Medical treatment
16. Mrs L questions how her mother’s health deteriorated so suddenly after three days in the Hospital. She says her mother was no longer able to communicate clearly.
17. The Medical Adviser told us there are several specific national guidelines about managing the conditions Mrs T had. She also had a history of dementia and heart disease along with being frail. Because of this, doctors should have considered multimorbidity, which means treating the acute conditions and background problems as a whole rather than as separate issues. They should have followed the Multimorbidity Guideline.
18. The Multimorbidity Guideline says healthcare professionals should consider an approach that takes account of multimorbidity for patients who have long-term conditions and frailty. This means they have to consider how the conditions and interact and affect quality of life. It says clinicians should improve quality of life by reducing treatment burden and planning care. Clinicians should carry out a comprehensive assessment of older people with complex needs.
19. The AF Guideline explains how doctors should diagnose and manage atrial fibrillation (an irregular and fast heart rate) in adults. It explains how they should arrange an electrocardiogram (ECG – a test that records the electrical activity of the heart) for patients who have chest pain. It says they should assess the risk of bleeding when considering starting anticoagulation in patients with atrial fibrillation. It explains how, for most people, the benefits of anticoagulation, to prevent strokes, outweighs the risk of bleeding.
20. The Gastrointestinal Bleeding Guideline says doctors should provide blood transfusions for people with massive bleeding. It says they should offer an endoscopy (OGD) to patients with severe bleeding within 24 hours. It says one in ten people in hospital who have upper gastrointestinal bleeding would be expected to die even with treatment.
21. Good Medical Practice says doctors must provide a good standard of care. This includes carrying out adequate assessments, taking account of the patient’s history and examining them if necessary. Doctors should also arrange timely treatment and appropriate investigations or referrals if needed.
22. The Medical Adviser told us doctors in the emergency department carried out comprehensive assessments of Mrs T on 8 January 2023. They found she had symptoms suggesting a chest infection (pneumonia) and atrial fibrillation. They also completed an ECG. The ECG showed an abnormality called ‘left bundle block’ which can be longstanding but can also indicate a heart attack. Doctors started treatment for atrial fibrillation and pneumonia. Our provisional view is that doctors followed the AF Guideline.
23. Doctors promptly sought advice from cardiology specialists. This was because of the abnormality on the ECG. This led to further investigations to check what had caused the problem. Blood tests confirmed Mrs T had ACS. This refers to a range of conditions between unstable angina and a heart attack. Mrs T did not have the typical symptoms of a heart attack. The Medical Adviser said this is recognised to be the case for some patients who are older, frail, and female. We will refer to how doctors treated the ACS later in this report.
24. The clinical records show doctors noted Mrs T’s delirium from her admission to the Hospital. On 13 January doctors considered her health was improving, although her delirium continued. The next day records referred to Mrs T’s family expressing concerns that she had become less responsive and increasingly drowsy.
25. We consider doctors carried out appropriate assessments of Mrs T’s condition. They considered her history and examined her. They arranged appropriate investigations and obtained advice from specialist colleagues. They also treated Mrs T appropriately. They followed Good Medical Practice.
26. Mrs T’s condition suddenly deteriorated after five days in the Hospital. Doctors recognised she had the signs of a gastrointestinal bleed. She experienced blood loss from her rectum, a sudden drop in haemoglobin levels (a substance in red blood cells that carries oxygen around the body) and other observations suggesting sudden blood loss.
27. OGD is the usual method to diagnose and treat the type of bleeding Mrs T had. But Mrs T was too frail and unwell (because of the ACS) to have this procedure. Doctors sought advice from a gastrointestinal specialist. They treated Mrs T using fluid resuscitation (giving intravenous fluids to replace blood volume lost from bleeding) and proton pump inhibitor medication (to suppress stomach acid which can contribute to bleeding). Doctors also stopped all anticoagulant medication.
28. The Medical Adviser noted doctors did not follow the Gastrointestinal Bleeding Guideline, but this was appropriate because of Mrs T’s other health problems, particularly the ACS and her frailty. Mrs T was too frail for an OGD, which is recommended in the guideline. The evidence shows doctors carried out a comprehensive assessment and took account of her health as a whole. They followed the Multimorbidity Guideline.
29. We find no failings relating to Mrs T’s medical treatment. We appreciate how upsetting it must have been for Mrs L and her family to observe. Our view is the doctors followed Good Medical Practice and the other guidelines we have referred to above.
