Discharge 17. Mr I says he is concerned that staff were wrong to discharge his father on 21 January 2022. He says his father was very breathless and struggled to get into the car and his home.
18. Mr I says, at home, his father was very unwell and struggled to climb the stairs due to his oxygen levels being so poor. He was subsequently taken back to hospital via ambulance a few days later.
19. The records show at 9.45am on the day of discharge, the consultant had noticed Mr P’s oxygen levels were dropping when he exercised but it was not affecting his mobility or falls risk. It is also documented that Mr P was keen to go home.
20. The records also say Mr P was willing to accept a commode and urine bottles to reduce the frequency that he would need to go up and down stairs at home. The records say his oxygen levels were fine when he was sat in the chair or resting. The consultant deemed that he was safe for discharge if the stair assessment was satisfactory.
21. The stair assessment documentation shows Mr P’s Sp02 (the amount of oxygen in your blood) was 89% on air at rest prior to the assessment (resting oxygen saturation). As per BTS guidelines, Mr P’s target should be between 94-98%.
‘The recommended target saturation range for acutely ill patients not at risk of hypercapnic respiratory failure is 94–98%.’
22. The records show Mr P was then put on two litres of oxygen to take him to the stair assessment, which took his oxygen saturation to 94%. Even with Mr P being given oxygen, his sats were only just in the target range.
23. The records show he did the stair assessment with oxygen and staff noted he was breathless but completed it okay. He was then discharged home without oxygen.
24. Our adviser said they do not have any concerns about Mr P being on oxygen the day before discharge. This is because a patient’s condition can change and the Government discharge guidance states that a patient should be reviewed twice a day to see if they still meet the criteria to reside in hospital. As soon as a patient no longer meets the criteria to reside then they should be assessed for discharge.
25. Our adviser said it did not make clinical sense for Mr P to have done the stair assessment whilst on oxygen and then to have been discharged without oxygen.
26. As Mr P’s resting oxygen saturations were below target, our adviser also said that would have warranted an assessment for him to have oxygen at home.
27. The records show Mr P’s readmission on 25 January was due to breathlessness, a cough and fever. The diagnosis made was of pneumonia on top of the recent COVID-19.
28. The records also show that the family had said how distressing it was seeing how breathless he was at home.
29. There are multiple entries within the records of conversations between Mr P and clinical staff that say Mr P was eager to go home. However, the evidence shows Mr P should have had an assessment to determine whether he required oxygen at home.
30. It seems likely that as Mr P needed the oxygen to do the stair assessment, if he had been assessed for home oxygen, it would have been given.
31. Our adviser said, had the Trust discharged Mr P on oxygen, it would not have prevented the pneumonia or the subsequent hospital admission.
32. Our adviser said the main impact is that Mr P struggled for the days he was at home, he likely would have been breathless, uncomfortable, and distressed.
33. We find the Trust should have completed an assessment to determine whether Mr P required oxygen before discharging him home. We believe it is likely Mr P would have either been given oxygen to go home or he would have remained in hospital. This likely would have made him more comfortable. We also find that this caused Mr P’s family a significant amount of distress at seeing him struggle so much.
34. The Trust has not acknowledged any failings regarding Mr P’s discharge or oxygen management, and the impact that had. Therefore, we cannot say this injustice has been remedied.
Sarilumab 35. Mr I says his father was given Sarilumab but staff did not monitor him afterwards for side effects.
36. He says according to NHS guidelines, patients who receive Sarilumab have a reduced immune system for at least three months. It also poses a ‘high risk’ of infection such as pneumonia which Mr P developed a few days after being discharged.
37. The Trust said Sarilumab was prescribed as standard treatment for COVID-19 pneumonitis. This is also supported by the records.
38. The records show Mr P was given a one-off dose of Sarilumab whilst in hospital.
39. Our adviser said during the pandemic there were a lot of drugs tried to treat COVID-19. Sarilumab is no longer in the current NICE guidance for treatment for COVID-19. A lot of the drugs tried were anti-inflammatory drugs, which work by blocking some of the inflammation caused by the virus, but they do not kill the virus. Like Sarilumab, they do reduce the immune system and therefore all slightly increase the risk of infection. The benefit is that the medication may improve outcomes.
40. The NHS guidance on Sarilumab does not give any indications that health professionals should monitor or treat patients for pneumonia post treatment.
41. There is a study called ‘Sarilumab plus standard of care vs standard of care for the treatment of severe COVID-19’ where the drug was tested during COVID-19. The clinicians were obliged to report any side effects related to the treatment compared to those who did not get the treatment. The results showed in the treated group, secondary pneumonia was only slightly increased compared to those who did not receive the medication, but this did not reach statistical or clinical significance.
42. We cannot say the Trust should have monitored Mr P for pneumonia after providing Sarilumab. The Trust was correct to provide this medication for COVID-19 but did not need to monitor Mr P after this was given.
