’s complaint.
Complaint handling
130. Mr E says the Trust’s complaint responses, and comments made at the complaint meeting, were inaccurate and incomplete and it has failed to accept responsibility for its failings. He is dissatisfied with the action the Trust has taken in response to his complaint.
131. The Principles of Good Complaint Handling say organisations should be ‘open and accountable.’ This includes providing honest, evidence-based explanations and reasons for decisions. It also says organisations should be ‘put things right,’ which includes acknowledging mistakes and apologising where appropriate. It also says organisations should use information from complaints to improve services.
Was the Trust open and accountable?
132. Mr E first complained to the Trust on 7 October 2020. He raised several different concerns and included an additional issue about a specific nursing incident in an annex.
133. The Trust replied to the initial complaint on 3 December 2020. For the most part it provided comprehensive answers to the issues in Mr E’s complaint. But it did not provide a clear answer about when doctors diagnosed sepsis. We consider this was understandable to some extent given Mrs E had indications of sepsis throughout her admission to the Hospital.
134. The Trust also did not fully identify the failings in care and treatment we have seen. It did not recognise that Mrs E’s oedema was probably masking weight loss or that the dietician reviews were not of the required standard. It also did not recognise the failings we identified about care immediately following Mrs E’s death. Finally, it did not respond to the annex referring to the specific nursing incident.
135. For the most part the Trust’s first response was based on the evidence. But the omissions referred to above meant the response was incomplete and was not evidence-based.
136. Mr E sent his second complaint to the Trust on 6 May 2021. In this complaint he raised 26 numbered questions. He also referred to the annex from his first complaint.
137. The Trust sent its second response to the complaint on 26 October 2021. As with its first response it provided clear responses to most of the questions Mr E asked. This included a clearer response to the question about sepsis. However, the Trust did not acknowledge the failings in nutrition we have seen. While the Trust accepted some failings relating to care following Mrs E’s death, it suggested these related to a doctor rather than the nurse. It did not acknowledge that a nurse verified Mrs E’s death and did not follow the relevant policy when doing so. The response did not refer to the incident in the annex.
138. The Trust’s second response also provided answers that did not reflect the clinical records. For example, it suggested the midline was replaced on 2 January 2020 when there is no evidence of that. It also said there was no need for the ward team to contact critical care about dressings, but the records clearly state that someone should contact critical care about the most appropriate dressings. In our view the second response was not evidence-based in some respects.
139. Mrs E’s third complaint was dated 7 February 2023. On this occasion he focused on four main areas relating to nutrition, critical care, the midline, and the incident mentioned in the annex to his first complaint.
140. The Trust sent its third reply on 3 May 2022. It recognised its previous responses had not provided a comprehensive review of nutrition and hydration. For the first time it accepted its staff had not taken Mrs E’s oedema into account. However, this did not include any consideration of the role of the dieticians or recognise the failings we have seen in that respect. The Trust also replied to the issues set out in the annex to the first complaint.
141. We consider the Trust’s third response was more comprehensive than the first two responses. In general, the response was evidence-based and shows the Trust was attempting to be ‘open and accountable.’
142. Mr E and his sons attended the meeting with representatives from the Trust on 15 July 2022. The representatives apologised that the first two complaint responses had not led to enough recommendations to learn from what had happened. In general, they provided explanations based on the available evidence. They said nurses missed possible signs of malnutrition because they failed to take account of Mrs E’s oedema. They also accepted that nursing records were incomplete. They said the Trust ‘has a huge problem with nutrition and hydration’ and there was now a stricter process in place including spot checks and audits.
143. There was a discussion about the nurse’s actions after Mrs E’s death. The representatives did not appear to recognise the nurse had not followed the correct procedure. They did, though, accept it was not right that the family was left alone for so long afterwards which they agreed was insensitive.
144. Following the meeting the Trust sent two further written responses to Mr E on 29 July and 4 October 2022. The first of these listed actions the Trust had taken or was proposing to take in response to the issues raised by Mr E. Mr E also sent a further letter, reiterating his complaint that the nurse who attended after his wife died had not followed the correct process. The Trust’s final response still failed to acknowledge that this was a failing. It did not explain how it considered the nurse had followed the Verification Policy.
145. We recognise Mr E’s complaint was complex and that he raised multiple questions about different aspects of his wife’s care and treatment. While the Trust’s complaint responses appropriately addressed many of his concerns there were notable exceptions, which meant the responses were incomplete and, in some crucial areas, not based on the evidence.
146. We find the Trust was not open and accountable in its complaint handling. We can see how this was distressing for Mr E at a time when he was grieving.
Has the Trust put things right?
147. In its first complaint response the Trust considered the only action required was to ‘remind staff of the end of life process.’ Its view appeared to be that the major failing in relation to Mr E’s complaint was poor communication with the family when his wife was approaching the end of her life. At this point the Trust had not accepted there were any significant failings in care and treatment and so did not acknowledge the errors we have seen or apologise for the impact they had.
148. The Trust’s second complaint response accepted there were ‘elements of [Mrs E’s] care that could have been improved, including the recording of food charts and verification’ of death and it said this had been fed back to the medical and nursing teams. It accepted two other administrative actions that needed to be taken.
149. Again, the Trust had not recognised the extent of the failings in nutrition and care after Mrs E died. It did not appear to recognise that a nurse had not followed the Trust’s own policy and so it is unlikely feedback about that issue would have been helpful.
150. At the complaints meeting the Trust’s representatives accepted Mrs E’s family should not have been left alone for several hours with her after she died. However, in written responses the Trust maintained that there were no failings in this respect.
151. The Trust’s later responses included more detailed information about the actions it has taken. These included a review of the information contained in food charts and developing a new procedure for midline insertions. In relation to events after Mrs E died the Trust said it would ‘remind all staff they should let families know who they can speak to when they are ready and not left alone for that length of time.’ It added it would share the family’s experience in a monthly newsletter.
152. We do not consider the Trust has fully acknowledged its mistakes or apologised for the effect they had. While we recognise the Trust has taken some steps to try and improve services, we do not consider these are sufficient.
153. We find the Trust has not put things right for Mr E. We can see how this would have been frustrating for him.