Communication
22. We asked our nurse adviser and our first physician adviser about the communication documented in Mr O’s medical records. We asked these two different clinicians because nurses and doctors have different roles when communicating with patients and families. Nurses will usually update patients and their families on the general, day-to-day care provided; whereas doctors are responsible for informing the patient and their family about the diagnosis, prognosis, and treatment.
23. NICE guideline NG27 sets out that the admitting team should provide the person and their family with information about the reason for their admission. In line with this guidance, the nurses should have told Mr O’s family:
• how long he might be in hospital • the care options and treatments they could expect • when they could expect to speak with the doctors • the name of the main point of contact.
24. Mr O’s medical records show that on 7 December the Trust advised Ms O of the reason for her brother’s admission and the need to inform DVLA about his stroke. However, following this there is insufficient evidence of any communication where the nursing team told the family how long Mr O may be in hospital or when they may be able to speak to a doctor about his care. There was also no main point of contact for Mr O’s family.
25. Our nurse adviser also highlighted that the Trust’s daily nursing notes form contains a section for updating family about the patient’s care, and that this was consistently left blank during Mr O’s admissions. Our nurse adviser explained that the fact this section is present on the daily nursing form indicates the Trust expects nursing staff to regularly update the family, or document where this was not possible. This did not happen. This communication was important because Mr O lacked mental capacity and was confused during his admissions. This meant he could not reliably update his family about his care.
26. We have found the communication from the nursing team fell short of NICE guideline NG27 and the Trust’s own expectations for communication with families. The nursing team appears to have communicated in line with this guidance at the point of his admission to hospital in November 2022, but did not communicate appropriately with Mr O’s family after this point until his discharge in late January 2023.
27. With regards to the doctors’ communication with Mr O and his family, the GMC’s Good Medical Practice guidance sets out the standard of communication expected from physicians. In line with this guidance the Trust’s physicians should have provided Mr O and his family with information about:
• his condition(s), likely progression, and any uncertainties about diagnosis and prognosis • the options for treating or managing the condition(s), including the option to take no action • the potential benefits, risks of harm, uncertainties about, and likelihood of success for each option.
28. This guidance also states that the clinicians should have been considerate and compassionate to Mr O’s family and been sensitive and responsive in giving them support and information.
29. Our first physician adviser explained that there was consent for clinicians to speak with Mr O’s family and there are multiple entries reflecting that they did so. Unfortunately, the documentation of what was discussed is poor and there is not enough information documented to know what information was conveyed to the family.
30. The Best Interests meeting, which occurred on 24 January 2023, communicated a lot of information to the family about Mr O’s care. However, this meeting took place a long time after he was first admitted to hospital in November 2022, which is concerning.
31. The GMC’s Good Medical Practice guidelines state that doctors should formally record their work clearly, accurately and legibly. We think the documentation of the discussions the clinicians had with Mr O’s family falls short of being recorded clearly. This is because we cannot ascertain what information was provided to the family during these conversations.
32. We consider that either the Trust’s clinicians failed to communicate with Mr O’s family in line with the GMC’s Good Medical Practice guidelines, or failed to document these conversations as required by this guidance.
33. Ms O says these failings caused her brother to decline dramatically from when he was admitted to hospital and contributed towards his death. She adds that this was very distressing for her family.
34. We cannot link a failing in communication to Mr O’s clinical deterioration or death. This is because poor communication is not the same as poor care, and a person can receive good care that is poorly communicated.
35. We understand, however, that not receiving updates about his condition, care and prognosis would likely have caused Mr O’s family distress, worry and anxiety. This is an injustice to his family, and we have considered whether the Trust has appropriately addressed this.
36. Communication was specifically raised in the local resolution meeting with the Trust and the Trust acknowledged its communication was poor and apologised. We are not satisfied that an apology is sufficient to put right the impact of what went wrong. This is because the repeated nature of the poor communication and poor documentation indicates a broader, systemic issue. It is understandable that on some occasions it might not be possible to update a family, due to staffing issues or unprecedented demand on the ward; however, to not do this consistently over a period of three months indicates a wider problem.
37. Our NHS Complaint Standards state organisations should take action to improve services. We have not seen any evidence the Trust has taken action to improve its communication with families following this complaint. Therefore, we have outlined recommendations to address this later in our report.
