Mr F’s treatment
14. When Mrs B complained to the Trust, she said staff left Mr F self-ventilating for too long and they delayed escalating treatment for his conditions to the ITU. She questioned why staff did not use breathing support methods like continuous positive airway pressure (CPAP) and extracorporeal membrane oxygenation (ECMO).
15. She complained staff put Mr F on end-of-life care drugs like midazolam and morphine too early in his admission. She was concerned staff decided to withdraw treatment when they should not have.
16. In its complaint process, the Trust said staff admitted Mr F to the ITU at 1.26am on 12 April. This followed the reviews staff did in the ED. The Trust said he had respiratory failure associated with his COVID-19 illness. ED staff identified he needed advanced respiratory support and transferred him to the ITU following his arrival in the ED.
17. ITU staff noted his shortness of breath and what oxygen he needed. They started him on CPAP therapy. Prior to this, the Trust said he was maintaining his own breathing.
18. At 6am, staff noted his respiratory failure worsened. They then decided to put him to sleep, intubate him, and support his breathing with controlled mechanical ventilation. The Trust said staff used midazolam and morphine to help sedate Mr F during ventilation.
19. The Trust added ITU staff referred Mr F to the Trust’s ECMO centre. Staff there decided he would not benefit from ECMO.
20. By 18 April, the Trust said Mr F was not responding to the treatment available, and he continued to decline despite maximum ventilatory support. His illness had severely damaged his lungs. Therefore, the Trust said staff explained to Mrs B they could only provide endoflife support.
21. We saw staff treated Mr F in line with relevant standards and guidelines.
22. As we said in paragraph one, Mrs B complained about the treatment staff gave Mr F for three conditions. We explain our decision about the treatment staff gave Mr F for each of these conditions in turn. Within this consideration, we give our views about the specific actions Mrs B has concerns about which we set out in paragraph 14 and 15.
23. From paragraph 73, we give our consideration about the Trust’s decision to withdraw treatment for Mr F.
COVID-19:
24. Our consultant said, when Mr F was a patient at the Trust, there were no proven treatments or recognised national guidelines on how to treat COVID-19.
25. Mr F’s admission, in April 2020, came in the early phase of the COVID-19 pandemic. NICE did not publish NICE Guideline 191 until March 2021. This guidance recommended medications like dexamethasone (a steroid medicine) and tocilizumab (an antiviral medicine) to treat COVID-19.
26. As such treatments were not yet available and recommended, our consultant said staff needed to decide on treatment for Mr F’s COVID-19 in line with the principles set out in Good Medical Practice. Section 15 and 16 sets out doctors must:
• promptly provide or arrange suitable advice, investigations, or treatment where necessary • refer a patient to another practitioner when this serves the patient’s needs • prescribe drugs or treatment only when they have adequate knowledge of the patient’s health and are satisfied that the drugs or treatment serve the patient’s needs • provide effective treatments based on the best available evidence • take all possible steps to alleviate pain and distress whether or not a cure may be possible.
27. In his ED records, staff noted Mr F confirmed the test he took around a week before his ED attendance showed he had COVID-19. Since then, he had been self-isolating at home. However, his condition, including his cough and shortness of breath, was worsening. In his initial assessment in the ED, his oxygen saturation level was 89% (a normal level is between 95% and 100%).
28. Therefore, we saw evidence of Mr F’s COVID-19 illness, and that this was causing him respiratory problems. Based on this evidence, to manage these problems and support his breathing, our consultant said the treatments staff had available at the time included giving Mr F oxygen (through a face mask) and ventilation.
29. Mr F’s ED records show, given the respiratory problems he reported linked to his COVID-19, staff decided to give him supplemental oxygen through a mask at 8.45pm on 11 April. Staff aimed to increase his oxygen saturation level to at least 90-92%. Staff then gave him this oxygen. They noted this improved his oxygen saturation level to 92%.
30. Therefore, we saw staff gave Mr F initial (oxygen) treatment which our consultant said served his needs. They did so having noted his COVID-19 diagnosis and evidence they saw about this causing him respiratory problems. This is in line with Good Medical Practice, and we saw this treatment improved Mr F’s saturated oxygen level.
31. We appreciate Mrs B is concerned about how long staff left Mr F self-ventilating, and how long it took staff to escalate his care to the ITU. As we set out in paragraph 28, the other available treatment for Mr F’s COVID19 was ventilation. We have considered this below.
