Fluids and hydration
15. Miss T says that from her mother’s admission on 7 July, to when they transferred her to ICU on 11 July, staff did not adequately hydrate her mother. She says staff did not give her sufficient fluids and that her water jug was not in reach. She says her mother was not able to move or lean to reach the water because of her injuries. Miss T says there was also a delay in setting up fluids the Emergency Department (ED) doctors prescribed when she moved to the ward.
16. The Trust acknowledge ward staff did not set up fluids prescribed by ED doctors as there was a lack of communication between its systems. When in the ED, Mrs V was nil by mouth. Mrs V arrived on the ward at approximately 8.15pm and the Trust say that water was at her bedside and within reach. The ward doctors prescribed IV fluids which nurses set up at 2.38am.
17. The RPS guidance says staff should administer medicines (which includes IV fluids) in accordance with the prescription from medical staff.
18. The NICE guidelines on fluid therapy say that for maintenance, a person needs about 25-30mls of fluid per kilogram, per day. Mrs V was about 57kg at the time so according to the NICE guidelines, she would need approximately 1425mls of fluid a day as a minimum, which equates to 60mls per hour.
19. The records show that from her admission to the ward on 8 July, Mrs V received IV fluids running at 84ml per hour, and she had water to drink until midnight, from which time she was nil by mouth in preparation for surgery. Records show Miss T was present at that time.
20. There is further reference to IV fluids running on 8 July at 11.07pm, and 9 July at 3.49am. Mrs V had surgery on her hip on 9 July. In addition to the IV fluids overnight, Mrs V had a cup of coffee on 9 July, after her surgery. In total, records show Mrs V had 1569mls of fluid on 9 July.
21. IV fluids continued on 10 July and increased to 100mls per hour, which our nursing adviser says was most likely in response to the Acute Kidney Injury warning in her blood test results. As well as the IV fluids, Mrs V had 200mls of tea and 350mls of water on 10 July, the day after her surgery.
22. In the early hours of 11 July, medical staff increased IV fluids further to 167ml/hr. Records show that at 10.37am 2L of fluids were given ‘overnight’.
23. Prior to Mrs V’s ICU transfer on 11 July, there was a documented conversation between the doctor and Miss T. Miss T raised concerns about her mother not receiving enough fluids and thought that the Acute Kidney Injury (AKI) she had developed was avoidable. The doctor explained that it was hard to obtain a blood sample from her mother, so increased fluids were prescribed on 10 July. Increasing the fluids can help blood flow making the sample easier to obtain, it does not mean that Mrs V was not receiving enough fluids. The doctor said that due to the difficulty in obtaining a blood sample, it was not possible for them to determine AKI any earlier.
24. We appreciate that it was upsetting for Miss T to witness her mother’s condition deteriorate whilst on the ward. Although dehydration was noted as a possible cause of Mrs V developing AKI, sepsis was also noted. Our nursing adviser says that sepsis was the most likely cause of the AKI.
25. Our geriatrician adviser agrees with the comments from the nursing adviser and explains that if a patient is becoming increasingly dehydrated to an extent it would lead to AKI, the urea and then creatinine in the blood would steadily rise.
26. From 7 July to 9 July, Mrs V’s urea and creatinine levels were reasonable. On 10 July, Mrs V’s kidney function suddenly got worse and continued to worsen in spite of the increased fluid therapy. The geriatrician adviser told us that if AKI was caused by dehydration, then fluid treatment would fix the AKI.
27. Mrs V’s kidney function worsened at the same time her C-reactive protein (CRP) rose from less than 1 on 7 July to 327 on 10 July. CRP is a sign of infection. Our geriatrician adviser said the substantial rise in Mrs V’s CRP would suggest a severe infection.
28. Nurses administered Mrs V’s IV fluids in line with the prescriptions after the initial delay in the ED. This is in accordance with the RPS guidance quoted in paragraph REF _Ref164938602 \r \h 17. Although there was an initial delay, it is unlikely the delay caused Mrs V’s AKI.
29. The IV fluids given to Mrs V, from admission to the ward on 8 July to when she moved to ICU on 11 July, were more than the minimum recommended 1425mls of IV fluids. In addition, Mrs V had extra oral fluids and was in receipt of IV drugs.
30. Having looked at all the evidence and the comments from our geriatrician and nursing advisers, we find the Trust did not fail to ensure Mrs V was adequately hydrated. We consider it more likely than not that an infection caused Mrs V’s AKI.
31. We acknowledge that Miss T says that her mother’s water jug was out of reach, and we appreciate this has been a cause of upset for her and can see why she thought this was a contributing factor to her mother’s AKI. We hope we have been able to provide assurance that her mother had adequate hydration during her admission to the ward.
Pressure sores and body mapping
32. Miss T complains the Trust did not appropriately body map, check pressure areas or turn Mrs V during her admission from 7 to 11 July when on Ward 16. She says as a result she developed a pressure sore on her sacrum.
33. The Trust made no specific comment on this aspect of the complaint but apologised that a pressure sore developed.
34. NICE clinical guideline 179 on Pressure ulcers: prevention and management says staff should carry out and document an assessment of pressure ulcer risk for adults being admitted to secondary care.
35. At section 1.1.3 it says staff should consider using a validated scale to support clinical judgement (for example, the Braden scale, the Waterlow score or the Norton risk-assessment scale) when assessing pressure ulcer risk.
36. Section 1.1.4 says staff should reassess pressure ulcer risk if there is a change in clinical status (for example, after surgery, on worsening of an underlying condition or with a change in mobility).
37. To prevent pressure sores developing section 1.1.9 outlines that staff should encourage adults who are assessed as being at high-risk of developing a pressure ulcer to change their position frequently and at least every four hours. If they are unable to reposition themselves, staff should offer help to do so, using appropriate equipment if needed. Staff should also document the frequency of repositioning required. The definition of a high-risk patient includes those who have limited mobility, have serious illness or are undergoing surgery.
