Prescription for ambulatory oxygen
12. Before we decide if we should conduct a detailed investigation of a complaint, we look at whether there are signs the organisation has got something wrong. We do this by comparing what should have happened with what did happen. We have done this and have not found any indications that something has gone wrong.
13. BTS guidance on home oxygen use in adults’ section (or page) i9 says when a patient’s condition is stable with a resting blood oxygen level of less than 7.3 kilopascals (unit used to measure oxygen levels), clinicians should prescribe long term oxygen therapy (LTOT). This guidance is accurate for patients with Interstitial lung disease (ILD), also known as pulmonary fibrosis.
14. Section i19 of the BTS guidance says ‘AOT [ambulatory oxygen therapy], should not be routinely offered to patients who are not eligible for LTOT.’
15. The same section also says ‘there may be some patients, for example with ILD and disabling breathlessness, who do not qualify for LTOT but who do desaturate on exercise, who may benefit from AOT. Once all other medical interventions have been optimised, these patients could be considered for AOT following formal assessment and AOT use could continue following demonstration of benefit and compliance.’
16. Mr E has a diagnosis of fibrosis. A doctor at the Trust previously prescribed ambulatory oxygen to ensure he maintained his oxygen levels while he is active.
17. Mr E told us he was not very active during the winter of 2022. He had a painful ankle and attended few activities outside of his home. As a consequence, he says he did not use much ambulatory oxygen.
18. A nurse from the Home Oxygen Service (HOSAR) team at the WL Trust attended Mr E at home on 10 February 2023. The purpose of the visit was to determine Mr E’s ambulatory oxygen needs.
19. During a multi-disciplinary meeting at the WL Trust on 20 February 2022, clinicians discussed the HOSAR home visit and Mr E’s treatment going forward. A doctor from the Trust attended the meeting as the team’s respiratory consultant. The consultant decided to discontinue Mr E’s oxygen. We acknowledge this was a difficult time for Mr E and he experienced considerable frustration as a result.
20. In its response on 3 May 2023, the WL Trust said, ‘you stated you have not required ambulatory oxygen over the previous six months and therefore you were of the view that you did not require it any longer.
21. When invited, you also declined the 6-minute walk test to assess ambulatory oxygen needs and said you will not be using oxygen regardless of the results.’
22. The WL Trust also said, ‘based on the findings your oxygen should be discontinued and you should be discharged from HOSAR.’
23. Mr E believes the Trust cancelled his prescription because he was not as active as usual during the winter of 2022.
24. We explored Mr E’s medical records to establish if the Trust acted within the BTS guidelines in its decision to cancel his ambulatory oxygen and if it based this decision on his activity levels.
25. We saw from Mr E’s home oxygen assessment completed on 10 February 2023; his blood oxygen level was at 8.4 kPa. We note this recording was above the threshold for clinicians to prescribe long term oxygen therapy (LTOT) as outlined section i9 of the BTS guidance.
26. As Mr E’s oxygen levels were higher than the 7.3 kPa, he did not qualify for LTOT. However, section i19 of the BTS guidance says a patient with fibrosis may benefit from ambulatory oxygen therapy (AOT) even if they do not qualify for LTOT.
27. The guidance states clinicians should prescribe AOT if it would benefit the patient and they can demonstrate they will use it. It also says the patient would need to complete a formal assessment.
28. We have seen that Mr E declined part of the formal home oxygen assessment (a six-minute walking test) which would have indicated whether he would benefit from AOT.
29. We then considered the ‘compliance’ aspect of the guidance. In Mr E’s medical records from the West London Trust on 10 February 2022, we could see he stated ‘he does not use oxygen and does not intend to use it. He goes out 2-3 times per week for shopping and uses his car. He states he finds the oxygen difficult to carry.’
30. Our adviser agreed this showed that on the date of the assessment, Mr E was not compliant with ambulatory oxygen use and staff could not complete a complete formal assessment to determine if he would benefit from it.
31. We noted from Mr E’s medical records that the WL Trust did explore alternatives with him, such as light weight cylinders and portable oxygen concentrators (a device used to provide oxygen therapy to people that require greater oxygen concentration than that found in air). Staff reported Mr E declined both of these and stated that he wanted the oxygen removed.
32. Mr E also expressed concerns to us that the Trust removed his prescription for oxygen based on his activity levels.
33. After our review of his medical records, we found no evidence to suggest the Trust cancelled Mr E’s prescription based on his activity levels. A nurse from the West London Trust had documented that Mr E was leaving the house to go shopping two-to-three times per week.
34. Notes from the multi-disciplinary meeting held on 20 February 2023, say ‘[Dr] agreed that based on patient declining assessment, ABG [arterial blood gas] results and him requesting for equipment to be removed, HOOF [home oxygen order form] removal can be requested and patient can be discharged as he is not compliant and has expressed that equipment should be removed.’
35. We also saw that when the WL Trust received feedback from Mr E about this issue, staff offered an AOT assessment during a phone call on 6 March 2023. We note he declined this offer.
36. We can see the Trust based its decision to cancel Mr E’s oxygen based on benefit and compliance. We also saw Mr E refused part of the home assessment. Our adviser agrees the clinician acted within the sections of the BTS guidance we have outlined.
37. We have not seen any indications there were any failings in the clinician’s decision to remove Mr E’s home oxygen prescription or that they based their decision on Mr E’s inactivity levels. We will therefore take no further action on this complaint.
38. We are sorry for any distress Mr E felt as a result of the Trust discontinuing his ambulatory oxygen and we hope any remaining issues have been resolved.