MEWS score and observations
20. Mr A said the Trust did not perform observations and record Mrs A’s MEWS score on the 27 April 2018 despite him reporting that she was hallucinating and was generally unwell. Mr A said the nurses told him they would contact the doctor, but a doctor did not attend to visit Mrs A.
21. Mr A said the Trust did not perform observations until 10pm that evening, and Mrs A had a MEWS score of 6. Mr A said the Trust did not correctly follow the MEWS escalation policy following this score.
22. MEWS guidance says if a patient scores 1-3 to increase the frequency of observations. Our nursing adviser explained this was open to clinical judgement on how often the observations should be repeated as the guidance does not state a timeframe.
23. MEWS guidance says if a patient scores 4, staff should contact a junior doctor for a review within 30 minutes of the MEWS score. It also says to repeat observations every 30 minutes until the MEWS score is below 4.
24. From the evidence we have seen, we have found the Trust did not perform observations as often as it should have on 27 April. At 7.30am Mrs A scored 4 and in line with the MEWS guidance, this should have prompted a junior doctor review and observations every 30 minutes until the MEWS score reduced. Mrs A’s observations were not repeated until 2 hours and 20 minutes later and this is not in line with the Trust’s own MEWS guidance.
25. We can see in the nursing notes that at 7.35am, the Trust bleeped the doctor to review Mrs A and handed this over to the day team. Mrs A was not reviewed by the doctor until the ward round at 10.50am, approximately 3 hours and 20 minutes following the MEWS score. This is not in line with MEWS guidance, which says a junior doctor review should have taken place within 30 minutes of a MEWS score of 4.
26. Mr A said he informed nursing staff at approximately 6.30pm, 8pm and 10pm that Mrs A was hallucinating and generally unwell. MEWS guidance says if a patient scores 1 then observations should be completed more often, but it does not specify how frequently.
27. Following a score of 1 at 2.20pm the Trust did not complete any further observations for approximately 7 hours and 50 minutes, when Mrs A scored 6. We think the MEWS score of 6 supports Mr A’s account that his wife’s condition was concerning, and her condition had deteriorated during the evening of 27 April.
28. In line with the MEWS guidance the Trust should have completed Mrs A’s observations between 2.20pm and 10.10pm, based on her MEWS score of 1 and Mr A’s reports that she was unwell. Also, in line with the MEWS guidance, Mrs A should have been escalated for a medical review before her MEWS score of 6 was recorded. This is because of Mrs A’s previous MEWS score and reports that she was unwell. Our nursing adviser said these suggested Mrs A was at risk of deteriorating.
29. We have found the Trust did not complete Mrs A’s observations as often as it should have in line with the MEWS guidance, on 27 April. We will consider the impact of this below.
30. MEWS guidance says if a patient scores 6 or more staff should call a junior doctor and the critical care outreach team to attend. It says if they are unable to attend then a senior doctor should review the patient. It also says the patient should be reviewed by a specialist registrar or consultant within one hour of the MEWS score and that observations should be repeated every 30 minutes until the MEWS score is below 4.
31. NMC the Code says nurses should complete records at the time or as soon as possible after an event. It also says to make sure any entries are clearly written, dated and timed.
32. We can see on the MEWS chart the Trust ticked yes to CCOT (critical care outreach team) and doctor contacted following the MEWS score of 6. We have not seen any evidence a doctor, CCOT, specialist registrar or consultant reviewed Mrs A.
33. Mrs A should have been reviewed by a specialist registrar or consultant by 11.10pm at the latest. We can see Mrs A was not medically reviewed until approximately 7 hours and 35 minutes later, at 6.45am on 28 April following a further MEWS score of 8. This is not in line with the MEWS guidance which says a consultant or specialist register review should take place within one hour.
