20. Before we decide if we should conduct a detailed investigation of a complaint, we look at whether there are signs the organisation has got something wrong. We do this by comparing what should have happened with what did happen.
21. If we find signs something has gone wrong, we also look at whether there are signs the events complained about had any negative effects which the organisation has not yet put right.
22. We will only carry out a detailed investigation where we have seen signs the organisation did something wrong and has not yet taken steps to help put matters right. We have carefully considered this in Mrs A’s case.
Concerns about ventilation
23. Mrs A is concerned staff placed her mother on a ventilator when this was unnecessary. Mrs A explains her mother should not have been on a ventilator at all during her admission. She is also concerned that when staff attempted to remove her mother from the ventilator, they placed her back on this soon after due to her agitation.
24. The ICM clinical guide explains that certain individuals are at a greater risk of worsening clinical outcome if they develop COVID-19. These risks are:
• Over 50 years old, substantial risk over 70 years old • Male • Obesity • Comorbidities (health conditions that co-exist alongside a primary diagnosis)
25. Upon admission, Mrs B was over 50, and had a history of obesity and asthma. This meant she was already at an increased risk of becoming seriously unwell after contracting COVID-19.
26. The ICM clinical guide explains some COVID-19 patients can be managed with supplemental oxygen, or CPAP treatment. However, patients with the most severe respiratory failure can only be managed with sedation and invasive mechanical ventilation. This helps maintain appropriate oxygen and carbon dioxide levels in the blood and reduces the ‘work of breathing’ for the patient.
27. The ICM clinical guide explains patients within hospital should have a steady oxygen saturation of no lower than 90-93%. If oxygen saturation levels fall below 90%, this could lead to a life-threatening condition.
28. We can see Mrs B was initially admitted with significant breathlessness and low oxygen saturations. Staff provided her with oxygen, in line with the ICM clinical guide, to see if her oxygen saturations improved. Whilst she was on 3L of oxygen (this means 3 litres of oxygen per minute) her saturations did improve to 95%.
29. However, later that same day, Mrs B’s saturations reduced to 92% and in the morning of 31 January this fell again to 89%. Sadly, 3L of oxygen was not sufficiently maintaining Mrs B’s oxygen saturations, so staff continued to increase the amount of oxygen she was receiving. On 2 February Mrs B’s oxygen saturations were 90% whilst she was on 15L of oxygen.
30. Because Mrs B’s need for further oxygen kept increasing, but her oxygen saturations kept falling, staff felt she needed further breathing support. They moved her into the intensive care unit to try another form of non-invasive breathing support alongside oxygen, CPAP. This was in line with the ICM clinical guide.
31. Mrs B responded well to receiving oxygen and CPAP initially as her oxygen saturations increased to 97%. However, later that same day, Mrs B’s oxygen saturations fell again to 91%.
32. Staff continued to increase the level of oxygen Mrs B was receiving whilst she was on CPAP. Unfortunately Mrs B’s oxygen saturations continued to decrease. On 6 February Mrs B’s condition deteriorated further and her oxygen saturations were 88% whilst she was receiving significant oxygen and CPAP treatment.
33. At this stage, staff decided she needed to be incubated and medically ventilated to ensure she received sufficient support with her breathing.
34. Our adviser explained Mrs B was already at an increased risk of becoming seriously unwell because she had increased risk factors associated COVID-19. It was vital for staff to further support her breathing in order to maintain oxygen saturations above 90%. To do this, staff had to provide Mrs B with invasive medical ventilation.
35. As detailed by the ICM clinical guide, the last form of treatment to support a patient’s breathing would be to place them on invasive medical ventilation. Taking into consideration non-invasive forms of support were not managing Mrs B’s breathing, it was appropriate to place Mrs B on medically invasive ventilation at this stage.
36. Mrs A remained on the ventilator from this point. Her oxygen saturations continued to remain lower than 90%, whilst her oxygen requirement increased significantly. Our adviser explained that Mrs B’s medical records do not show staff attempted to remove her from the ventilator at all during her admission.
37. Mrs B’s records do show on 4 March staff attempted to reduce the level of sedation she was under to help promote her breathing. However, Mrs B’s breathing became very rapid and shallow. Her heart rate also increased significantly, and it was clear she was under distress. For this reason, staff increased the dose immediately after attempting to reduce it.
38. The Intensive Care guidelines explains that staff should reduce the level of sedation a patient is under to see if the patient is able to breathe for themselves. This is the necessary first step in considering whether staff can start the process of removing a patient from the ventilator.
