The Practice
25. 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.
26. Mrs U is concerned the ANP who saw her husband on 19 November did not prescribe him with antibiotics.
27. The NICE chest infections guidance in place at the time said COVID19 pneumonia is a virus meaning antibiotics are ineffective. The guidance says clinicians should not offer antibiotics as a treatment for, or prevention of pneumonia if COVID19 is likely to be the cause and symptoms are mild.
28. When the ANP assessed Mr U remotely, they noted he had a one-week history of a cough, fever, and dizziness. He reported feeling very unwell. The APN documented he was alert on the phone and advised him to test for COVID-19 at home. They also prescribed him medication for dizziness.
29. Mrs U is concerned that Mr U had pneumonia and that the nurse should have prescribed antibiotics for this. We understand why Mrs U is so concerned about this. In hindsight we know Mr U developed COVID-19 pneumonia. However, our nurse adviser said it is now not clear from the notes taken during this consultation whether Mr U had this.
30. Regardless of whether Mr U had COVID-19 pneumonia at the time or not, the NICE chest infections guidance would not have required the ANP to prescribe antibiotics to Mr U. This is because it appears the ANP suspected Mr U had COVID-19 and advised him to take a test at home.
31. We have therefore seen no indications of failings in the decision not to prescribe antibiotics to Mr U. We hope this provides some reassurance to Mrs U.
Nottingham Trust Infection from ventilation equipment 32. Mrs U complains her husband caught an infection during the admission which a doctor advised her had been from ventilation equipment used to sedate him.
33. We can see the treating team first raised concerns of Mr U potentially having another infection in addition to COVID-19 on 3 December. This was three days after the treating team had ventilated him. The treating team documented the source of the infection was unclear.
34. Our intensive care adviser agreed there is some evidence to suggest Mr U caught another infection during the hospital admission in addition to COVID-19. He explained the most likely source was from another infection in the lungs.
35. However, extensive testing never confirmed another infection. Our intensive care adviser said Mr U’s symptoms could also have been a further immune reaction to the initial COVID-19 infection or a worsening of Mr U’s COVID-19 pneumonitis.
36. The ICS guidance says that infection of the lungs occurs in 10 to 20 percent of patients who are mechanically ventilated. This is because the breathing tube the clinical team put into the airway can allow bacteria and viruses to enter the lungs and cause pneumonia.
37. The ICS guidance recommends interventions to help prevent this which include:
• elevation of head of bed (30 to 45 degrees) • daily sedation interruption and assessment of readiness to extubate • use of a specialised endotracheal breathing tube for secretion drainage in the airway • avoidance of scheduled ventilator circuit changes
38. For the most part, there is evidence the treating team followed these guidelines. The medical records show they placed Mr U in the head up position. The daily ICU charts show the treating team regularly reviewed Mr U for the appropriateness of continued sedation. There is also no documentation of routine ventilator circuit changes.
39. The Nottingham Trust confirmed it did not routinely use specialised endotracheal breathing tubes for ventilated patients. A specialised tube would drain away secretions which pool above the breathing tube and help prevent ventilation acquired pneumonia.
40. Our intensive care adviser explained that although the ICS guidance recommends the use of these specialised tubes, this is just guidance and not a must follow protocol. We can see that previously withdrawn guidance published by NICE in 2008 for mechanically ventilated patients did not recommend the use of these tubes.
41. Our intensive care adviser explained it is up to the individual hospital Trust to decide whether to use the specialised tubes. He explained many hospitals do not use them. Our intensive care adviser explained this is because most patients are only in intensive care for a few days. He explained the benefit of their use is if a patient is in ICU for a longer period.
42. Our intensive care adviser explained the added complication with COVID-19 was that it was not known at the time how long patients would require ICU care for. We can see from the medical records that the plan was to reduce Mr U’s sedation. As such, the clinicians would have thought Mr U would be coming off mechanical ventilation sooner rather than later.
43. Our intensive care adviser also explained hospital staff do not usually put the specialised tubes in when they initially ventilate a patient. He said patients often arrive in ICU with a tube already in place. He explained this means ICU staff would have to change the breathing tube following ICU admission which carries further risk of infection.
44. Considering this advice, we have not seen any indications of failings on the Trust’s part here. For the most part, it appears the hospital staff were complying with the ICS guidance for preventing ventilator associated pneumonia. The actions they took would have contributed to preventing infection.
45. We recognise they did not use a specialised tube. We do not think this is an indication of a failing because it is not common practice across the UK. We have also considered that the records indicate it was not the Trust’s intention to keep Mr U on ventilation for a long time.
46. We were sorry to hear that Mr U may have caught another infection during his hospital stay. We understand why Mrs U is so concerned about this. Sadly, this is a recognised complication in a ventilated patient and does not automatically mean there was a failing on the Trust’s part.