32. To monitor his condition, ED staff did a blood gas test at 10.59pm. This showed a partial pressure of oxygen reading of 8.73 kilopascals. It showed a partial pressure of carbon dioxide reading of 4.36 kilopascals. Our consultant said this showed a blood oxygen reading in keeping with a patient adequately self-ventilating while receiving oxygen through a mask, and normal carbon dioxide levels.
33. Mr F’s ED records show staff considered whether he may need ITU care to meet his oxygen needs. They decided escalation of his care to the ITU may be appropriate, and they asked ITU staff to review him. ITU staff then reviewed him at 11.03pm and agreed to admit him to the ITU.
34. His ITU records show staff noted his shortness of breath worsened following his transfer. Therefore, at 3.08am on 12 April, they started Mr F on CPAP therapy.
35. CPAP is a type of non-invasive ventilation therapy designed to support a patient’s breathing. It provides a positive pressure of air from a machine through a connected face mask. This helps a patient keep their airway open, which helps increase their saturated oxygen level and remove carbon dioxide.
36. Despite the introduction of CPAP therapy, Mr F’s respiratory failure progressed. Therefore, at 6am, staff intubated him. This is a more invasive and intensive type of ventilation.
37. Our consultant said staff escalated Mr F’s care to the ITU in a timely manner. They said staff also escalated his oxygen and ventilation treatments in a timely manner.
38. All this shows, after starting initial treatments, ED staff promptly considered whether they needed to refer Mr F’s care to ITU colleagues. This resulted in a transfer to a unit which could provide more intensive treatment to meet his needs.
39. When the observations ITU staff did showed evidence of worsening respiratory failure they started giving Mr F more intensive ventilation treatments to manage this. These were treatments our consultant said were suitable in the circumstances.
40. Therefore, having considered this evidence and advice, we saw staff acted in line with the principles from Good Medical Practice we set out in paragraph 26 when giving Mr F treatment for his COVID-19 illness.
41. Mr F’s ITU records show staff continued with ventilation to see if he responded. Our consultant said staff often refer to intubation and ventilation as a life support measure. Therefore, this escalation meant he was receiving an intensive level of treatment. Staff noted this was the maximum level of treatment they could provide.
42. We note Mrs B is concerned staff did not consider ECMO. An ECMO machine is a life support machine that takes over the function of the heart and lungs. It takes blood out of the body. It passes the blood through an artificial lung to oxygenate it before returning it to the body. The machine does the work of the patient’s lungs to give their lungs time to heal.
43. Section 2.1 in NICE Procedure 391 says staff can consider ECMO in patients with severe acute respiratory failure as a supportive therapy. Staff should use ECMO only if they think the patient has reversible causes to their respiratory failure. Section 1 says only staff or teams with specific training and expertise should decide on and carry out ECMO.
44. Having allowed time for Mr F to respond to ventilation efforts, our consultant said ITU staff referred him to a specialist team for consideration of ECMO 2.08pm on 16 April. Given his worsening COVID-19 and increasing oxygen requirement, despite receiving such intensive treatment already, ECMO staff decided the treatment would not help him.
45. Our consultant said the Trust’s referral for a specialist opinion on this was what they would expect to see according to the guidelines we have referred to (Good Medical Practice and NICE Procedure 391).
46. As staff could not be confident Mr F’s respiratory failure was reversible, given the progression of his COVID-19 illness, we saw reasons why NICE Procedure 391 indicated staff should not provide it. Therefore, we did not see a failing in staff deciding against ECMO and continuing with the ventilation treatment they were giving Mr F at the time.
47. We also recognise Mrs B has concerns staff gave Mr F midazolam and morphine. Mr F’s ITU records show staff started using these drugs on 13 April.
48. We appreciate the BNF Midazolam and the BNF Morphine Guidance says staff can use these drugs within end-of-life care. Staff can use midazolam to help with restlessness when a patient is at the end of their life. Staff can use morphine to manage pain and breathlessness.
49. That said, these drugs have other uses. This includes using them to sedate a patient so staff can intubate them and provide ventilation.
50. The Sedation Guidance recommends the use of both drugs in intubation. It says staff can use midazolam to help sedate a patient. Staff can use morphine to help manage pain associated with intubation.
51. Our consultant said it is not possible to put breathing tubes into the lungs of a patient who is awake. The patient would cough out the breathing tube. They added it is not possible to ventilate an awake patient using a life support machine. Staff must sedate the patient to allow the machine to breath for them in a coordinated fashion.
