DNACPR decision
18. Miss N says a doctor completed a DNACPR form and treatment escalation plan without any discussions with Mr N or his family. She says there was no consideration of his capacity, or the fact that he was independent before his admission.
19. Miss N feels her father’s diagnosis of dementia was used without exploring how this affected him. She says the family were not made aware of this decision until weeks later.
20. She feels the decision on the ceiling of care (the maximum level of care he would receive) affected the subsequent care and treatment Mr N received. She says there was a decision not to provide surgery which may have prevented his death.
21. A doctor completed the DNACPR form in Mr N’s notes on 6 May 2022. They ticked a box to say he was for ‘ward level’ ceiling of care, meaning that staff would not consider a referral to intensive care if he needed it. They ticked a box to indicate a discussion had taken place with Mr N’s wife, but she and her daughter dispute this. There is no further documentation of a capacity assessment, or of the discussion that took place.
22. The Trust’s DNACPR policy states at section 8.6: ‘If a potential decision about CPR is deemed appropriate, then this should be discussed with individual and/or those close to them (such as relatives or carers) and this must be documented in the individual’s notes. The individual’s views and wishes in this situation are essential and must be taken in to account.’
‘Where the DNACPR decision has been made on the grounds that CPR will not work the individual should be informed of the DNACPR decision unless the clinician considers that to do so is likely to cause the person to suffer physical or psychological harm or they have indicated a clear desire to avoid this discussion. In both cases, the clear and comprehensive reasons for excluding the individual from the discussion should be fully documented, as well as recording the decision about DNACPR.’
‘If the DNACPR decision has been made and there has been no discussion with the individual then, if they have capacity to make the decision, you should seek their agreement to share relevant information with those close to them (such as relatives and/or carers) so that they may support the individual’s treatment or care.’
‘A DNACPR information leaflet should be made available where appropriate to individuals and their relatives or carers.’
‘It is only in very rare circumstances that a DNACPR decision should be placed in an individual’s notes without the person and/ or their family being informed. The reasons for doing so should be fully documented.’
23. On reviewing Mr N’s records, the doctor ticked the box ‘no’ in answer to ‘Does the patient have capacity to make this decision?’ However, there is no documentation of a mental capacity assessment. Miss N says her father could understand a DNACPR decision, but the doctor had made an assumption due to his dementia diagnosis, without considering his independence prior to admission.
24. In the section of the form for discussion with Next of Kin, this box is ticked and states ‘wife’. The space on the form for discussion with patient/family, is blank. There is no reference to a discussion elsewhere in the medical records. Miss N says her mother would not have discussed any matters with staff without including her daughter in them. Mrs N was never given a leaflet as per the Trust policy.
25. Miss N’s account is further supported by a documented conversation on 2 June 2022 in which the notes state ‘Re DNACPR – family do NOT recall any discussion prior to this and say they were not informed’.
26. If a mental capacity assessment had taken place but was not documented, the Trust policy states at 8.7 to consult with the Lasting Power of Attorney (LPA). Miss N was the holder of the LPA for her father and there is no evidence of discussion of this matter with her.
27. Section 8.8.2 of the Trust policy states ‘Information regarding the background to the DNACPR decision, the reasons for the decision, those involved in the decision and a full explanation of the process must be recorded in the individual’s notes.’ There is no evidence of this in Mr N’s notes.
28. Based on the evidence, the Trust did not act in line with several aspects of its own policy.
29. Miss N is concerned that decisions made early on impacted the care provided to her father. She acknowledges that the decision on whether to provide CPR, and on the suitability for surgery, is made by clinicians, based on risks and benefits. She is worried that the DNACPR decision was based on an incorrect assumption of his baseline function, and this then prevented him getting the care he needed.
30. Mr N’s records show that the surgeons reviewed him on 23 May. They explained there was no clinical need for surgery at this point, but if the situation changed, they would reassess. They explained he was high risk for surgery but did not say he was not eligible due to his background of dementia, or the DNACPR that was in place.
31. On 2 June, when he had deteriorated, the surgeons and anaesthetist reviewed Mr N in consideration for surgery. The surgeon noted he was high risk. The anaesthetist acknowledged Mr N’s functional status prior to his hospital stay, but explained that surgery would not be in his best interests due to his current condition.
32. We can therefore see that doctors made decisions based on Mr N’s clinical condition at the time, and not because of a decision about ward-based care made on 6 May. Our gastroenterology adviser confirmed they saw no evidence that Mr N’s active treatment was adversely affected due to this decision being made.