39. If a patient responds well to reduced sedation, staff can then consider if it is appropriate to remove them from the ventilator. However, if a patient does not respond well to the reduced sedation, or if their clinical condition decreases rapidly, then they will remain on the ventilator.
40. Our adviser explained Mrs B did not tolerate the reduced sedation well and still required significant support with her breathing. Staff increased the sedation she was under and maintained ongoing ventilation support. This works in line with Intensive Care guidelines.
41. From 6 March, Mrs B began to develop multiple organ failure and her clinical condition was getting worse. Staff felt her condition was unlikely to improve and the ventilator was prolonging the dying process rather than increasing her chances of survival.
42. End-of-life care guidelines explains staff must discuss initiating end of life care with the medical team, nursing team and the patient’s family. This is important to ensure differing views are considered before end-of-life care is initiated.
43. Staff discussed initiating end-of-life care with Mrs B’s family from 6 March. On 8 March, staff and her family agreed to initiate end-of-life care. Mrs B’s family wanted to visit Mrs B on 9 March and staff assured Mrs B’s family they could do this and would not remove her from the ventilator until after they had visited. This works in line with end-of-life care guidelines.
44. We recognise Mrs B is concerned staff removed the ventilator on 9 March. From reviewing Mrs B’s medical records, we can see staff had detailed discussions with Mrs B’s family about initiating end-of-life care. We have however not seen any evidence to suggest that Mrs B’s family raised concerns about the ventilator being removed on 9 March at the time.
45. We recognise this would have been a very difficult time for Mrs B’s family. We hope our explanation has provided Mrs A with some answers to her concerns and reassurance that staff provided her mother with appropriate care and treatment.
Concerns about fungal infection
46. Mrs A is concerned her mother developed an aspergillus infection soon after being put on a ventilator. She is concerned that this contributed to her mother’s worsening clinical condition.
47. The study on COVID-19 associated fungal infections explains aspergillus is a one of the main fungal pathogens in patients with COVID-19. This shows that patients who are COVID-19 positive have an increased risk of developing aspergillus as an infection too.
48. NICE guidelines on COVID-19 explain antifungal medication should be offered for treatment of COVID-19 associated aspergillus infections. We can see that staff provided Mrs B with antifungal medication promptly when they discovered she had an aspergillus infection. This treatment continued throughout her admission.
49. Taking into consideration the increased risk of developing a fungal infection in patients with COVID-19, and the treatment staff provided, we have seen no evidence to suggest Mrs B developed a fungal infection because of a failing. Staff provided care and treatment in line with NICE guidelines on COVID-19.
Concerns about kidney failure
50. Mrs A is also concerned her mother developed kidney failure during her admission. She is concerned this contributed to her deteriorating clinical condition and very sad death.
51. The ICM clinical guide shows patients who are ventilated with a COVID-19 infection are at an increased risk of developing kidney failure. The ICM clinical guide explains staff should provide dialysis to help support kidney functions. Although this can support a patient’s clinical condition, it does not reverse kidney failure.
52. We can see that staff provided Mrs B with dialysis promptly. Our adviser explained that Mrs B’s kidney function did not recover even though she was on dialysis. This showed she was developing significant multiple organ failure. Our adviser explained there was no additional treatment that staff could have given to Mrs B at this stage.
53. Taking into consideration the increased risk of developing kidney failure in patients with COVID-19, and the treatment staff provided, we have seen no evidence to suggest Mrs B developed a kidney infection because of a failing. Staff provided care and treatment in line with ICM clinical guide.
Concerns about DNAR
54. Mrs A is concerned staff filled in a DNAR order without discussing this with her or her family first. She is also concerned a DNAR was implemented soon after her mother’s admission.
55. We can see staff discussed implementing a DNAR order with Mrs A on 6 March. At this stage Mrs B had been on medical ventilation for several weeks and her clinical condition had not improved. She had also not responded well to reducing sedation to help promote her breathing and had begun to develop multiple organ failure.
56. NHS England guidance on DNAR explains it is a medical treatment decision and can be made by the doctor, even if a patient does not agree. The patient and the patient’s family must be told about it and must be given a chance to understand what it is and how the decision is made.
57. We can see from 6 March staff discussed the DNAR order with Mrs B’s family in detail prior to implementing it. They explained why they felt CPR would not support Mrs B’s clinical condition and why a DNAR was suitable. Mrs B’s family recognised this and did not raise any concerns at the time or after end-of-life care was initiated.