Anticoagulant medication
30. Mrs L said doctors told her family that anticoagulant medication had been stopped on 11 January 2023. She says this was untrue and doctors waited three days before stopping the medication. She recalled that a doctor at the complaints meeting said doctors gave her mother aspirin. Mrs L says this should not have happened because her mother was allergic to aspirin.
31. The Medical Adviser told us doctors considered anticoagulants for two reasons in Mrs T’s case. These were ACS and atrial fibrillation.
32. The ACS Guideline explains how doctors should treat heart attacks. The type of heart attack Mrs T had was an NSTEMI. This usually happens when the heart does not receive enough oxygen. The ACS Guideline says doctors should offer aspirin as soon as possible to all people with unstable angina or NSTEMI and consider this indefinitely unless they are at risk of bleeding or have a sensitivity to aspirin.
33. The ACS Guideline recommends a single dose of 300mg aspirin as soon as possible unless there is clear evidence the patient is allergic to it. It also says they should offer fondaparinux (medication to help blood clotting) to people with an NSTEMI who do not have a high risk of bleeding. If patients have a high risk of bleeding doctors should consider using clopidogrel (to prevent blood clots) along with aspirin. Clopidogrel is often used as an alternative to aspirin to reduce the risk of further heart problems in the future.
34. Doctors should also have followed the AF Guideline as mentioned earlier in this report. This says doctors should consider offering anticoagulants to manage atrial fibrillation. They must first assess the patient’s risk of stroke and their risk of bleeding.
35. The clinical records show doctors diagnosed Mrs T’s atrial fibrillation when she arrived at the Hospital. Atrial fibrillation can lead to a stroke and the risk of this is reduced if anticoagulant (or blood thinning) treatment is used in the long-term. Anticoagulants can lead to a risk of bleeding.
36. The Medical Adviser said doctors calculate risk scores for both strokes and bleeding. The records show doctors assessed both of these for Mrs T. They calculated a CHADSVASC score for stroke risk and HASBLED score for bleeding. The results showed Mrs T was at greater risk of a stroke than bleeding over the long-term. This meant it was appropriate for doctors to use anticoagulants. Doctors followed the AF Guideline in this respect.
37. Doctors initially prescribed aspirin, clopidogrel and fondaparinux to Mrs T. They cancelled the prescription for aspirin when they noted Mrs T was allergic to it. The records clearly show doctors first administered clopidogrel and fondaparinux on 9 January 2023. Clopidogrel and Fondaparinux continued until 13 January. The medication charts do not contain any reference to aspirin being administered. There are repeated references in the clinical records to Mrs T being allergic to aspirin.
38. We are persuaded that clinicians completed Mrs T’s clinical records at the time of the events and that they are accurate. They did not administer aspirin to Mrs T during her admission to the Hospital. They gave her clopidogrel and fondaparinux, which was in line with the ACS Guideline. Doctors stopped this treatment on 14 January 2023 (with the last medication being given the previous day) when they suspected bleeding. There was no reason for doctors to stop the medication before then.
39. We can see one of the Trust representatives wrongly stated at the complaints meeting that Mrs T had aspirin. This was clearly an error.
40. The records also contain a note the doctor who spoke with Mrs L and members of her family made on 11 January 2023. The note refers to the treatment plan continuing and other records from that date state the doctors’ plan was to continue with anticoagulant medication. Mrs L and her family clearly have a different recollection of the discussion. It could be that the doctor did not provide a clear explanation or that his comments were misunderstood. It is not possible for us to establish exactly what was said or what was intended.
41. We find the doctors followed the ACS Guideline and the AF Guideline when managing Mrs T’s medication. We hope Mrs L is reassured we have seen no evidence of any failings in this respect.
Dementia care
42. Mrs L says she understood there was a specialist in dementia care at the Hospital. However, staff at the time said there was no specialist. She questions whether her mother should have had more support for her dementia. She says there is no evidence of a dementia care plan for her mother.
43. The NMC Code contains the professional standards nurses in the UK must follow. It says nurses must act in the best interests of people at all times. It says they should ensure the interests of people who lack capacity are at the centre of the decision-making process.
44. The RCN Guideline outlines the SPACE principles. These are principles to support nurses and other staff in healthcare settings when caring for patients who have dementia. One of the key principles is that staff should produce care and support plans which are person-centred and individual. It also says organisations should have clear delirium protocols in place to ensure people receive the right treatment and care.
45. The Nursing Adviser told us the guidelines referred to above meant the Trust should have recognised Mrs T’s needs as a person with dementia. They should have assessed her and provided individualised, person-centred, care. This can be done within a personal profile. Nurses should also have assessed Mrs T’s risk of delirium and taken a proactive approach should she exhibit distress.