Swallowing and dietary needs 38. We have considered both the assessment of Mr O’s swallowing needs and the plan formulated by the Trust’s SALT team. This is because whether or not the diet recommended was appropriate depends on whether the assessment was appropriate.
39. During Mr O’s first admission to hospital, from 29 November to 15 December 2022, he was referred to the SALT team for communication only. He was documented as having normal diet and fluids, and the SALT assessment on 30 November focused on communication.
40. Following his discharge from hospital, Mr O was assessed by the community SALT team on 29 December. They undertook a detailed assessment of his needs and recommended a level six diet (soft, bite sized pieces) to reduce the risk of choking or aspirating. They documented a need to review him in two weeks.
41. Mr O was admitted to hospital on 4 January 2023, and was referred to the hospital’s SALT team due to concerns about his swallowing. Difficulty swallowing is known as ‘dysphagia’ and Royal College of Speech and Language Therapists (RCSLT) has published guidance on how to assess and manage dysphagia. In line with this guidance, the Trust’s SALT team should have:
• undertaken a detailed and accurate assessment (there may be multiple assessments over time) • ensured safety (reducing or preventing aspiration), whilst balancing this with Mr O’s quality of life and individual preferences.
42. The SALT team assessed Mr O’s needs on 6 January. The notes of from this assessment reflect that the speech and language therapist was aware of the prior assessment by the community SALT team and the recommendations from this.
43. This SALT assessment only considered Mr O’s swallowing function with water and the speech and language therapist documented that he declined to try more textured foods. Our SALT adviser explained that this was not a sufficient assessment because the SALT team had been unable to assess his swallowing function with food. When drinking water, the speech and language therapist did not document any evidence of aspiration or choking.
44. The speech and language therapist then recommended a level four diet on the basis of this insufficient assessment. They did not document a clear rationale for this recommendation, nor was there any documentation about his quality of life and preferences. They did not document why this had changed from the detailed assessment undertaken by the community SALT team one week prior, which did trial foods of different textures and noted no choking or aspiration. This assessment was not in line with the dysphagia guidance from the RCSLT.
45. Our SALT adviser also highlighted that prior to this assessment on 6 January, the nursing team had identified Mr O was at risk of malnutrition. This was important to consider as part of this assessment because the use of modified texture foods (for example, a pureed diet) contributes to the high prevalence of malnutrition in people with dysphagia (O’Keeffe 2018). There was no documented consideration of this risk by the speech and language therapist who assessed Mr O that day.
46. Our SALT adviser told us the plan for a level four diet appears to be very risk averse. This is especially because O’s swallowing function had been comprehensively assessed the week prior, and the recommendation was for a level six diet, whilst the hospital’s speech and language therapist had not undertaken any assessment of his swallowing function with food. The notes do not document a clear rationale for this plan and why the plan had changed from one week earlier. This means the diet recommended may not have been appropriate for Mr O because the assessment of his needs was inadequate and not in line with the dysphagia guidance.
47. The SALT assessment of 6 January noted that Mr O should be reviewed for an upgrade of his diet when he was able. Although the guidelines on dysphagia do not explicitly state that reviews should take place, or at what frequency, it is accepted by the guidance that multiple assessments may need to take place. It is standard to review a patient when documented as needed, or when referred/re-referred by other members of the multidisciplinary team.
48. Mr O was reviewed by the SALT team again on 13 January. This review documented that a further review was not clinically indicated if Mr O was managing thin fluids and a pureed diet. We know from Mr O’s food charts that he had consistently refused the pureed food since the first assessment, which indicated he was not managing the prescribed diet.
49. During this assessment, the speech and language therapist documented ‘minimal intake on occasion’, which was not consistent with the information in Mr O’s nursing notes. The nursing notes reflected very minimal food intake each day since the first assessment. This assessment also did not assess his swallowing function and the speech and language therapist noted that no swallowing difficulties had been raised by the clinical team.
50. There was also no consideration of whether his diet could be upgraded, as recommended following the assessment on 6 January, during this second assessment. The speech and language therapist then discharged Mr O from the SALT team and the level four diet remained in place. This assessment was not in line with the dysphagia guidance from the RCSLT because it failed to document a detailed and accurate assessment of Mr O’s needs.
51. From 14 January the nursing team began to document concerns being raised by Mr O’s family about him not eating and drinking. The family became so concerned that a Best Interests meeting was held on 24 January. The SALT team did not attend the best interests meeting as the team was too busy. This was a missed opportunity for the SALT team to review its assessments of Mr O’s dietary needs.
