Hydration 24. Blood tests can be taken to show the level of urea and creatinine in a person’s blood. These are markers that tell clinicians how well a person’s kidneys are working and whether they may be dehydrated.
25. Blood tests taken on 8 December show Mr G’s urea and creatinine levels were within the normal range. When his bloods were tested again on 10 December his creatinine level remained the same and his urea level had risen, just slightly outside of the normal range. This suggested Mr G was a little dry.
26. At this time, the Trust was giving Mr G diuretics (commonly called ‘water tablets’) to help treat the fluid overload caused by his heart failure. Diuretics aim to remove excess fluid from the body, which means slight dehydration can result.
27. Our clinical adviser says it can be difficult to get the right balance between minimising fluid overload to treat heart failure and keeping the patient fully hydrated. We think the minor dehydration demonstrated by Mr G’s blood tests was an understandable consequence of him getting the appropriate treatment for his heart failure.
28. Whilst this minor dehydration may have left Mr G feeling a little thirsty, we can assure Mrs G it did not have any other impact. We know Mrs G is concerned this was the cause of her husband’s confusion, agitation and aggression. We do not find any evidence to suggest this was the case. There is no biochemical (laboratory results) evidence of any kidney injury nor derangement of other markers to any extent to have had a medical impact.
29. Clinically, the evidence suggests Mr G was sufficiently hydrated and only slightly dry, which we think was reasonable in the context of concurrent treatment for his heart failure. We do not identify this as a service failure.
Oxygen 30. Mr G’s oxygen needs were appropriately assessed on his admission. It was known he was very oxygen dependent, demonstrated by his saturations (the percentage level of oxygen in the blood) dropping when off oxygen and recovering and rising when on. The Trust documented a clear aim to reach an 88-92% saturation which was appropriate for a man of Mr G’s age with chronic lung disease, and in line with BTS guidelines.
31. The Trust put Mr G on a continuous oxygen saturation monitor. Records show his saturation levels varied at times, as can and does happen even with appropriate oxygen provision. When it dropped, Mr G was able to tolerate this, and staff acted promptly to vary the oxygen dose to ensure he could swiftly recover.
32. We find his oxygen therapy was delivered in an acceptable fashion. He had his oxygen delivered either by a nasal cannula (a lightweight tube sitting in the nostrils) or by a venturi mask (placed on the face over the nose and mouth). Our clinical adviser explains these are standard methods of oxygen delivery for ward-based care.
33. Records show Mr G had a DNACPR order in place and a clinical decision had already been made that he was not for further escalation outside of ward-based care. The cannula and mask were appropriate oxygen delivery methods on this basis.
34. Whilst the assessment, prescription and delivery of oxygen was appropriate, we find there was a lack of appropriate supervision to ensure Mr G always received the levels of oxygen prescribed to him.
35. We do find Mr G was monitored frequently. His saturations were measured alongside other vital signs making up his national early warning score (NEWS), a standard way of assessing the clinical response needed to a patient’s condition. Records show times where nursing staff appropriately escalated Mr G’s care to the acute response team in line with NEWS guidance.
36. Yet, the evidence shows Mr G should have been continuously monitored by nursing staff due to his fluctuating confusion and capacity. As early as 8 December it was recognised Mr G was confused. In line with NICE CSK guidance, the Trust completed a recognised screening assessment for delirium, the 4AT. Mr G was assessed using the 4AT on 9 December and again on 10 December, scoring seven each time. This suggested he had cognitive impairment due to delirium.
37. At this point, it should have been recognised Mr G needed constant observation to maintain his safety. Our nursing adviser explains the most relevant and up-to-date guidance comes in the form of individual hospital trust standards and policies. One such policy provides a framework, underpinned by NICE guidance, in which patients can be assessed to decide whether they need heightened levels of observation. Using this framework, Mr G would have been assessed as needing constant observation – to be within eyesight at all times.
38. Mr G was not provided constant observation, which we identify as a service failure. We consider this further below.
Overnight between 12 and 13 December 39. We do not find evidence to suggest nursing staff failed to check Mr G when seeing his mask on his forehead. Evidence from the clinical records and statements taken from staff for the SI investigation state when the mask was first seen to have been removed, staff found Mr G awake and assisted him to put it back in place. When the mask was then found on his head, staff checked and found him unresponsive, immediately giving 15l oxygen and alerting the acute response team.
40. Mrs G complains nursing staff failed to hear or act upon the oxygen alarm. At a meeting to discuss her concerns, the Trust said staff could not recall hearing the alarm and said sadly it is unlikely it would ever know whether the alarm sounded.