33. The impact of the failure to communicate the DNACPR decision, is the emotional distress it caused to Mr N’s wife and daughter discovering this at a later date. It also led to Miss N’s concerns that her father’s treatment had been impacted, which we hope she can now be reassured by.
34. In the second local resolution meeting (LRM), the Trust confirmed it would feed back to the doctor and nurse who were involved in the DNACPR decision. It stated there had been a learning and development session about this topic and that Miss N would receive a summary. Miss N has not received any further information.
35. We approached the Trust about this, and it stated there needs to be further review and training within the organisation around DNACPR as this was not an isolated case. This had not yet been arranged. The Trust therefore has not yet carried out any actions to put this right and we are recommending further action. Our recommendations are set out in paragraphs 92 to 100.
Delays in investigations, procedures, and treatment
36. Miss N is concerned that her father’s oesophago-gastro-duodenoscopy (OGD – a camera to look into the upper part of the gut) and sigmoidoscopy (a camera to look into the lower part of the bowel) were delayed. Both tests were requested on Thursday 19 May. The referral for both tests were made on a ‘Urgent- 24 hours’ priority.
OGD: 37. NICE Guidance CG141 says at section 1.3 ‘offer endoscopy within 24 hours of admission to all other patients with upper gastrointestinal bleeding’. Mr N had his OGD on Sunday 22 May, three days after staff requested it.
38. Miss N says the Trust told her this was due to capacity and skeleton staff levels at the time. Our gastroenterology adviser commented that it is not unusual for there to be delays in obtaining an urgent OGD, particularly over the weekend. They explained there was no evidence of cardiovascular instability meaning Mr N’s heart rate and blood pressure were stable, and therefore it was unlikely that he had ongoing bleeding.
39. Our adviser noted that the delay did not appear to impact Mr N’s outcome as there was no active bleeding found during the procedure and therefore no intervention was required.
40. Although there was a delay of two days, which is not ideal, we consider that it was a reasonable one in the circumstances. There were practical barriers to doing the procedures due to limited service availability at that time. We see that there is little to indicate Mr N needed the procedures more urgently and so staff considered it was safe to wait a little longer. We do not find that there was an impact on Mr N’s care as a result of this and so the decision is justifiable.
41. In response to Miss N’s complaint, the Trust advised us it has introduced weekly meetings on a Friday morning to discuss all patients awaiting procedures. It said this is to ensure effective communication between departments and to minimise delays with the procedures. We consider these actions as sufficient to help minimise delays where possible.
Sigmoidoscopy: 42. This test was cancelled on 22 May, whilst Mr N was having his OGD. There is no documentation as to why, and the decision was not communicated to Miss N.
43. Our gastroenterology adviser explained that literature supports not performing sigmoidoscopies in patients with Clostridium Difficile due to its inherent risks and costs. The risks of the procedure include perforation and peritonitis (infection of the inner lining of the abdomen). They explained the treatment would not be altered by findings at sigmoidoscopy and the procedure could increase the risk of bowel perforation.
44. On 24 May, the notes show a gastroenterologist saw Mr N and advised, as he had an infective cause of his symptoms, he did not need the sigmoidoscopy.
45. The Trust acknowledged there had been a breakdown in communication and apologised for this. It said it would feed back to the clinical director.
46. We do not find a failing in the failure to carry out a sigmoidoscopy. It appears that carrying this test out would not have altered Mr N’s management and so it was appropriate to avoid the risks associated with it.
47. However, there was acknowledged poor communication, for which the Trust provided an apology. We think this is sufficient to recognise and address that oversight and we are not making any further recommendations.
Failure to follow up care plans
48. Some aspects of Miss N’s concerns about care plans have been addressed under separate headings in paragraphs 64 to 69 and paragraphs 80 to 87 below, for clarity.
49. Miss N advised us her main remaining concern was about a delay in providing steroids and antibiotics after her father’s CT scans. Mr N had CT scans on 18 May, 23 May and 1 June. There is no documented action plan for medications after these scan results.
50. The first mention of steroids in Mr N’s records was following a gastroenterology review on 25 May and they were started the same day.
51. Mr N was on a variety of antibiotics between 3 May and 1 June. He completed a course of antibiotics on 22 May. On 24 May, the team sought further advice from microbiology, and they advised another course of antibiotics due to Mr N’s ongoing symptoms. On 25 May, microbiology was contacted again, and they suggested a change in antibiotics which commenced the same day. There was no delay in implementing any changes to Mr N’s antibiotics as per microbiology’s advice.