52. We have found the Trust’s SALT team did not undertake an assessment of Mr O’s swallowing needs that was in line with the RCSLT’s dysphagia guidance. This was a failing in the care provided to him.
53. The evidence also reflects that the rationale for why the level four diet was recommended was never documented by the SALT team, nor was it appropriately reviewed by the SALT team. Because these assessments were inadequate, this could mean the diet recommended was not appropriate for Mr O’s needs. This was a further failing in his care.
54. With regards to the information given to Mr O’s family, our SALT adviser explained there are no specific guidelines on what information should be provided to families. The HCPC’s Standards of Proficiency for speech and language therapists outline that speech and language therapists should: ‘understand the need to provide service users or people acting on their behalf with the information necessary, in accessible formats, to enable them to make informed decisions’. This should include making sure those caring for Mr O knew about his modified diet and what foods he could and could not eat.
55. We know that detailed information was given to the family about Mr O’s dietary needs, including what his modified diet was and what foods he could/could not eat, during the Best Interests meeting on 24 January. We can also see in Mr O’s medical records that the nursing staff documented conversations with his visitors regarding the reasons why he could only eat pureed food. We also know that prior to his discharge from hospital on 27 January the family were given a level four diet leaflet, which outlined a level four diet in detail.
56. We have found the information given to Mr O’s family regarding his dietary needs was sufficient to meet the requirements outlined in the HCPC’s standards of proficiency. The matter at hand does not appear to be that the diet was poorly communicated to Mr O’s family but, rather, his family had serious concerns about the diet recommended.
57. Ms O says the failings in the diet recommended by the SALT team caused her brother to decline dramatically from when he was admitted to hospital and contributed towards his death. She says this caused her family a lot of distress.
58. Our second physician adviser explained that the NICE Guideline CG32 (nutrition support for adults) outlines the key indicators for a person who has become clinically malnourished. These are:
• a loss of more than 10% of body weight in the previous 3-6 months • a body mass index (BMI) of less than 18.5kg/m2 • a BMI of less than 20kg/m2, with a 5% loss of body weight in the previous 3-6 months.
59. Mr O weighed 88kg on 30 November 2022 and his MUST screen did not indicate he was at risk of malnutrition at that time. His BMI was 30 on admission, which is overweight; however, this may have been miscalculated as his height was later noted to be two inches taller. There were no concerns raised about his dietary intake during this admission. When weighed again on 10 December he was 84.8kg. This indicates he lost weight but that this was not a significant weight loss (less than 10% of his body weight). He was discharged from hospital on 15 December.
60. Mr O was readmitted to hospital on 4 January 2023 and weighed 75.8kg, which was a loss of 9kg since his discharge from hospital, and 13kg since 30 November 2022. He scored two on the Malnutrition Universal Screening Tool (MUST), which is a tool used to identify patients who are at risk of malnutrition, due to unexpected weight loss of more than 10% of his body weight during the past 6 months.
61. He was weighed again on 9 January 2023 and was recorded as being 76.5kg, an increase in weight. On 19 January and 25 January, he weighed 73kg, which reflects he lost weight but this was not significant and his weight remained relatively stable during that time. The majority of his weight loss appears to have occurred between his discharge from hospital on 15 December 2022, and his readmission to hospital on 4 January 2023. This is supported by the detailed community SALT assessment that took place on 29 December 2022. He did also lose some weight during his first admission to hospital, but this was not significant and he was not on a modified diet at that time.
62. Our second physician explained that weight loss in a patient with Mr O’s clinical background could have been due to a number of different factors, with his suspected dementia and increasing frailty contributing significantly.
63. On balance, whilst Mr O did lose a small amount of weight after the level four diet was implemented, this was not significant. This weight loss does not indicate he became malnourished to the point it would have been detrimental to his prognosis or a cause of clinical deterioration. The dietician who assessed Mr O on 26 January 2023 assessed him to be at low risk of refeeding syndrome, which is a serious medical condition that occurs in malnourished patients. This further supports the conclusion he did not become seriously malnourished during this admission.
64. What we can say is that good nutrition support would have been advantageous in promoting Mr O’s recovery from his stroke. We cannot link the failings in his nutrition support to his deterioration and death, but we recognise that knowing his care was not provided to the required standard will be very distressing for his family.