52. Our consultant also said inserting a breathing tube into the lungs and being on a ventilator can be painful and distressing. Therefore, staff should sedate the patient and provide pain relief.
53. Our consultant said Mr F’s ITU records show staff used midazolam and morphine to keep him intubated (replacing a drug staff previously used called cisatracurium). They saw no evidence staff introduced these drugs as part of any end-of-life care.
54. On this basis, we saw staff gave Mr F midazolam and morphine in line with relevant guidance to provide the ventilation treatment he needed to treat his COVID-19 illness.
55. We recognise Mrs B also has concerns staff later stopped treatment for all Mr F’s conditions. She believes staff did so earlier than they should have. We address this concern from paragraph 73 after first considering the treatment the Trust gave Mr F for the other two conditions she complains about.
56. We appreciate Mrs B expected staff to do everything possible to treat her partner’s COVID-19. We hope our review on this matter helps assure her about the treatment he received for this condition.
Pneumonia:
57. Our consultant said pneumonia is a general term for lung inflammation and/or infection. They added Mr F had lung inflammation linked to his COVID-19 illness. Therefore, the main actions staff needed to take was to treat his COVID-19. We have explained staff did this in line with guidelines in paragraphs 24 to 56.
58. The BNF Co-amoxiclav Guidance says staff can give a patient co-amoxiclav to treat a bacterial infection. Coamoxiclav is an antibiotic which can treat a wide range of infections throughout the body, including infections in the lungs.
59. Our consultant said the blood tests staff did when they admitted Mr F to hospital showed a bacteria called streptococcus. They said this can cause pneumonia.
60. The BNF Co-amoxiclav Guidance says coamoxiclav is an appropriate antibiotic to give a patient to manage this type of bacteria. Mr F’s medical records show staff gave him intravenous (IV) coamoxiclav based on the evidence from his blood tests. Staff continued giving him antibiotics throughout his admission.
61. Our consultant added staff kept his antibiotics under review. They said Mr F’s later blood tests in the ITU showed evidence of strep epidermidis (a skin contaminant) rather than a pneumonia causing infection. Staff then altered the antibiotic treatment they gave him to manage this source of infection.
62. Having considered all the above, beyond the treatment staff needed to give Mr F for COVID-19, we saw they also gave him the antibiotics they should have to manage any bacterial cause of his pneumonia.
Sepsis:
63. Recommendation 22 in the RCOP Guidance says staff should consider sepsis in a patient with known or suspected infection, and if they have a NEWS of five or higher. Sepsis is a lifethreatening reaction to an infection. It happens when someone’s immune system overreacts to an infection, and this starts damaging the body’s own tissues and organs.
64. NEWS assess a patient’s breathing rate, oxygen saturation level, blood pressure, heart rate, level of consciousness, and temperature. Staff give each parameter a score between zero and three. A score of zero means the parameter is normal. Higher scores indicate the patient is more unwell.
65. Staff add up scores for each parameter to give a total score. They should add two to this score if they need to give a patient supplemental oxygen. A higher overall score means the patient is more unwell and at higher risk of deterioration.
66. When Mr F arrived at the Trust’s ED, staff recorded he had NEWS of nine at 8.45pm. Our consultant said this indicated a septic response to his COVID-19 illness. Staff completed a sepsis screening tool at 8.50pm. They noted they needed to start Mr F on a sepsis treatment pathway.
67. To treat Mr F, section 1.6 in NICE Guideline 51 says staff should have:
• given him broad-spectrum antibiotics within one hour • given him an IV fluid bolus within one hour • performed blood tests • referred him to ITU staff to review his management and whether he needed an ITU admission.
68. Mr F’s ED medication charts show staff started IV co-amoxiclav and IV fluids at 9.10pm. Our consultant said co-amoxiclav was a suitable broad-spectrum antibiotic.
69. As we noted in paragraph 32, at 10.59pm, ED staff analysed the blood tests they did and asked ITU colleagues to review Mr F. This resulted in ITU colleagues accepting him for an ITU admission. His ITU records show staff continued to monitor his response to antibiotics and fluids and provide these treatments during his admission.
70. Therefore, we saw staff started the antibiotic and fluid treatments they should have within an hour of suspecting sepsis. They also performed the tests and made the referrals NICE Guideline 51 recommends. Our consultant said staff conducted these tests and referrals in a timely manner and escalated Mr F’s treatment.