34. It has been difficult for us to determine what happened on the 27 April as there are untimed entries within the records on this date. There are also no entries between 4.30pm which says Mrs A is for a thigh ultrasound, and 28 April at 2am. Mr A has told us Mrs A was hallucinating and unwell on 27 April and scored 6 on the MEWS.
35. Mr A also informed us he was told a doctor had been called to review Mrs A. We have not seen any evidence of these conversations within the records or any record of Mrs A’s condition at this time. We have found this is not in line NMC the Code which says all entries should be completed as close to the time as possible, and timed.
36. We have also found the Trust did not review Mrs A in line with MEWS guidance following a score of 6 and did not complete records in line with NMC the Code. We will consider the impact of this below.
Delay to test results
37. Mr A said the Trust requested Mrs A’s voriconazole (anti-fungal medication) levels to be checked on 30 April and the results were not available until 21 May. Mr A said the Trust informed him if this was a certain level then it would need to stop the use of this medication. Mr A said he was informed by the Trust voriconazole was not recommended for Mrs A’s condition, but on the balance of risk, her outcome would have been worse if she did not have it.
38. The Trust said it said it could not identify any samples requesting voriconazole levels and that Mrs A’s deterioration was not due to taking voriconazole. The Trust said it had requested galactomannan and beta D glucan tests (tests to check for evidence of fungal infection). The Trust said the results for these tests became available on the 21 May 2018 (10 days following Mrs A’s death) and were negative for fungal infection.
39. GMC Good Medical Practice says clinicians must promptly arrange suitable investigations where necessary.
40. On 27 April we can see the Trust documented Mrs A’s temperature was 38.6°C and she had a MEWS score of 4 which prompted a review from a doctor at 10.50am. The doctor documented Mrs A had a fever, nausea and that there was an indication of nodules (growths) on her lungs. The doctor prescribed voriconazole and requested a galactomannan (test to identify fungal infection) test.
41. On 30 April we can see the Trust noted it would request testing for B-D-glucan (tests for fungal infections), however we have not seen evidence this was requested.
42. On 4 May the Trust noted if the galactomannan test was negative for fungal infection, it could stop the voriconazole medication. The Trust also documented it was waiting for the microbiology results to guide it on the antifungal medication.
43. We have not seen any evidence within the records that the Trust requested Mrs A’s voriconazole levels to be checked. Our adviser told us there are no guidelines which mandate that voriconazole levels need to be checked once being commenced on this medication. Based on this we did not find a failing in the Trust not requesting Mrs A’s voriconazole levels to be checked.
44. We think the test Mr A is referring to is the galactomannan test. This test checks for fungal infection and in a note on 4 May the Trust noted it would stop the voriconazole based on the results of this test. This is in keeping with what Mr A told us which is that the Trust informed him it would stop the use of voriconazole depending on the results of testing.
45. Our adviser told us if the galactomannan test was negative then it would indicate it was less likely Mrs A had a fungal infection and so the voriconazole would no longer be needed.
46. From the evidence we have seen, we have found the Trust has acted in line with GMC Good Medical Practice. We can see the Trust requested tests to confirm the presence of a fungal infection. This is in line with Good Medical Practice which says to promptly arrange suitable investigations.
47. We can see that the results of these tests became available on 9 May and our adviser told us it was negative for signs of fungal infection. It appears the test was sent to a second trust for the sample to be analysed. Our adviser said there are specialist laboratories for fungal testing and that there can be delays due to transport, bank holidays and weekends.
48. We acknowledge that 27 April (when the galactomannan was requested) to 9 May is a long time to wait for the test results. Within this timeframe we can see there were two weekends and a bank holiday. The results of the galactomannan test were available within seven working days.
49. Whilst we appreciate this is a still a long time to wait, we do not think it is a failing on the actions of the Trust. We can see the Trust requested the galactomannan testing on the 27 April and the sample was taken and sent the same day. We find this is in line with GMC Good Medical Practice which says to promptly arrange suitable investigations where necessary.
