Treatment from 23 - 24 April 14. Miss F has concerns around how the Trust managed her mother when her condition was deteriorating. Specifically, she says the Trust did not appropriately manage her antibiotic regime and made the decision to withdraw active treatment.
15. The Trust says it was actively treating Mrs P for aspiration pneumonia when she suddenly developed a high temperature in the night and deteriorated rapidly the next day.
16. We have firstly considered how the Trust managed Mrs P’s antibiotic treatment. The antimicrobial guidance sets out clinicians should consider reviewing intravenous antimicrobial prescriptions at 48–72 hours. This includes considering the patients response to treatment, and any microbiological results to determine if the antimicrobial needs to be continued or switched to an oral antimicrobial.
17. From the start of Mrs P’s admission, she was on a combination of antibiotics with antiviral treatment. As the source of her infection was initially unknown, she was intravenously prescribed broad-spectrum antibiotics. These are a class of antibiotics that act against an extensive range of disease-causing bacteria and have the ability to work against different bacterial groups.
18. Following tests, the Trust ruled out meningitis as a potential diagnosis. Mrs P’s antibiotics were subsequently changed to oral co-amoxiclav. This is an antibiotic specifically used for treating chest infections. This is because more information was known about Mrs P’s condition. An oral antibiotic opposed to IV antibiotics was appropriate management in line with the antimicrobial guidance.
19. As Mrs P’s blood test results started to improve, her antibiotics were changed to oral. Our physician adviser explains as more results about Mrs P’s condition became available, changes were appropriately made to her antibiotic routine. Regarding Mrs Ps antibiotic management, she remained on full active treatment and her antibiotics were not withdrawn at any point. This management was in line with the antimicrobial guidance.
20. We have also carefully considered how the Trust managed Mrs P’s condition when she started to deteriorate.
21. The NICE deterioration guidance details the type of physiological monitoring that is required in a hospital setting to identify patients whose clinical condition is deteriorating, or if they are at risk of deterioration.
22. This guidance sets out the national early warning score (NEWS) system should be used to monitor a patient’s response to any treatment given, and to ensure a patient’s care is escalated when necessary. This is a national tool used in hospitals to help identify deterioration quickly.
23. At 11.09pm on 23 April, Mrs P’s NEWS became 11. This is very high. A score of seven or more is classed as high and means an urgent or emergency response is needed.
24. If a patient’s score is high, the NICE deterioration guidance says healthcare professionals should initiate appropriate interventions, assess the response, and formulate a management plan.
25. Based on this, a senior doctor reviewed Mrs P at 11.51pm. The doctor arranged for Mrs P’s antibiotics to be escalated, fluids overnight, blood cultures, input and output monitoring and for a chest X-ray. Our physician adviser explains this was the appropriate treatment and management plan in line with the deterioration guidance.
26. Mrs P’s NEWS then improved, as it dropped to a score of five at 1.06am. However, it then rose overnight, to nine at 3.07am and 12 at 4.33am. These NEWS scores indicated Mrs P needed to be urgently reviewed again by a doctor. This is because as her score was rising, this shows she was not responding to treatment.
27. Mrs Ps NEWS stayed between nine and 11 throughout that night and the next morning, rising to 15 at 11.47am.
28. The last recorded review by a doctor prior to Mrs P’s death was the review referred to above, at 11.51pm on 23 April. Although her NEWS was high on seven occasions, she was not reviewed by a doctor again. There is no evidence of any medical reviews taking place to act on these early warning scores.
29. As set out previously, the purpose of this national scoring system is to be able to quickly respond when a patient is deteriorating. Mrs P’s scores indicated she was deteriorating, but no action was taken.
30. The nursing records between 7.13am and Mrs P’s death also support how unwell Mrs P was at that time. Alongside her high NEWS, she had a low urine output level. The nurse asked for a doctor to review Mrs P at 6am, but this did not take place and Mrs P was not reviewed by a doctor before her death.
31. This is not in line with the deterioration guidance, which outlines the need for an urgent review, and we have found a failing here. We know this will be very upsetting for Miss F to read, recognising her mother should have been seen by a doctor when she was becoming increasingly unwell. We recognise she has serious concerns about if more could have been done at this time. We have carefully considered whether if the Trust had taken further action, there is any evidence to suggest the outcome might have been different.
32. Our physician adviser explains if Mrs Sylester had been reviewed by doctor there may have been a change to the quantity and rate of fluids she was given. This is because When Mrs P was seen by the medical registrar at 11.51pm, she was given a fluid bolus of 500mls over 15 minutes. The deterioration guidance says you should then assess the response to this, and if blood pressure is still low and a patient is still scoring high, to give a second bolus. Mrs P got the first bolus, and then was given a litre of fluids over eight hours. She did not get a second bolus. The lack of response to her NEWS meant that Mrs P missed out on treatment she would have otherwise revived.
33. Our physician adviser explains if the response had been appropriate and the treatment was given, we cannot say the outcome would have been different. The evidence shows despite the lack of review by a doctor overnight and potential change to fluids, Mrs P was otherwise on virtually all the maximum treatments that were able to be provided. She was exceptionally unwell at that time and had very poor levels of function.
34. The only further level of intervention available to Mrs P would have been an admission to ICU, and to be ventilated. We sought advice from a consultant in intensive care around the treatment ceiling for Mrs P. The treatment ceiling is the maximum level of treatment which a patient can receive in the clinical circumstances.