65. The Trust has not yet acknowledged these failings, nor has it taken steps to put things right. We have outlined recommendations at the end of this report.
Therapies input 66. NICE guideline NG236 (stroke rehabilitation in adults) outlines that the Trust should have supported Mr O’s rehabilitation using a core multidisciplinary team. This team should have included therapies input from physiotherapists, occupational therapists, speech and language therapists, and dieticians.
67. In line with this guidance, the roles and responsibilities of each member of the multidisciplinary team should have been communicated to Mr O and his family. In line with section 13.2 of the NMC Code, nurses should make a timely referral to another practitioner when any action, care or treatment is required.
68. Mr O was promptly identified as needing input from the therapies teams in the ED on 29 November 2022. This was also documented as being required in the follow up assessments on 30 November and 1 December, and a referral was promptly made by the nurses. This was in line with the NMC Code.
69. At these assessments the occupational therapists identified that Mr O would require a home assessment. Physiotherapists noted that he had problems with his balance that could expose him to the risk of instability and possibly falling. Mr O was further assessed by both the occupational therapists and physiotherapists, who continued the plan of supervising him when he mobilised. This plan was well-documented and there were multiple entries recording that Mr O was mobilising well, either with the assistance of one staff member or independently.
70. He was also assessed by occupational therapists on 6 December, who undertook a kitchen assessment and confirmed he was not yet safe for discharge.
71. We have found the requirement for therapies input, as outlined in NG326, was identified and implemented promptly in November and December 2022, following referral from the nursing team. This was in line with the NMC Code because the nurses identified that Mr O needed a referral to the therapies teams and promptly arranged this referral.
72. Mr O was discharged from hospital on 15 December 2022, and readmitted to hospital on 4 January 2023. His notes from 5 and 6 January reflect that he was being nursed in bed due to being at high risk of falls, and that he needed a review from the physiotherapy team. He was not reviewed by the physiotherapy team until eight days into his admission.
73. Our nurse adviser said it is unclear why this delay happened. Mr O’s medical records indicate that whilst the nurses promptly identified the need for a review from the physiotherapy team, they did not action this referral in a timely manner. This was not in line with the NMC Code.
74. During this admission, there was a prompt referral to the SALT team, which reviewed Mr O on 6 January. This was in line with the NMC Code.
75. Our nurse adviser also explained there was a delay in referring Mr O to the dietetics team. On 4 January the nurses completed a MUST screen which indicated he was at risk of malnutrition. This meant the nurses should have kept food charts to monitor his intake.
76. The MUST tool also states that if a patient eats less than two meals and one snack per day for three days, a referral to dietetics should be made. Following the MUST screen, Mr O was documented as having eaten very little, most days just a couple of spoonfuls of food, but no referral was made to the dietetics team.
77. The records indicate that a referral for dietetic support was only made on 24 January, after the Best Interests meeting. It is unclear why the nurses did not facilitate this referral before this meeting.
78. In line with the NMC Code, nurses must also:
• identify any risks or problems that have arisen and the steps taken to deal with them, so that colleagues who use the records have all the information they need • make a timely referral to another practitioner when any action, care or treatment is required.
79. Mr O was eating very little during this admission and the nursing staff should have referred him to the dietetics team. This did not happen and, instead, the daily nursing reviews only record that he required encouragement to eat. This was not in line with the NMC Code.
80. Following the Best Interests meeting on 24 January, the dietetics team made recommendations for Mr O’s diet that included nutritional supplements. The team also recommended keeping strict food charts and weighing Mr O weekly. This assessment should have happened far sooner than it did, and there was a long period where Mr O did not have the right dietary support in place.
81. We have found the Trust’s nursing team delayed in referring Mr O to dietetics and physiotherapy teams during his admission in January 2023. This delay fell so far short of the NMC Code that it amounts to a failing.
82. Ms O says these failings caused her brother to decline dramatically from when he was admitted to hospital and contributed towards his death. She adds that this caused her family a lot of distress.
83. For the reasons already outlined, we have not seen evidence that Mr O became malnourished during this admission, and we cannot link the delay in referring him to the dietetics team to his deterioration and death. Knowing Mr O’s care was delayed, however, will cause his family distress.