50. We do not underestimate how distressing this time was for Mr A, especially as his wife’s condition was deteriorating at this time and he did not know the results of the galactomannan test.
51. We have found the Trust acted in line with GMC Good Medical Practice and we understand Mr A will be disappointed by our decision.
Incorrectly labelled blood samples
52. Mr A said the Trust incorrectly labelled blood samples which were rejected by the Pathology department. Mr A said samples were rejected for being miss-labelled and this caused delays at a time that was critical in Mrs A’s treatment.
53. IBMS sample criteria guidance says samples should be correctly labelled and request forms completed to agreed standards.
54. From the records we can see on 11 April a sample was rejected due to being incorrectly labelled. On 13 April we can see a sample was rejected due to the Trust not requesting a specific test, so the laboratory did not know what to test. On both occasions the Trust was made aware the next day that the samples had not been tested.
55. Lastly, on 16 April a sample was rejected due to being incorrectly labelled and the Trust was informed of this the following day.
56. From the evidence we have seen, we have found the Trust has not acted in line with the IBMS sample criteria guidance. We can see on 11, 13 and 16 April the Trust sent incorrectly labelled samples which could not be tested by the laboratory. This is not in line with IBMS guidance which says all samples should be correctly labelled.
57. We have found the Trust did not label the samples in line with IBMS guidance. We will consider the impact of this below.
PICC line placement
58. Mr A said when reviewing Mrs A’s medical records, he discovered a high priority email sent to Mrs A’s doctors. The email was advising Mrs A’s doctors and other professionals, that her PICC line appeared to be in the right atrium and to consider withdrawing this. Mr A said neither Mrs A or himself was made aware of this, and the PICC was not withdrawn to his knowledge.
59. The RCN infusion guidance describes a PICC as a catheter that is inserted via the upper arm veins. It says this is advanced into the central vein, with the tip located in the superior vena cava. The superior vena cava is a large vein that carries blood from the head, arms, and upper body to the heart.
60. The RCN infusion guidance says the cephalic, basilic or median cubital veins of the patient’s arm can be used for the insertion of a PICC. These are superficial veins that connect to the superior vena cava. It also says the tip of the PICC should sit in the lower third of the superior vena cava or the upper right atrium (upper chamber of the heart).
61. NICE ultrasound guidance says 2-D imaging ultrasound guidance should be used when inserting a central venous catheter.
62. From the records we can see on 6 April 2018 the Trust documented the plan to insert a PICC line for infusion of IV (intravenous) medication for Mrs A’s cancer treatment.
63. We can see on 9 April the Trust inserted the PICC line. The Trust documented it obtained written informed consent from Mrs A. The Trust documented it isolated and identified the right basilic vein using ultrasound guidance. The Trust documented the basilic vein was punctured successfully on the first attempt. The Trust documented the PICC could be used immediately.
64. We can see on 17 April the Trust documented it had removed Mrs A’s PICC line, due to increased swelling of her right arm.
65. On 24 April the Trust documented it inserted a new PICC line into Mrs A’s left arm. The Trust documented it gained written consent from Mrs A. The Trust documented the line was inserted into Mrs A’s left basilic vein using ultrasound guided access. The Trust documented there was no complications and the PICC line was ready for use.
66. We can see the next recorded information about the PICC line was on 6 May. On 6 May the Trust documented it inserted a PICC line into Mrs A’s right basilic vein for TPN (total parenteral nutrition). The Trust documented it used an ultrasound to guide placement and the line was advanced to 45cm and sutured in place. The Trust documented the PICC line was safe to use.
67. Later that day we can see the Trust performed a chest X-ray bedside to confirm the placement of the PICC line.
68. We can see on 7 May the radiographer documented the right sided PICC line appeared to be within the right atrium and to consider withdrawing the PICC line. The radiographer documented the left PICC line was in a satisfactory position.