Transfer on 13 December 47. Mrs U complains that on 13 December, the Nottingham Trust transferred Mr U to the Chesterfield Trust, even though he was still critically ill. She says hospital staff told her this was because her husband was stable, and they needed the bed for a sicker patient.
48. We understand why Mrs U feels the hospital staff should not have moved her husband. We appreciate how devastating this decision must have been at an already stressful time.
49. The ICU transfer guidance says a contentious issue which sometimes arises is when a transfer is necessary because of lack of availability of critical care beds. It says doctors may have to decide whether to transfer the new and potentially unstable patient, or an existing more stable patient who is less likely to deteriorate.
50. The guidance says it may on occasion be necessary to transfer one patient out of a critical care unit for the sole purpose of making room for another as the most pragmatic approach.
51. The ICS COVID-19 capacity guidance also provided guidance to hospitals during the COVID-19 pandemic. The Nottingham Trust confirmed that at the time it transferred Mr U, the hospital was at ‘CRITICON-PANDEMIC level 3’. This means hospital resources were starting to be overwhelmed. The guidance says that in this situation the hospital response should be: • active decompression from hot sites • high volume transfers within and across regional boundaries • maximum coordinated effort to prevent any individual site progressing to ‘CRITICON 4’.
52. The doctors caring for Mr U were therefore acting in line with these guidelines by actively moving patients to another hospital site. This was in response to the overwhelming demand for critical care caused by the pandemic.
53. Our intensive care adviser said there is no national guidance in place to guide how stable a patient should be prior to transfer. However, the ICU transfer guidance says the decision to transfer a patient is the joint responsibility of the referring and receiving clinicians.
54. From the documentation it appears three intensive care consultants were involved in the decision to transfer Mr U in line with this guidance. Overall, we have found the Trust acted in line with national guidance in deciding to transfer Mr U. We recognise that despite this, this was a heartbreaking situation for Mrs U.
Communication about transfer 55. Mrs U complains the hospital staff did not advise her they would need to fully sedate her husband for the transfer even though the objective had been to reduce his sedation.
56. The ICU transfer guidance says clinical staff should keep patients and their relatives informed at all stages of the transfer process and provide them with appropriate written information.
57. We can see the hospital staff initially updated Mr U’s family on Mr U’s condition on 13 December at 3.40pm. They explained that due to capacity they would need to transfer Mr U to Chesterfield ICU.
58. The clinical team provided a further update to the family to inform them Mr U had left the hospital and was on the way to Chesterfield ICU. They documented the family were ‘happy’ with both updates and had no further questions.
59. Our intensive care adviser explained the Trust acted in line with the ICU transfer guidance as they had spoken with Mrs U on two occasions about the transfer. He said this guidance did not require the clinical team to specifically tell Mrs U that they would fully sedate Mr U prior to transfer. He explained the decision to sedate Mr U would be dependent on the responsible clinician at the time of the transfer.
60. Overall, we have found the Trust acted in line with national guidance regarding communication about the transfer and so we can see no failings in this area of the complaint.
Tracheostomy 61. Mrs U complains the Trust did not perform a tracheostomy for Mr U which the treating team first mentioned on 10 December. She says they moved her husband to the Chesterfield Trust before carrying this out.
62. The tracheostomy guidance recommends consideration for a tracheostomy between seven to ten days if ongoing mechanical ventilation is necessary. This says ICU doctors should consider the timing of the tracheostomy on an individual basis.
63. The guidance says that balancing the risks of managing an airway with a prolonged tracheal tube, versus the risks of tracheostomy is usually difficult.
64. We can see the ICU team considered a tracheostomy or a trial of removal of the breathing tube without mechanical ventilatory support on 10 December. The ICU team explored this in subsequent days with the family.
65. The medical team completed a consent form on the evening of 12 December in preparation for the tracheostomy. They documented that ‘it is increasingly likely that he will need a tracheostomy’. There is no mention of the exact timing of when this would occur.
66. In summary, there is documentation the medical team considered a tracheostomy at day seven and began to prepare for this procedure through a consent form at day ten. This is in line with the tracheostomy guideline.
67. Unfortunately, we can see the treating team transferred Mr U to another hospital before a tracheostomy occurred. We understand why Mrs U was so concerned about this.
68. We hope Mrs U will be reassured the decision to transfer Mr U was in line with national guidance. We have seen nothing wrong in the Trust transferring Mr U before performing a tracheostomy.
Chesterfield Trust
Transfer
69. Mrs U complains that following transfer to the Chesterfield Trust on 13 December, staff then transferred her husband again to the University Trust.
70. The ICS COVID-19 transfer guidance says what the critical care team should do if they consider they do not have the resources to provide the care required by a patient. This says they should consider whether another site can provide that care instead (if the patient’s condition would enable a transfer).