71. This means, having considered the evidence and advice, we did not see failings in the sepsis treatment the Trust gave Mr F.
72. We recognise Mr F was very unwell when he attended the Trust’s hospital, and this was extremely difficult for Mrs B. We hope we have clearly explained our decision about the treatment the Trust provided for his conditions, and this helps assure Mrs B about the standard of care her partner received.
The Trust’s withdrawal of treatment:
73. Mr F’s ITU records show staff withdrew his treatments at 10.20pm on 18 April and commenced end-of-life care. This included stopping the drugs they used to intubate him, with a plan to remove the breathing tubes when the effects of the drugs wore off.
74. In reaching this decision, staff should have considered the End-of-Life Care Guidance. Section 24 says staff should assess a patient’s condition and consider their prognosis in deciding whether they are reaching the end of their life.
75. Section 40 says staff should weigh up the benefits of the treatment they are providing against the burdens or risks before reaching a view on whether continuing with it is in the patient’s interests.
76. Staff should consider whether the treatment may prolong a patient’s life, improve their condition, or manage their symptoms. They should consider how burdensome the treatment is when the focus of care is changing from active treatment to managing their symptoms to keep them comfortable.
77. Mr F’s ITU records show staff considered his prognosis on 18 April. They noted his COVID-19 continued to worsen. This was despite staff trying the treatments they should have, including intensive ventilation methods. This was not improving his lung function. Therefore, they considered there was no prospect of him recovering. On this basis, staff concluded the harm of continuing treatment outweighed the benefit.
78. Our consultant said the observations staff made about his worsening condition despite treatment supported their judgement about Mr F approaching the end of his life. They agreed the burdens of his ventilation treatment outweighed its benefit given they saw no realistic chance he would recover.
79. We also recognise our consultant said, in paragraph 52, intubation and ventilation is distressing and painful for patients. Therefore, we can see how this can be burdensome, and how these burdens outweighed the benefits given this treatment would not help Mr F recover.
80. Having considered this evidence and advice, we saw staff decided on withdrawing Mr F’s treatment in line with guidelines. They did so at a time when the evidence on his conditions indicated he would not recover, and on the basis the burdens of his treatments outweighed the benefits.
81. We do not underestimate how distressing Mrs B found this decision. We hope our review of this matter gives her some assurance about the Trust’s decision to withdraw care.
Updates about Mr F’s care plan and condition
82. In her complaint to the Trust, Mrs B set of the following issues on this matter:
• staff did not tell her about the change in Mr F’s condition after he arrived in the ED • staff did not tell her they intubated him at 6am on 12 April until she called later that morning • after that, she called the ITU several times to get updates on Mr F’s care plan and condition, but a matron did not call back until 16 April to provide this information • staff did not make her aware of the extent of Mr F’s deterioration when she called on 18 April • staff did not discuss or tell her about Mr F’s do not attempt cardiopulmonary resuscitation (DNACPR) order on 18 April and their decision to provide end-of-life treatment before staff decided on this.
83. In its complaint process, the Trust said staff updated Mrs B on the phone on 12 April about Mr F’s intubation. Before Mrs B said she spoke to the Trust’s matron, the Trust said Mr F’s notes indicated staff gave her and Mr F’s sons updates during this period.
84. On 18 April, the Trust said a doctor spoke to Mrs B. The Trust considered the doctor explained how poorly Mr F was despite the treatment staff had provided as part of his care plan. At the time of this call, staff had not yet decided on a DNACPR order.
85. The Trust said Mrs B came to hospital during the evening of 18 April. At this stage, through discussions, staff explained they had no more treatment options available for Mr F. His lungs were severely damaged, and they showed no sign of improvement despite the treatment. On this basis, staff did not think he would recover, and they could provide only end-of-life care.
86. We saw staff acted in line with guidelines in updating Mrs B about changes in Mr F’s care and condition.
87. Section 33 in Good Medical Practice says doctors must be considerate to those close to a patient and responsive in giving them information. Section 5.5 of the NMC Code contains similar wording. It says nurses should share the information families want and need to know about a relative’s health, care, and ongoing treatment.
88. Our consultant said there is no guidance which states how often updates like this should take place and what staff should tell relatives. However, based on the above guidance, they would expect to see regular updates.