69. We think it is likely Mr A is referring to the PICC line that was inserted in Mrs A’s right arm on 6 May, not April.
70. From the evidence we have seen, we have found the Trust has acted in line with guidance. We can see the Trust documented it inserted the PICC line into Mrs A’s basilic vein which is in line with RCN infusion guidance. The Trust also documented it used an ultrasound to guide placement of the PICC line on each insertion which is in line with NICE ultrasound guidance. Mrs A’s PICC line sitting in the right atrium is also in line with RCN infusion guidance which says the PICC line can sit in the lower third of the superior vena cava or the upper right atrium.
71. Our critical care nurse adviser said the PICC line is meant to be in the right atrium, as it is in this case, and can commonly be too high or too low within the atrium.
72. We can see the radiologist reported on 7 May the PICC line was within the right atrium and to consider withdrawing this. We have not seen any evidence within the records that the Trust considered this. Our critical care nurse adviser confirmed the PICC was in the correct place but was slightly too low. Our critical care nurse adviser said unless the line was causing complications, it would not need to be repositioned.
73. We acknowledge there is a shortcoming in the Trust not taking any action from the radiographer’s report. We think that even if the Trust had acted on this, the outcome would have been the same. This is because our critical care nurse adviser said the PICC line was in the correct place, although slightly too low, and would not need to be removed unless it was causing complications.
74. We have not seen any evidence within the records Mrs A’s PICC line was causing any complications. Based on this we have found the Trust has acted within guidelines in the insertion of Mrs A’s PICC line, and the placement of the PICC line being in the right atrium.
Changes to MEWS documentation
75. Mr A said following his wife’s sad death he attended a bereavement meeting at the Trust. Mr A said in this meeting he raised that staff were completing the MEWS assessment form differently. He said some staff would put ‘n’ or ‘y’ for no and yes, and other staff would put a tick, cross or a squiggle. Mr A said the tick, cross and squiggle could be misinterpreted and affect the treatment being provided.
76. Mr A said the Trust informed him it would implement a standardised way to complete the MEWS form, but he has not received any evidence this has been completed.
77. Our Principles of Good Administration say organisations should do what they say they are going to do, or let customers know if they cannot.
78. We can see in a letter to Mr A dated 12 April 2019, the Trust acknowledged Mr A had raised there were inconsistencies in how staff were completing MEWS charts. The Trust said it would agree on a standard symbol for each observation being undertaken. We asked the Trust to provide evidence that this had been implemented.
79. The Trust provided evidence that in November 2020 it began the rollout of PICS across its hospital sites. PICS is an electronic system for logging patient information, including MEWS observations. PICS has a standardised way of completing MEWS charts and staff would be unable to insert incorrect characters.
80. We acknowledge there is a one year and seven-month gap from the Trust informing Mr A it would make changes, to the changes being implemented. PICS is a large system that would have taken time to be implemented and time for the Trust’s old system to be decommissioned.
81. We have found the Trust acted in line with Our Principles of Good Administration. The Trust informed Mr A it would implement a standardised way of completing MEWS charts, and we can see this has been actioned.
Impact
82. In summary, we have found the Trust failed to correctly label samples sent for testing in line with IMBS guidance. We have also found the Trust did not perform observations as often as it should on 27 April and did not medically review Mrs A following a MEWS score of 4.
83. We have also found the Trust failed to escalate Mrs A’s care following a MEWS score of 6 and did not accurately record information in line with NMC the Code.
84. We have considered the impact of these failings.
85. Mr A says Mrs A’s treatment was delayed due to blood tests being rejected and needing to be redone. Mr A said this was frustrating and worrying for him at a time that was critical for Mrs A.
86. In complaint correspondence the Trust apologised for the delays caused and for incorrectly labelling samples. The Trust said staff undergo annual training to ensure the potential for error is reduced but that regrettably errors will occur. We do not think this apology goes far enough to address the impact this had on Mr A.