84. Our second physician adviser explained that whilst low mobility in hospital can lead to nursing home placement and loss of independence, Mr O was already experiencing increasing frailty linked to his stroke and suspected dementia. He was still able to mobilise independently but was awaiting the physiotherapy assessment due to his high risk of falls. Our second physician adviser explained that in this context, we could not robustly say that a delay in referring Mr O to physiotherapy caused him to deteriorate clinically or that it contributed to his death.
85. We recognise that knowing this referral was delayed will cause his family distress. The Trust has not yet acknowledged what went wrong, nor has it taken steps to put things right. We have outlined what we are asking the Trust to do to put this right later in our report.
Discharge 86. Patients’ discharge from hospital should be managed in line with NICE guideline NG27. This guidance states that there should be a multidisciplinary approach to discharge planning, and this should start as soon as a person with complex needs is admitted to hospital. It also states that, with the patient’s consent, this should include the views and wishes of family and/or carers.
87. In addition, in line with NICE guideline NG236 (strokes in adults) early discharge support should be offered to those being treated for a stroke.
88. Mr O’s medical records reflect that there was a multidisciplinary approach to planning his discharge, with input from doctors, nurses, therapies teams, the Mental Health Liaison Team, and Mr O’s social worker. Whilst the teams identified that he would need support upon discharge, there was also a documented focus on making sure his admission to hospital was not prolonged.
89. The records also reflect that the staff attempted to engage Mr O in the discharge planning, but he lacked the mental capacity to make decisions relating to his discharge plan.
90. Both NICE guidelines NG27 and NG236 highlight the importance of a designated member of the multidisciplinary team co-ordinating a patient’s discharge from hospital. This involves designating a ‘discharge co-ordinator’ who will be the point of contact for health and social care practitioners, the patient, and their family during discharge planning. This person should be involved in all decisions about discharge planning and a named replacement should be available when this person is absent.
91. Despite the evidence of a comprehensive, multidisciplinary approach to assessing Mr O’s discharge needs, there was no Best Interests meeting until late January, which was after his first discharge from hospital. There is also no evidence that the Trust appointed a discharge co-ordinator at any point during this admission. Instead, there is just one entry, dated 15 December, that indicates the discharge arrangements for his first admission had been deferred to and finalised by Mr O’s social worker.
92. At the time of Mr O’s discharge in December 2022, the Trust documented that his family would provide care and a package of care would be set up by his social worker. There is no record of what referrals had been made or what community support should look like. This was not in line with NICE guideline NG236, which states stroke rehabilitation should continue after discharge from hospital. It was also not in line with NICE guideline NG27, which requires multidisciplinary discharge planning via a named discharge co-ordinator. It was not sufficient for the Trust to defer all responsibility for managing Mr O’s discharge from hospital to his social worker.
93. Overall, whilst there is evidence of a multidisciplinary approach to discharge planning, the records indicate this was inconsistent and lacked co-ordination. There was no discharge co-ordinator appointed, no record of the referrals made for ongoing stroke rehabilitation upon discharge, and little evidence that Mr O and his family were engaged appropriately. This was a failing in his care.
94. When Mr O was readmitted to hospital in January 2023, the Trust documented a review from the Mental Health Liaison Team and held a Best Interests meeting with Mr O’s family. This reflects a greater engagement with Mr O’s family, and there is evidence of a referral to the Single Point of Access for discharge to an appropriate service. This was an improvement on the previous discharge planning; however, no discharge co-ordinator was allocated to manage this discharge. Whilst this was an improvement, the discharge planning did not align fully with NICE guideline NG27 and was a failing in his care.
95. We have found the Trust failed to plan Mr O’s discharge from hospital in December 2022 and January 2023 in line with the national guidance. Ms O says these failings caused her brother to deteriorate and contributed to his death, which was distressing for her family.
96. Our second physician adviser explained that the lack of community stroke rehabilitation would be unlikely to have had a large impact on Mr O’s overall deterioration or his death in February 2023. His deterioration was more likely than not a result of his stroke and suspected dementia, rather than a lack of input in the short term from the community stroke team.
97. We recognise that knowing Mr O’s discharges were not managed in line with the national guidance will be distressing for his family. The Trust has not yet acknowledged what went wrong, and we recommendations to put this right at the end of our report.
Pain relief in February 2023 98. Clinicians in EDs should assess and manage pain in line with the Royal College of Emergency Medicine’s Best Practice Guidelines for the Management of Pain in Adults (the Pain Management guidelines). In line with this guidance, the Trust should have assessed and recorded Mr O’s pain level on admission. The guidance describes this as ‘an essential component’ of the initial assessment and recommends using a scale of 1-10 to score pain. This should have happened within 15 minutes of arrival at the ED.