38. On 8, 9, 10 July and the morning of 11 July, when on Ward 16 and prior to Mrs V’s ICU transfer, the records show that Waterlow pressure area risk assessments were completed. We can also see that Mrs V was repositioned every four hours from 7 to 11 July.
39. The pressure area risk assessment of 8 July records Mrs V’s pressure areas as discolouring. On 9 July, the skin assessment prior to surgery shows her sacrum area was red ‘but blanching’. Our nursing adviser says this would indicate that the skin in this area was at risk of pressure ulcers. Staff also gave Mrs V a pressure relieving mattress to remove the pressure from the bed surface as her heels were ‘red.’ On 10 and 11 July, Mrs V’s pressure areas show as ‘discoloured’ but not broken.
40. There is no evidence Mrs V had any pressure ulcers prior to her transfer to ICU.
41. It is clear from the records that staff assessed Mrs V on a daily basis using the Waterlow pressure area risk assessment and any changes in her skin were duly noted. Staff also repositioned Mrs V every four hours as she was unable to do this herself due to her injury and subsequent surgery.
42. Having looked at all the evidence and taken the views of our nursing adviser into account, we consider that pressure ulcer prevention was appropriate and in line with NICE guideline 179 referenced at paragraphs REF _Ref164939268 \r \h 34 to REF _Ref164939327 \r \h 37. We acknowledge that it was upsetting for Miss T to learn that her mother had developed a pressure sore. Unfortunately, Mrs V was in the high risk category of pressure sores developing because of her surgery and reduced mobility.
Oxygen therapy
43. Miss T complains staff did not keep Mrs V's oxygen saturation levels in line with recommended levels for a patient with COPD from 7 to 11 July.
44. The Trust acknowledged that Mrs V was retaining carbon dioxide and when staff realised, her oxygen levels were reduced.
45. The relevant guidance that outlines what oxygen levels should be, is the BTS Guideline.
46. Paragraph A3 says that ‘for most patients with known chronic obstructive pulmonary disease (COPD)… a target saturation range of 88–92% is suggested pending the availability of blood gas results.’ The saturation target range of 88-92% is also referred to as scale 2.
47. Between 7 and 9 July, Mrs V did not require oxygen prior to her surgery as her oxygen saturation levels were normal without supplementary oxygen.
48. Immediately after the general anaesthetic for her hip replacement operation on 9 July, Mrs V was on oxygen, which the adviser says is standard practice.
49. The vital signs charts within the records show that staff put Mrs V on scale 1 oxygen saturation targets, which is 94-98% saturation. This is not in line with the BTS Guideline which recommends scale 2, with a target saturation at 88-92% in COPD patients pending a blood gas test to check the carbon dioxide level.
50. When discharged from recovery, Mrs V had 90% oxygen saturation levels. In line with the BTS guidelines, 90% oxygen saturation was an acceptable level for Mrs V however, there is a note in the records that Mrs V was kept on oxygen because she was not maintaining oxygen saturation levels above 91%.
51. When Mrs V returned to the ward, the vital sign charts within the records show that staff also monitored her in accordance to scale 1 oxygen targets, until 10 July. Her oxygen saturations during this time ranged from 94% to 99%. This is not in line with the BTS guideline which recommends scale 2, a target saturation at 88-92% in COPD patients.
52. We find that using the wrong target saturation scale is a failing. We considered the impact of this.
53. Miss T says her mother’s high oxygen saturation levels caused her mother to retain carbon dioxide and become drowsy and unresponsive. Mrs T says she informed staff of the increased carbon dioxide saturations, but they dismissed her concerns, implying Mrs V was still recovering from the surgery and the anaesthetics. She believes her mother never fully recovered from the effects of her high carbon dioxide saturations and this contributed to her death. She says that witnessing her mother like this caused her additional worry in what was already a stressful situation.
54. As stated above, staff should have put Mrs V on scale 2 saturation targets (88-92%) from 9 July. This was not done until the evening of 10 July. There is no doubt it was incredibly worrying for Mrs T to realise that her mother’s carbon dioxide saturations had increased. It must have been even worse to feel that staff were dismissive of her concerns. It is understandable, given that Mrs V moved to ITU shortly after these problems arose, that Miss T believes that they were the cause of her mother becoming more unwell. However, as we shall explain, our physician adviser says this was not the cause of her deterioration and subsequent ITU admission.
55. Our physician adviser told us the reason Mrs V deteriorated on 10 July was because she had a combination of opiate toxicity (excessive drowsiness due to morphine-type drugs accumulating in the blood), acute kidney injury, and sepsis due to pneumonia. This caused a metabolic acidosis in the blood. This means that her blood acids were high due to acute illness (sepsis and AKI).
56. The physician adviser explained that had the deterioration been due to over-treatment with oxygen then the blood gas would have shown respiratory acidosis. This is where the blood acids go high due to very high levels of carbon dioxide in the blood because the lungs are not expelling the carbon dioxide correctly. This situation tends to occur in patients with COPD who always have low levels of oxygen even when they are well. Mrs V’s oxygen saturations were normal without supplementary oxygen on admission, so this did not apply to her.
57. Having carefully considered the evidence and the comments from our physician adviser, on balance, we consider that the failure to keep Mrs V’s oxygen saturations within the recommended levels following surgery did not cause her overall deterioration. Although, as already noted, we think that knowing that her mother’s oxygen saturations were above the target range and feeling like staff did not take her concerns seriously will have caused Miss T unnecessary upset and worry. This is an injustice to her.
58. The recommendations we make relating to this are set out below.