Communication 43. Mr I says the communication from the Trust about his father’s condition was poor before he died. He says the Trust had also told Mr P he was going to die before the family had arrived to be present with him for this news. This was also after the Trust had asked his wife to come to hospital to help reassure him.
44. The Trust said several conversations with Mr P and his family took place during this final illness and it is understood and acknowledged that these conversations are extremely difficult and upsetting.
45. The Trust said at no point during the assessment of Mr P did the ACCP (Advanced Critical Care Practitioner) intend to have a discussion around breaking bad news. However, this was a conversation that Mr P initiated with the ACCP due to the rapid deterioration that he was experiencing. This is also reflected in the records.
46. The Trust said following this discussion, Mr P’s wife and two sons were called to the unit and there was a conversation detailing the seriousness of his current condition, and the symptom management was the most appropriate treatment plan considering Mr P did not wish to have CPAP (Continuous Positive Airway Pressure). This is type of breathing support that provides positive pressure of air through a mask to keep the airway open.
47. The Trust also said sensitive conversations are considered very carefully and wherever possible, facilitated to include all relevant family members. Unfortunately, on this occasion this could not be facilitated due to the deterioration in Mr P’s condition, and the need to have such an honest discussion at his request. The Trust apologised that Mr P’s wife was not present for these discussions and said it appreciated how difficult this was for the family as whole.
48. The records show that on 27 January, in the morning, Mr P’s oxygen levels took a big dip. At 1pm the same day, there is a note to say Mr P’s wife was updated on his condition. The notes say his chest was worse and he was being given oxygen. The records also summarise a long discussion on 28 January with Mr P’s son and wife about what was happening.
49. The records show a telephone conversation between Mr I and a doctor on 28 January at 7.50am. The doctor explained Mr P was very unwell and was being treated for an infection on top of having damaged lungs by COVID-19. Mr I and the doctor confirmed understanding of Mr P’s wishes about not wanting to be intubated if he was to deteriorate. Mr I asked to be updated if anything changed.
50. Our adviser says if someone takes a turn for the worst or if there is a significant change in their condition, clinicians would normally speak to the next of kin.
51. GMC good medical practice says:
‘You must listen to patients, take account of their views, and respond honestly to their questions.
You must be considerate to those close to the patient and be sensitive and responsive in giving them information and support.’
52. Our adviser says if a patient asks clinicians to talk to them about their prognosis and how unwell they are, clinicians are required to do that. Our adviser said in an ideal world, if they are going to be having that discussion, clinicians should offer for the patient to have someone close to them present. Our adviser said this was made difficult because it was during the COVID-19 pandemic and was an emergency situation.
53. The evidence shows the doctors acted in line with GMC guidance by keeping in contact with Mr P’s family to provide updates on his condition. The doctors updated the family on 27, 28 and 29 January and accommodated Mr P’s family to visit him on 28 and 29 January during the COVID-19 pandemic.
54. We find it was in line with GMC guidance for the Trust to have the discussion with Mr P about the likelihood of interventions prolonging his life. We recognise it would have been more ideal for Mr P’s family to be present for this conversation. However, the evidence shows Mr P was asking questions about his care and the doctors were correct to give this information to him as per the GMC guidance.
55. Mr I also says his mother was not allowed to stay with Mr P overnight in ICU which turned out to be his final night.
56. The Trust said that on the night of 28 January, Mr P was in ICU and his family remained with him until 2.15am on 29 January. It said Mr P was sleeping and following review, the consultant felt that he was more settled and that he would likely survive the night.
57. The Trust said the continuing plan was to focus on Mr P’s comfort, by aiding his distress and promoting sleep. His wife was able to return to the unit later, on 29 January and was with Mr P at the time of his death, 2.57pm.
58. We have considered whether Mr P’s wife should have been allowed to stay with him overnight whilst he was in ICU. Our adviser said there is no guidance specific to visiting or staying with patients overnight within ICU.
59. In terms of the COVID-19 aspect of visiting, the Trust’s visiting policy and the Government guidance at the time essentially says careful visiting policies remain appropriate.
60. Our adviser said in their experience, if a patient is stable and they are not thought to be at an imminent risk of dying, clinicians would recommend family go home and get some rest. Our adviser said the Trust’s actions do not stand out as unusual.
61. Our adviser says ICU is a high intensity environment and due to this, it is not always ideal to have visitors there all the time as patients need rest and treatment.
62. The family were noted in the records to have been visiting until 2.15am on 29 January and were able to return to the hospital to visit the following day. Although Mr I says the Trust staff asked the family to leave before midnight and got the call at 7.30am the next day to say come back as Mr P had deteriorated. The Trust believed Mr P was not at imminent risk of dying.
63. We find the Trust was under no obligation to allow Mr P’s wife or family to stay overnight whilst he was in ICU. Suggesting she go home seems to have been done in her best interests.
64. We recognise it will be emotional for the family to know, in hindsight, that this was Mr P’s last night alive.