71. In Mr U’s medical records, the critical care team documented on 14 December at 2.50pm that they informed the family of the need to transfer Mr U to the University Trust. They documented this was due to bed unavailability at the Chesterfield Trust.
72. In the Chesterfield Trust’s complaint response, it stated that initially the hospital had been able to accommodate Mr U’s care. However, it stated that the situation had changed by the following day, and it was experiencing a surge in demand for critical care beds. It said this placed all patients at risk of harm in critical care.
73. This means it no longer had sufficient resources to provide the care Mr U required. Following a clinical assessment, the treating team reached the decision that Mr U was stable enough to transfer to another site. Again, the treating team reached this decision in line with the national guidance in place during the pandemic.
74. We again understand why this decision continues to be so devastating to Mrs U, especially given her husband had already undergone an earlier transfer.
Attempts to wake Mr U
75. Mrs U also complains the Chesterfield Trust made no attempts to wake her husband. She feels this was because they were planning to move him again.
76. The ICS guidance recommends ‘daily interruption of sedation and assessment of readiness to extubate’ in ventilated patients.
77. At 5.15pm on 13 December, we can see documentation in the medical records which shows a plan to change Mrs U’s sedation medication. The new medications were shorter acting and therefore when stopped or reduced could potentially result in a patient waking sooner. The plan also raised the suggestion of a sedation break or tracheostomy,
78. From the documentation it appears the ICU team changed the sedation medications in preparation for a potential interruption of sedation the following day. However, during the review the following day, the consultants caring for Mr U decided this was not in Mr U’s best interests. This was due to concerns of ongoing infection.
79. Our intensive care adviser said the clinical records support this decision as they show Mr U had an ongoing high fever. They also show the doctors had arranged a sampling of his blood to test for a range of fungal and bacterial infections.
80. Our intensive care adviser said the Chesterfield Trust were compliant with the ICS guidance in aiming to interrupt Mr U’s sedation. However, this did not go ahead so that clinical staff could explore the possibility of ongoing infection.
81. We can see no reference in the medical records that the clinical team did not undertake an interruption to sedation due to them planning to transfer Mr U to another hospital. We have therefore seen no indications of failings here. We hope this provides some reassurance to Mrs U around the decisions taken at this time.
University Trust
Communication about tachycardia
82. Mrs U complains the Trust did not communicate that her husband had become tachycardic on 16 December.
83. We note Mr U had tachycardia for most of his stay at the University Trust. Our intensive care adviser said what appears different on 16 December from the previous two days is the degree of tachycardia and the type of rhythm.
84. NICE guideline CG138 says if a patient cannot indicate their agreement to share information, doctors should ensure they keep family members involved and informed.
85. From the medical records we can see that in the 24 hours prior to Mr U’s death, members of the clinical team spoke to Mr U’s family on four occasions. At 3.46pm on one of these occasions, a clinician documented they had updated Mrs U regarding ‘all current problems’ Mr U was facing. They advised Mrs U her husband was still in a critical condition.
86. Although there is no specific mention of tachycardia in this discussion, doctors advised they had informed Mrs U of all current problems. We recognise this conflicts with Mrs U’s account as she advises the doctors did not inform her that Mr U had tachycardia.
87. We have carefully weighed up these accounts. Because they are conflicting, we do not feel we would be able to reach a balance of probabilities decision on this part of the complaint. We appreciate this may be a disappointing outcome to Mrs U. We were reassured though that, in general, the Trust were keeping Mrs U informed of Mr U’s condition.
Bereavement meeting
88. Mrs U also says the Trust did not offer her a bereavement meeting following her husband’s death.
89. The COVID-19 visiting guidance said hospitals should signpost families to emotional and spiritual support and bereavement support services following the death of a loved one.
90. The guidance does not say that hospitals should offer a bereavement support meeting. Our intensive care adviser said that any decision to permit a bereavement meeting would be at the discretion of the local hospital.
91. On review of the medical records, we are unable to find any documentation of what information hospital staff provided to the family at the time of death. We can see a member of staff working in the bereavement department at the hospital signed a document confirming they had spoken to the family.
92. However, in the complaint response, the hospital said it provided the family with a copy of the hospital bereavement book before the family left the hospital. It said it was not undertaking bereavement meetings at the time because of the COVID-19 pandemic.
93. Overall, we can see no indication of failings here as there was no requirement for the hospital to provide a bereavement meeting to Mrs U. We can see it provided Mrs U with a bereavement book which provided contact information for bereavement support services. This was in line with the national guidance.
94. We in no way underestimate how difficult a time this was for Mrs U, and we were very sorry to hear that she felt unsupported after Mr U’s death.