89. We saw it would have been up to staff to update Mrs B. Within a few hours of his admission, staff intubated Mr F. Therefore, he would have been unable to call her.
90. In his ED records, we saw staff noted they spoke with Mrs B at Mr F’s request to update her at 12.10am on 12 April. Staff told Mrs B they were admitting Mr F to the ITU because he needed more oxygen. They advised she could obtain a further update in the morning if she called the ITU.
91. Mr F’s ITU records show staff updated Mrs B about his further deterioration at 9.11am. Staff called her to explain they needed to intubate him to manage his respiratory failure. Staff said they would continue this treatment to maintain his oxygen levels.
92. On 15 April, one of the Trust’s doctors updated Mrs B in a phone call. They explained staff continued with ventilation to improve Mr F’s oxygen levels. They hoped to see an improvement. However, they said there was a chance he would not recover.
93. On 16 April, staff updated Mrs B at 12.58pm and 1.28pm. The first call was from a nurse. They said a doctor would call her later after they had assessed Mr F. The nurse answered the questions Mrs B asked about ventilation and why staff commenced it.
94. At 1.28pm, the doctor called Mrs B. The doctor told her Mr F was still very ill despite receiving maximum respiratory support. They said there was little more they could do to escalate his treatment, and there was a real risk he may die. They said staff would keep her updated about his treatment and condition.
95. Staff gave Mrs B two updates on 17 April at 2.55pm and 4.43pm. They confirmed and answered questions Mrs B had about Mr F’s changing regime of antibiotics. They explained he remained critically ill, but they were continuing with the ventilation treatment they had been giving him.
96. On 18 April, staff noted they made three calls to Mrs B between 2pm and 3pm. In these calls, staff said, despite providing all the treatment they could, Mr F’s oxygen levels were deteriorating. They said there was a high possibility he may not survive.
97. In the third call, staff discussed arrangements for Mrs B to come to hospital. For example, the PPE she would need to wear and where she would need to meet staff to gain access to the ITU.
98. From 7.30pm, Mr F’s records show Mrs B was in hospital. Doctors updated her and then took her to see Mr F. During the evening, we saw staff discussed stopping his treatment with Mrs B and she was present when they disconnected Mr F from his ventilator at 12.11am on 19 April shortly before he died.
99. Our consultant said all this showed staff updated Mrs B regularly. When Mr F became more unwell and staff saw he may not survive despite the treatment they provided, staff told her about this.
100. Considering the evidence and advice, we saw staff contacted Mrs B when Mr F’s condition changed. For example, when his condition deteriorated, and staff intubated him on 12 April. When they later considered he may not survive, and he had further deterioration in his condition, staff gave these updates. They also explained there was little more they could do to alter or escalate the care they were giving him.
101. On this basis, we consider this shows staff were responsive to these developments and gave Mrs B updates on them. This is in line with Good Medical Practice and the NMC Code.
102. Regarding Mr F’s DNACPR order and withdrawing his care, we did not see failings in staff communicating about this.
103. Section 132 of the End-of-Life Care Guidance says doctors should involve those close to a patient in a discussion about a DNACPR order in advance of deciding on one. Section 15 says staff should consult with those close to a patient about any end-of-life care or treatment if the patient does not have capacity to engage with this.
104. In an entry in Mr F’s records at 8.27pm on 18 April, we saw staff explained to Mrs B they considered her partner would not survive. They went into the reasoning we set out in paragraph 77 about why they felt they should not continue with active treatment, and they should start end-of-life treatment.
105. After this, staff completed a DNACPR form at 10pm. Staff noted the earlier discussion they had with Mrs B in the form. At 10.20pm, Mr F’s ITU records show staff stopped giving him the drugs they had been using to intubate him. This was in preparation for removing the breathing tubes keeping him alive.
106. This shows staff had the discussions the End-of-Life Care Guidance says they should have had with Mrs B before taking these actions. Therefore, we did not see a communication failing.
107. We recognise Mrs B wanted more regular updates about Mr F’s care and condition. Given the visiting restrictions in place at the time due to COVID-19, we appreciate she could not see Mr F and she was reliant on telephone updates from staff. We do not underestimate how difficult this must have been for Mrs B.
108. We hope we have clearly explained our decision on this matter and how we have considered Mrs B’s concerns about her partner’s treatment. We hope this assures her we only reached our decisions following careful review of the concerns she raised with us.