46. The clinical records show clinicians established Mrs T had dementia when they admitted her to the Hospital. Nurses completed an initial assessment of Mrs T’s needs, which noted she was severely frail and had dementia. However, clinical records were often completed incorrectly. Assessments frequently noted she had no problems with cognition when records completed around the same time referred to her being confused. Sometimes records suggested she did not have dementia and had no issues with mental capacity.
47. On 9 January 2023 clinicians recorded Mrs T had a mental test score of two out of ten which indicated she had severe mental impairment. Two days later further records noted Mrs T was restless and declined nursing interventions. On 12 January a nurse recorded Mrs T was ‘alert and orientated’ but the next paragraph said she was ‘very confused.’
48. Doctors clearly diagnosed delirium and nurses referred to Mrs T being agitated, declining medication and observations more consistently from 13 January 2023 onwards.
49. The Nursing Adviser told us there is no evidence of any nursing care planning for delirium or dementia throughout Mrs T’s admission to the Hospital. Checklists on 9 and 17 January 2023 noted that dementia care, mental capacity care and delirium care were all ‘not applicable.’
50. The nursing checklists contained only headline actions with no embedded detail. There seem to have been limited opportunities for nurses to record individualised plans of care. Many of the records contain ambiguous or contradictory information. There is no detail about how nurses supported Mrs T and her family with her dementia. The Trust confirmed it had a dementia lead nurse at the time of these events. There is no evidence that nurses made a referral to the dementia lead nurse during Mrs T’s admission to the Hospital. The Trust has not explained the circumstances when the dementia lead nurse should become involved in a patient’s care.
51. There is evidence that nurses provided some support to Mrs T’s family. One example is that they encouraged them to attend outside normal visiting hours. There is also evidence of a discussion with the family about deprivation of liberty safeguarding (DOLS). This is a process designed to protect the patient’s rights when they lack mental capacity to agree to medical treatment and care. We can see DOLS was requested but no evidence it was put in place.
52. There is no evidence that nurses provided person-centred care for Mrs T. There was no personal profile. Despite doctors diagnosing delirium there is little reference to nurses offering support or comfort to Mrs T at a time when she was clearly confused and agitated. This means there is no evidence that Mrs T was at the centre of the decisionmaking process despite her lack of capacity.
53. We find that nurses did not follow the NMC Code or the RCN Guideline. Mrs L is right to say there was no dementia care plan for her mother. The evidence also shows there was limited support for Mrs T regarding her delirium. It is unclear why the specialist in dementia care was not available to support Mrs T. The Trust’s complaint response simply said it apologised ‘if this was not done during your mother’s admission.’
54. We can see how these failings meant Mrs T experienced distress that could have been avoided. We can also see how it was distressing for Mrs L to witness the lack of support. We will make recommendations to the Trust relating to these issues.
Communication
55. Mrs L says doctors did not keep the family informed about how they were treating her mother.
56. Good Medical Practice says doctors must be considerate and compassionate to those close to the patient and be sensitive and responsive in giving them information.
57. We have explained earlier in this report how we are persuaded that Mrs T’s hospital records are contemporaneous and accurate. They contain several references to doctors meeting different family members throughout Mrs T’s admission to discuss her.
58. On 8 January 2023 a doctor in the emergency department noted a discussion with family members about whether to resuscitate Mrs T in the event of her heart or breathing stopping.
59. Another doctor reviewed Mrs T on 9 January 2023. They discussed recent developments with a family member at the bedside. This related to the ACS and the fact that Mrs T was too frail for any additional intervention.
60. On 11 January 2023 doctors met members of the family on two different occasions. They explained how Mrs T had had a heart attack and was experiencing delirium. They explained how they were treating these issues and outlined the DOLS process.
61. The next day a doctor met two family members and explained the treatment plan and reiterated the position about resuscitation. On 14 January 2023 doctors had two face to face conversations, and a phone call, with family members relating to Mrs T’s bleeding and how they intended to treat this. They pointed out Mrs T was very poorly by that stage.
62. The records show doctors had at least three conversations with family members on 15 January 2023. These related to Mrs T’s ongoing bleeding and how the treatment of that problem changed during the day. The next day doctors explained to family members that they had been unable to stop the bleeding and Mrs T was approaching the end of her life.
63. Clearly these events were incredibly upsetting for Mrs L and her family. We can see doctors had several conversations with family members during Mrs T's admission to the Hospital. These show they were considerate, compassionate, and sensitive in their communication. We recognise Mrs L and her family do not accept this view. We find the doctors followed Good Medical Practice in their communication with Mrs L’s family.