41. Unfortunately, we cannot resolve this any further. We would not expect to find documentary evidence about the alarm, meaning we also cannot say whether it sounded. We do not see anything to lead us to question the credibility or reliability of the recollection of staff. We cannot say nursing staff did not act appropriately if they did not hear an alarm.
42. Mrs G’s complaint is primarily about the Trust failing to provide continual monitoring to her husband during this overnight period, and we agree its monitoring was inadequate. We note that nursing staff saw Mr G just ten minutes before he was found unresponsive, and yet as explained, we think the Trust should have provided continual observation by this point in time.
Impact of the monitoring failing 43. Under constant observation, Mr G should have always been within eyesight of the nursing team. With this, the movement of the mask between 1.50am and 2am would have been seen as soon as it happened, allowing staff to respond, encourage and assist in its repositioning without delay. With the mask in place, Mr G’s saturations would have likely remained at appropriate levels.
44. This does not assist in identifying what caused Mr G’s death, which is very difficult to do. Mrs G believes her husband died from a lack of oxygen. It is possible his death was due to hypoxia, resulting from him having removed his mask. Considering his circumstances and known multiple health conditions, it is possible his death was due to an event unrelated to the positioning of the oxygen mask, such as a cardiac arrest, blood clot or stroke.
45. Often patients who are very unwell experience symptoms of confusion and agitation, as we know Mr G did. Our clinical adviser explains it is not uncommon for someone experiencing a cardiac arrest or stroke for example, to be agitated and to remove masks or cannulas.
46. It is therefore possible an event such as a cardiac arrest, blood clot or stroke led to the mask’s removal, rather than its removal being the cause of the event. Whilst it is possible Mr G’s death was driven by low oxygen levels, it is also possible it was not.
47. We must also reasonably consider the limitations of constant observation in this circumstances. Even with immediate supervision, assistance and encouragement, it is possible Mr G would have remained non-compliant and continued to remove his mask. We know he did comply with assistance given to him ten minutes earlier. Yet, we know just ten minutes earlier he had demonstrated non-compliance, by removing his mask.
48. It would not have been appropriate to have enforced the mask’s position. In this circumstance people are typically sedated. The drugs used would have started Mr G on an end of life, palliative care pathway. Our clinical adviser adds that these sedatives are respiratory depressants, which would only have added to Mr G’s known problems with chronic lung issues and being oxygen dependent.
49. Mr G was an 80-year-old man with poor clinical conditions and multiple health issues. He had known chronic respiratory disease and needed hospitalisation for significant cardiac conditions. He had a DNACPR in place and was clinically decided for ward-based care only, without escalation. Sadly, his outlook was very poor, and our clinical adviser explains at the point of his death, he was reaching – if not already at – the end of life stage.
50. Even had constant observation been in place as we think it should have been, it is possible the outcome would have been the same. On the balance of probabilities, we cannot say Mr G’s death was avoidable. He may have died, even if the failing had not happened. However, we acknowledge there is a possibility the outcome may have been different, if not for the failing. We recognise this will be difficult for Mrs G to hear.
51. Unfortunately, we are left in a position where we will never know if the outcome would have been any different for Mr G if the failing had not occurred. It has left Mrs G with ongoing uncertainty about whether the outcome could have been different. We recognise this is the cause of her considerable distress. We have carefully considered what remedy would reasonably put this right, and what she seeks to remedy her complaint.
52. We find the Trust has already accepted the failing we identify and sincerely apologised to Mrs G. We are assured that appropriate action has been taken to prevent this occurring again. Both our nursing adviser and clinical adviser agree the recommendations set and stated actions taken following the Trust’s SI investigation go far enough.
53. Mrs G came to us seeking acknowledgement of failings, an apology and to ensure lessons are learned for future improvement. We consider this has already been achieved and the impact already remedied in line with our principles for remedy.
Staff statements 54. The Trust told Mrs G it would not share staff statements with her due to the psychological safety of the staff involved and as they were written at a highly emotive time.
55. We have seen the content of these statements and find nothing of concern. They provide an account of events in appropriate objective language which, importantly, aligns with the entries made in the clinical records. We do not find they contain any information about what happened that night, that has not already been shared with Mrs G in the SI investigation report.
56. We understand why Mrs G remains concerned about the content of these statements due to the explanation given to her. This implied there was something more complicated or potentially something sensitive within the statements, that understandably heightened her anxiety about them. We do not find this to have been the case and consider the explanation given to her at the time was not ideal.
57. In comments made to us during our detailed investigation, the Trust explained there was no lawful basis for disclosing these statements to Mrs G in line with the Access to Health Records Act 1990 and the UK GDPR and Data Protection Act 2018, as they were requested for the purpose of the SI investigation. For this reason, we consider the Trust’s decision appropriate and do not see any service failure here.