99. A score of one or above should have prompted analgesia being prescribed, with the type of analgesia guided by the pain score. He should also have been reviewed, within 60 minutes, after the administration of analgesia in the ED.
100. Mr O’s medical records reflect he was asked about his pain, reporting a score of one out of three at 12.44pm by the triage nurse. Rating pain in this way does not align with the recommendation from the Pain Management guidelines but does tell us that Mr O was in pain and should have been offered pain relief. This did not happen, and this was not in line with the Pain Management guidelines.
101. At 3pm a doctor assessed Mr O and noted he had ‘abdominal pain’. No assessment of his pain level took place, nor was any analgesia documented in the clinical management plan from the doctor. The doctor prescribed an IV fluid infusion but did not prescribe pain relief. This was a missed opportunity to assess Mr O’s pain levels and provide appropriate analgesia, in line with the Pain Management guidelines.
102. At 9.30am the following day, the nursing notes reflect that Mr O’s family complained that he had still not had pain relief. This was updated 20 minutes later, where a nurse documented they could not administer pain relief because it had not been prescribed by a doctor. This meant that Mr O had been in pain for over 20 hours in the ED without an appropriate assessment of his pain levels and without pain relief.
103. We have found that the Trust failed to assess Mr O’s pain level and provide pain relief in line with the Pain Management guidelines. This was a failing in the care provided to him.
104. Ms O says this caused her brother unnecessary suffering in his final days and caused her family a lot of distress. We agree that Mr O likely experienced pain unnecessarily for a period of at least 20 hours, and that this would have been distressing for him and his family.
105. The Trust has not acknowledged what went wrong, nor has it taken steps to put this right. We have outlined what we are asking the Trust to do to put things right later in our report.
Monitoring 106. The National Early Warning Score (NEWS) 2 is a standardised method of assessing and responding to acute illness severity published by the Royal College of Physicians. This framework is used to indicate the frequency at which clinicians should monitor patients and when they should escalate their care.
107. NEWS2 measures six parameters of vital signs in patients and provides a scoring framework from 1-3 for each parameter. These parameters are:
• respiration rate • oxygen saturation • systolic blood pressure (the pressure exerted when the heart beats) • pulse rate • level of consciousness or new confusion • temperature.
108. Vitals signs within the expected range score zero on the NEWS2 scale. Vital signs outside the expected range are scored one to three, dependent on how far outside the normal range they are. The score for each parameter is added together to create an aggregate NEWS2 score, which helps clinicians identify how acutely unwell a person may be and what actions should be taken.
109. A score of four or below across all parameters represents a low risk and the patient should continue to receive ward-based care, with monitoring of physical observations taking place every four to six hours.
110. If a patient scores five or six across all parameters, this indicates a medium risk, and the patient’s vital signs should be monitored hourly.
111. A NEWS2 score of seven and above indicates a high risk that requires an emergency response. Continuous monitoring of vital signs should happen for patients scoring this highly on the scale.
112. Some patients may have a lower NEWS2 score but score three in one single parameter. When this happens, their vital signs should be monitored hourly.
113. Mr O’s observations were taken at the following times after his admission to hospital:
• 15 February at 1.17pm (NEWS2 score 1) • 15 February at 7.19pm (NEWS2 score 2) • 16 February at 12.36am (NEWS2 score 2) • 16 February at 5.04am (NEWS2 score 1) • 16 February at 9.15am (NEWS2 score 2) • 16 February at 10.12am (NEWS2 score 2) • 16 February at 11.20am (NEWS2 score 2) • 16 February at 2.44pm (NEWS2 score 2) • 16 February at 6.39pm (NEWS2 score 2) • 17 February at 12am (NEWS2 score 3) 114. When Mr O was admitted to the ED on 15 February his NEWS2 scores meant no escalation or enhanced monitoring was needed. His NEWS2 scores remained below four up until his death.
115. We have reviewed the individual scores for each parameter and Mr O did not score three in one parameter at any point during this final admission to hospital. Therefore, his vital signs should have been monitored every four to six hours, which consistently happened.
116. We have found that Mr O was monitored in line with the NEWS2 guidance published by the Royal College of Physicians.