35. Our ICU adviser explains clinicians are responsible for determining what treatment is of benefit to a patient in line with the GMC standards, which is what happened in this case. The ICU and ED consultant made the decision Mrs P would not be able to benefit from a further escalation of treatment in intensive care 36. Our ICU adviser explains this decision can be supported. The evidence shows Mrs P would not have had the physical reserve to withstand an intensive care admission at that time, as a result of her severe comorbidities.
37. Whilst we recognise Mrs P should have been reviewed, and could have had subsequently received extra fluids, due to her very frail condition, severe comorbidities and that she was not a suitable candidate to be ventilated, we think it is highly likely the outcome would not have changed. Mrs P otherwise was still receiving full active treatment and was sadly not responding.
38. We are mindful it will be distressing for Miss F to know her mother was left without the appropriate reviews and treatment at a time when she was very unwell. We also recognise it must have been extremely worrying for Miss F to have thought throughout the process her mother may have survived if things might have been different.
39. Despite the failings, she sadly would not have survived this admission. This does not detract from the failings we have identified.
40. Although we cannot say the outcome would have been different, we think there was a missed opportunity to contact Miss F sooner. When her mother’s NEWS was very high overnight, and at the time of the doctors’ review, it would have been reasonable to contact the family at this stage. There was a lost opportunity to prepare Miss F, and potentially the chance for her to be with her mother as she deteriorated and at the end of her life.
41. There is a window of around 15 hours from Mrs P’s deterioration, before she sadly died. We know that when Miss F was alerted about her mother’s deterioration (20 minutes before she died) she went straight to the hospital. Based on this, it is reasonable to conclude on a balance of probabilities she would have had the opportunity to be with her mother before she died, had she been alerted sooner. We recognise the shock Miss F experienced learning of the deterioration when she did. It is understandable this has also caused her distress.
42. We have looked to see what the Trust has done so far to put things right.
43. We recognise the Trust has clearly acknowledged there were opportunities to contact Miss F sooner, and it has reflected on this. We agree and think this has been appropriately recognised.
44. We are pleased to see the Trust has recognised there is learning to be taken from this. It says it has spoken to the ward and reiterated the importance of ensuring communication with patients and their loved ones are dealt with appropriately and in a timely manner, and that this is being monitored.
45. Our complaints standards say public bodies should use the lessons learned from complaints to ensure maladministration or poor service is not repeated. We can see the Trust’s response goes some way to resolving issues around communication. We have identified failings in how the Trust managed Mrs P deterioration when she was not reviewed. We are yet to see action has been taken to acknowledge this. We think the Trust should take further action to recognise this.
46. Our complaints standards also say where maladministration or poor service has led to injustice or hardship, public bodies should try to offer a remedy that returns the complainant to the position they would have been in otherwise. If that is not possible, the remedy should compensate them appropriately. We consider this appropriate to our findings and have not seen evidence of this having taken place. It is likely we will ask the Trust to take action.
DNAR decision 47. Miss F has concerns around how the Trust communicated with her about her mother’s DNAR decision, particularly as she did not agree with the decision.
48. The Trust says given Mrs P’s medical conditions she would not benefit from an ICU admission and CPR would be unsuccessful. The Trust says it intended to explain to Miss S there would be no attempt to resuscitate Mrs S but there is no documentation this took place.
49. The resuscitation guidance sets out clear and full documentation of decisions about CPR, the reasons for them and discussions around them is an essential part of high-quality care.
50. Our physician adviser explains the decisions around DNAR are not well documented. The records show this was considered with involvement from the appropriate medical professionals (the emergency department, intensive care unit and medical team), but the documentation is brief.
51. The records show reference to some discussion with Miss F with her understanding that her mother was not a candidate for ICU. This sort of discussion is usually part of a DNAR discussion, and combined with discussing if a patient is for resuscitation. This indicates a conversation took place, but this does not appear to have been clear and in a way Miss F could understand the extent of the situation.
52. Whilst we recognise the rationale is not clearly articulated in the medical records, the decision is clinically appropriate. This is due to Mrs P’s multimorbidity and functional status. Our physician adviser explains the decision is not based upon a person’s disability, but their likelihood of survival and response to intensive care treatment. We recognise Mrs P had been a candidate for ICU previously, but this was a few years previously and the situation was now different.
53. Our adviser says this does not appear to have been communicated properly, and the team has not prepared Miss F for how unwell her mother was. The notes about any discussions with Miss F are very brief and the information documented is ambiguous. There is a failing in how the Trust communicated the decision.
54. We have carefully considered the impact of the Trust not communicating this in line with the resuscitation guidance. We acknowledge this contributed to a misunderstanding of the situation, and there was a lost opportunity for Miss F to have as much knowledge about her mother’s condition as possible. This is also contributed to the family not being able to prepare for how unwell Mrs P was and there was a missed opportunity for clear communication. We understand this caused distress and exacerbated grief at an already difficult time.
55. The Trust has apologised for this and says it let Miss F and her family down. It says it will continue to reiterate to all members of the medical teams the importance of involving family members in these decisions. We think this is in line with our complaint’s standards referred to above, and hope Miss F can take some reassurance from the Trust’s learning.