52. From our review of the records, we cannot see that there was a delay in commencing steroids as they were started the same day they were recommended. Our gastroenterology adviser explained steroids were started to cover the possibility, even if it were unlikely, that Mr N had an underlying inflammatory cause for his symptoms. Our adviser confirmed earlier use of steroids would have been unlikely to have affected Mr N’s outcome.
53. While there was no delay, which we hope reassures his family, advice provided also indicates a different approach would also not have improved Mr N’s chances of a better outcome.
54. We do not find any failings in the provision of steroids or antibiotics.
Delayed access to a gastroenterology bed
55. Mr N was on two different respiratory wards and under the care of respiratory consultants. Staff requested a bed on a gastroenterology ward on 18 May and on 21 May. The gastroenterology doctors responded to these requests. They provided clinical advice on tests and agreed with a bed transfer on the same day as the requests. Further advice was requested on 24 May, and Mr N was seen by gastroenterology doctors on 24 and 25 May. He moved to a gastroenterology ward on 26 May.
56. Miss N feels that as her father was not on the correct ward, he did not receive the correct specialist care.
57. Our gastroenterology adviser explained there is no reason why Mr N’s infection could not have been managed on a respiratory ward with input from gastroenterology and microbiology teams, as did happen. They could not see any evidence that Mr N’s care suffered as a result of not being on a gastroenterology ward.
58. We recognise that it is not always possible to place a patient on a specific ward if there are shortages of beds due to service pressures. In such situations the type of ward Mr N was on should not affect the standard of care he received. The advice obtained indicates this was the case, as he received input in his care from the necessary specialists on the ward where he was.
59. The Trust acknowledged Miss N’s frustration about delays and explained this was due to a lack of capacity. It noted a plan to review the pathways in place for access to digestive diseases beds as it recognised this was an organisation-wide issue. The Trust has sent us minutes of this meeting reflecting steps being taken to improve pathways for patients needing gastroenterology care.
60. We find there was no failing in Mr N remaining on a respiratory ward. We also note the Trust has taken appropriate steps to improve services.
Medication errors
61. Miss N says there were multiple medication errors during her father’s admission. She says the medical records document her challenging the nursing staff’s competence but do not address the errors or report them appropriately. There were three specific incidents discussed at the LRM that she wished to focus on.
62. Royal Pharmaceutical Society Professional Guidance says: 17: ‘Records are kept of all medicines administered or withheld, as well as those declined.’
17.1: ‘Such records are completed at the time of the administration/refusal or as soon as possible thereafter and are clear, legible and auditable.’
17.2: ‘Where a medicine is not administered or refused, details of the reason why (if known) are included in the record and, where appropriate, the prescriber multidisciplinary team is notified in accordance with the organisation policies and procedures. Appropriate action is taken as necessary.’
63. The NMC Standards say, at point 1.1.6, a nurse should ‘demonstrate the ability to keep complete, clear, accurate and timely records.’
Vitamin K: 64. On 18 May, the doctors prescribed 1mg of Vitamin K ‘stat’ by mouth. The plan for this was created in the ward round at 9:43am and stated it should be prescribed orally or intravenously (IV). Vitamin K is a medication that can reverse the effects of blood thinning medication and was given in view of Mr N’s recent rectal bleed.
65. The nursing notes at 10am state that all medication was omitted due to Mr N being NBM (nil by mouth). The nursing notes then state at 7pm ‘all medication given as prescribed’.
66. At midnight, Miss N spoke to a doctor to point out the vitamin K had not been given. This was then re-prescribed intravenously and administered.
67. On recognising a ‘stat’ dose had not been administered, our nursing adviser explained the medication should have been given straight away, with the time of administration recorded. In keeping with point 17.2 above, as the medication was prescribed orally, the nurse should have notified the prescriber to change the route to intravenous and be able to administer the drug.
68. This did happen later in the day, but only after Miss N raised her concerns with staff. The nursing notes stated he had no further episodes of blood in his stools and he did not require any further intervention to reverse the effects of his blood thinners. We have not found any evidence to indicate that the delay in administering the dose had any impact on Mr N’s health.
69. A DATIX (incident report) was raised after this shift due to concerns around the actions of the agency nurse. This led to the nurse being reported to the agency and no longer being allowed to book shifts at the Trust. The DATIX was amended to add the concerns about vitamin K, following our communications with the Trust.
Paracetamol: 70. On 28 May, a dose of IV paracetamol was given at 6am but not signed for. An oral dose was given at 8am. Miss N informed staff of this error. Doctors were not concerned about the effect on Mr N and his lunchtime dose was omitted accordingly.