87. We appreciate the impact Mr A has said samples being rejected has had. We understand it would have been worrying and frustrating for Mr A to learn his wife’s tests were being rejected. We recognise at this time Mrs A was receiving chemotherapy for acute myeloid leukaemia. We understand this was a very upsetting and distressing time for Mr A that was exacerbated by tests being rejected.
88. We can see the Trust re-requested the tests that were rejected, and our adviser reviewed the results of these samples. Our adviser said there were no significant abnormalities that would have required an earlier intervention or action. Our adviser said incorrectly labelled samples is usually human error and does happen within a healthcare environment.
89. Whilst we have found the Trust did not label the samples correctly, we are not able to link this failing to a clinical impact or delays to Mrs A’s treatment. We do however acknowledge and appreciate the worry and frustration it caused Mr A at an already very difficult time.
90. Mr A said the Trust not performing observations as often as it should was very upsetting, worrying, distressing, and frustrating for him. We understand Mr A was concerned for Mrs A’s wellbeing and was asking staff to help.
91. We acknowledge the impact this would have had on Mr A. We do not underestimate the impact of Mr A witnessing Mrs A unwell and asking for staff for help has had.
92. Following a MEWS score of 4, the Trust did not complete observations every 30 minutes, and Mrs A was not medically reviewed. We can see that at 7.35am a registrar gave the nurse advice over the phone and advised the nurse to take Mrs A’s blood cultures and administer paracetamol which they did. Following this, Mrs A’s MEWS score decreased, and she was reviewed by consultants at 10.50am and 4.30pm.
93. Our physician adviser explained that completing 30-minute observations would not have made a significant different to Mrs A’s outcome. Our physician adviser also said being seen by a registrar would not have changed the management of her condition at this time. Based on this we have been unable to link any clinical impact to the Trust not performing observations or escalating Mrs A’s care. We do however acknowledge that this would have been upsetting, distressing, and frustrating for Mr A.
94. Mr A said he has been left with uncertainty and unanswered questions regarding the Trust not escalating Mrs A’s care and if this affected her survival chances. Mr A said he is confused about why a doctor did not attend and that his wife was let down at a time she needed help most. Mr A said he should not have left her that night until she was reviewed a doctor, and this has left him with feelings of guilt.
95. Our physician adviser said that whilst a MEWS score of 6 at 10.10pm should have prompted a review by a senior doctor, the Trust managed Mrs A’s condition appropriately. The Trust provided paracetamol and oxygen to Mrs A and by midnight her MEWS score was 0. We therefore think there was no impact on Mrs A’s condition from this lack of review.
96. At 6am on 28 April Mrs A had a MEWS score of 8. We can see the Trust took more blood cultures, administered paracetamol, oxygen, and a salbutamol nebuliser (medication that opens the airways) due to Mrs A being wheezy. Our physician adviser said when Mrs A was reviewed by a doctor at 7.50am the management of her condition did not change. Our physician adviser said an earlier review would not have changed the management plan or outcome for Mrs A.
97. We recognise the Trust not escalating Mrs A’s care after she had a MEWS score of 6 left Mr A with unanswered questions and uncertainty about the impact to her survival. We hope this provides reassurance to Mr A that Mrs A’s survival chances had not been impacted and an opportunity had not been missed. We hope this also helps to relieve Mr A’s feelings of guilt.
98. We understand this also caused confusion and feelings of being let-down for Mr A.
99. Mr A said he believes the medical records have been edited due to there being no entry between 27 April at 4.30pm and 28 April at 2am. Mr A said there should be notes during this time especially as he had been requesting assistance.
100. As set out above, we have found the Trust’s records are not in line with the NMC Code. Mr A said this has caused confusion and uncertainty regarding why there were no notes made during this time.
101. We appreciate the impact Mr A has told us this had. We understand the Trust not recording the conversations it had with Mr A on 27 April when he was reporting his wife was deteriorating would cause confusion and uncertainty.