58. We acknowledge the worry this has caused Mrs A and her family. We consider staff implementing a DNAR on 6 March was in line with national guidelines and clinical standards. We have not seen any evidence to suggest staff implemented a DNAR order soon after Mrs B’s admission, and no earlier than 6 March.
Concerns about communication
59. GMC guidance explains doctors must be responsive in giving those close to the patient information about their care and treatment. NMC guidance also explains nurses should share the information patients and their families want and need to know with them. This should cover the health, care and ongoing treatment of the patient.
60. Throughout January 2021, the prevalence of COVID-19 was very high nationwide. Staff were under increased pressure to maintain a sufficient level of care with limited resources, whilst ensuring patients’ families were kept well informed.
61. The Trust explained at the time it asked one nominated member of a patient’s family to call the ward for updates. It expected this family member to then share the information with the wider family. This is because a lot of staff time is taken up answering phone calls and repeating the same information to many different relatives.
62. Upon Mrs B’s admission, Mrs B’s son took responsibility for calling the ward and updating Mrs B’s wider family. Staff clearly discussed this with him, and they both agreed on this plan. Staff also emailed Mrs B’s son to let him know that he could also email the ward if he could not get through by telephone.
63. From this point, we can see staff-maintained communication with Mrs B’s son, and her wider family, throughout her admission. They provided him with regular updates on Mrs B’s clinical condition, and the treatment she was undergoing. This works in line with the NMC and GMC guidance we have referred to above.
64. We can see Mrs A raised concerns about the poor communication she had received on 17 February. She was concerned that staff were providing differing views on her mother’s clinical condition and did not fully understand what her mother’s current condition was.
65. Staff acted on this promptly by contacting Mrs A, and Mrs B’s son, on separate occasions to provide them with an update on Mrs B’s clinical condition and care plan.
66. Taking into consideration the high prevalence of COVID-19 and reduced availability of staff, we find this was reasonable. However, this does not diminish the very difficult time Mrs B’s family experienced.
67. Mrs A is also concerned staff did not call her to tell her that her mother had sadly died on 9 March. Mrs A explains she called the hospital at 5.05pm asking for an update on her mother’s possessions and staff only then told her that her mother had died at 4.30pm. The Trust acknowledge staff should have called Mrs A soon after discovering her mother had died.
68. Our Complaints Standards explain when things have gone wrong, staff should provide sincere apologies to help put matters right. We can see when Mrs A raised this at the time, the nurse apologised for this and explained what had happened. The Trust further apologised for this in its complaint response to Mrs A.
69. We do not underestimate the upset this would have caused Mrs A. We can see the Trust has already taken steps to help put matters right for this error. As the Trust’s actions work in line with our Complaints Standards, we will not consider this point further.
70. Mrs A is also concerned staff did not offer her or her brother bereavement support after her mother’s death. She explains they would have benefitted from some information on this, or a list of charities who they could contact for support.
71. We can see that staff provided Mrs B’s family with a bereavement leaflet in the morning of 9 March, when they visited their mother. This leaflet contained information on the bereavement process and how she could obtain further support if required. As we have seen staff did provide information on bereavement support, we cannot consider this point further.
Concerns about complaints handling
72. Mrs A explains the complaints team did not deal with her complaint adequately. She is concerned the Trust did not provide a further answer to her outstanding concerns after its initial response. This has left her with unresolved concerns about her complaint. She is also concerned the Trust did not invite her for a local resolution meeting.
73. Our Complaints Standards explain organisations must give fair and accountable responses. The organisation must provide a written final response. It does not say that patients or their families must be given the opportunity to have a local resolution meeting.
74. The Trust feel it addressed all of Mrs A’s main concerns in its initial complaint response. It explained a further response would not be sufficient and signposted her to us.
75. We recognise Mrs A does not agree with the response she received. However, taking into consideration the Trust’s response and the concerns Mrs A has raised with us, we consider the Trust addressed her main concerns first-time round. We find the Trust’s response fair and accountable. This works in line with our Complaints Standards.
76. We recognise Mrs A would like to attend a local resolution meeting with the Trust to discuss her concerns. As detailed by our Complaints Standard’s, this is not a requirement therefore we cannot say the Trust failed to do this. Instead, its written response was appropriate and in line with our Complaints Standards.
77. We would like to thank Mrs A for raising her complaint with us. We know our report cannot take away her pain, but we hope we have been able to reassure her that staff treated and cared for her mother in line with national guidelines. We hope we have been able to provide her with answers to her concerns.