71. The nurse who administered the 6am dose of paracetamol did not sign for it, and therefore did not comply with the Royal Pharmaceutical Society or NMC Guidance. A DATIX was completed and as an outcome, the Trust said staff were to complete reflections and medicines management training. It reiterated that staff were to ensure IV medications were checked and signed for by a second member of staff.
IV medications: 72. On 25 May, IV medications were signed for, but Miss N reports that her father did not have a cannula in place.
73. The notes show Mr N’s cannula was removed on 24 May at 7.54pm. It is not clear from the records when a new cannula was put in, but the LRM suggested this happened between 9pm and 10pm on 25 May. The drug charts show that Mr N’s 6pm dose of hydrocortisone (a steroid) was signed for. However, it is not possible that this was given without a cannula in place. The staff involved therefore did not comply with the Royal Pharmaceutical Society or NMC Guidance.
74. There is no documentation in the notes reflecting this and no DATIX was completed. In the LRM, the Trust said that conversations had taken place with the nurse involved and that the nurse’s performance had been managed.
75. Our nursing adviser noted that a DATIX would have been expected at the first opportunity the Trust were made aware of the incident. They also note that two nurses signed to say the hydrocortisone had been administered, and the same disciplinary action should have applied to both.
76. We understand that performance management is appropriate for individual nurses. However, we note that all these medications errors are not attributable to one individual. At the LRM, it was noted that gastroenterology generates a high percentage of DATIXs.
77. Overall, we have seen a theme of poor documentation in relation to incident reporting, and poor medicines management in this case. Our nursing adviser noted that this complaint suggests there may be systemic failings in the Trust with regards to medicines administration.
78. In the second LRM, the Trust explained work is being done on medicines management. The Trust completed a DATIX as a result of the complaint. However, this is about the reconstitution of hydrocortisone and not the incorrect documentation and failure to arrange for a cannula to be inserted so the drug could be given.
79. We find the Trust has not done enough yet to remedy the failings we have seen. We are recommending further action as set out in paragraphs 92 to 100.
Failure to provide adequate nutrition
80. Whilst waiting for investigations, Miss N says Mr N was left nil by mouth (NBM) for long periods of time. She says he was dehydrated and not provided with adequate nutrition.
81. Section 10.4 of the NMC Code says: ‘you must attribute any entries you make in any paper or electronic records to yourself, making sure they are clearly written, dated and timed, and do not include unnecessary abbreviations, jargon or speculation’
82. None of the food charts in Mr N’s records have been dated. Our nursing adviser noted that these charts may have been part of a booklet making the date more obvious when used. However, each separate page should have been dated.
83. There are two charts that are completely blank for the day, and four other mealtimes that have been left blank. There is no explanation of whether Mr N was NBM or had refused food due to a poor appetite. There is no documentation of snacks being offered. Our nursing adviser explained it is not clear if Mr N’s nutritional needs were met, because record keeping is so poor.
84. NMC Standards 1.16 say ‘demonstrate the ability to keep complete, clear, accurate and timely records.’
85. There are six days on which the fluid chart has not been dated. There are two days with evidence of poor fluid intake (10 May and 23 May). Fluid balance has not been calculated on one occasion (27 May). Our nursing adviser indicated there were 15 days on which it appears Mr N was adequately hydrated.
86. Our nursing adviser explained that unless rigorously maintained, fluid balance charts are poor indicators of hydration. They noted that nurses did not rigorously maintain Mr N’s charts and that record keeping was poor.
87. Due to the poor record keeping, it is not possible to determine Mr N’s hydration and nutritional status, and therefore any impact on his illness. However, we can say that the impact of poor record keeping is that Miss N will never know if her father was in receipt of appropriate and adequate nutrition and hydration. This understandably caused her and her mother distress. We are making recommendations in relation to this as set out below.
Our views on impact
88. We have seen failings in relation to Mr N’s DNACPR decision, medication errors, and nutrition and hydration.
89. It has not been possible to link these failings directly to an impact on Mr N’s failing health affecting the outcome for him. We recognise that he was very unwell, and his underlying illness is likely to be the key factor in his decline. However, we can link these areas of concern to emotional distress for Mr N’s wife and daughter.
90. The poor communication around the DNACPR decision led to a period of uncertainty for Miss N surrounding the treatment her father received, and whether this had impacted his outcome. The medication errors led to distrust and concerns about ongoing care, plus the failure to incident report and learn from these errors.
91. The poor record keeping has led to uncertainty about Mr N’s hydration and nutritional status, and his family are left without an answer as to whether he was adequately cared for or not.