Mersey and West Lancashire Teaching Hospitals NHS Trust

3. Mr X complains about the nursing care provided to his wife during the night of 18/19 March 2022. He says the nurse failed to check and assess his wife from 10pm to 6.30am the following morning. Mr X believes that if the nurse had assessed Mrs X during the night she would have seen an improvement and her treatment could have been restarted. He believes his wife could have lived longer.

4. ​​Mrs X’s medical history included chronic liver disease and severe malnutrition. She was admitted on 17 March 2023 for nasogastric tube feeding (NGT). This is a method of delivering nutrients to the stomach through a tube inserted through the nose. It is used when a person is unable to eat or drink enough by mouth. Unfortunately, Mrs X’s condition deteriorated and a doctor considered she was dying.

5. The Trust contacted Mr X on 18 March at 9pm to advise his wife was deteriorating and he should attend hospital to be with her. Mr X said he arrived at 10pm. He has complained that a nurse responsible for his wife’s care did not attend to her during the night until after 6.30am the following morning. He complains that during this period his wife appeared to be improving and that the nurse could have sought advice regarding her treatment plan.

6. Mr X complained to the Trust which has provided two responses. Mr X remains unhappy and has complained to us.​

Nursing care

10. Before we decide if we should conduct a detailed investigation of a complaint, we look at whether there are signs the events complained about had a negative effect on Mrs X. Having done so we have not found any indication that the nursing care complained about had a negative effect on Mrs X’s outcome.

11. Our physician adviser confirms that Mrs X did appear to be actively dying when the decision was made to put her on end of life care on 18 March 2023. A senior doctor reviewed Mrs X and documented that she appeared to be actively dying. The doctor made this judgement after they had read the previous records, considered Mrs X’s medical background, recent investigations and performed a clinical examination.

12. This assessment was thorough and in line with the above GMC Good Medical Practice which states doctors must:

• adequately assess the patient’s conditions, taking account of their history (including the symptoms and psychological, spiritual, social and cultural factors), their views and values; where necessary, examine the patient • promptly provide or arrange suitable advice, investigations or treatment where necessary • refer a patient to another practitioner when this serves the patient’s needs.

13. Our physician adviser said Mrs X’s medical records show she had severe underlying medical conditions, and was at risk of deterioration and death at any time. She had symptoms, signs and X-ray findings in keeping with a pneumonia on 18 March when she acutely deteriorated. She was reviewed multiple times during the course of 18 March, with a clear progressive clinical deterioration.

14. The doctor’s plan indicates that Mrs X was dying and the focus was now on her comfort, i.e. palliative care. Routine checking of observations (including temperature, pulse, blood pressure, breathing rate etc.) would stop and calls to the medical escalation team (MET) – the team that would respond to patients with a high NEWS score who may need a change in their treatment – were no longer indicated. Anticipatory medications were prescribed which include medications available for the nurse to use if Mrs X has any uncomfortable symptoms associated with the end of life such as pain, agitation, respiratory secretions or nausea/vomiting. Our physician adviser explained that such symptoms are not inevitable at the end of life, and there would be no need to give these medications to Mrs X if not required.

15. As indicated above, following their review the doctor advised Mrs X should receive comfort care. The NMC’s code – professional standards of practice and behaviour for nurses, midwives and nursing associates states a nurse should,

“13.1 accurately identify, observe and assess signs of normal or worsening physical and mental health in the person receiving care

16. We note that Mr X complained to a senior nurse in the morning that the nurse had not been into the room overnight. He also raised his concerns with the Trust. The Trust has responded to this issue in its letters dated 23 July and 27 October 2023. It has said the nurse apologised to Mr X if she had not attended to Mrs X in line with his expectations. There is a discrepancy in the Trust response to Mr X’s account of events who has maintained his position on this issue that the nurse never entered the room. We have not reached a conclusion on that point at this stage but there are indications of potential failings so we have considered if this had any impact on Mrs X’s outcome.

17. We further note that there are no documented references to Mr X, who was with his wife throughout this timeframe, and no attempt to ensure that he was actively engaged and given the opportunity to discuss his concerns about his wife’s care, whilst she was drowsy and unable to discuss her needs with nursing staff independently. The NICE guidance ‘Shared decision making’ aims to ensure shared decision making becomes part of everyday care in all healthcare settings. The guidance suggests that family members should be actively engaged in discussions and decisions about care, risks, benefits, and consequences specific to the person receiving care.

1.2.3 Ask the person if they want to involve family members, friends, carers or advocates (being aware of safeguarding). If so, include them as a way to help the person: • actively engage in the discussion • explain what matters to them • make decisions about their care • remember information they have been given during the discussion.

18. The indications are that Mr X was not given the opportunity to actively engage in discussions about his wife’s care overnight when it was documented that she was actively dying. This was the responsibility of the nurse caring for Mrs X over this timeframe. This left Mr X feeling that his wife may not have been comfortable and also that she might have lived longer (as per his discussion with the senior nurse on the morning his wife died). If he was actively engaged, the nurse would have had the opportunity to confirm Mrs X was actively dying and provide reassurance when his wife had squeezed his hand.

19. There are indications of potential failings on the part of the Trust relating to the nursing care and we have considered if this had any impact on Mrs X’s outcome. Mr X has been left wondering if there was any chance of medical intervention had the nurse reviewed his wife more regularly and noted a change in her condition. Our physician adviser has said there was no medical intervention indicated as Mrs X was sadly dying. The medical team had provided appropriate medical treatments for her conditions, but unfortunately she continued to deteriorate despite these. Further escalation of care was not possible, she was already receiving the most comprehensive treatment that could be provided.

20. The medical team had also sought an opinion from the intensive care team as to whether it would be appropriate to pursue treatments that can be provided there. However, Mrs X was deemed not to be suitable for such treatments as she would not survive them due to her multiple medical conditions and poor functional baseline.

21. There are potential failings regarding the nursing care provided to Mrs X and her family. However, we do not feel this affected Mrs X’s treatment or outcome. It is for this reason we are not carrying out a detailed investigation. We recognise that the loss of Mrs X has greatly impacted on Mr X and his family and we offer our condolences on their sad loss. We hope we have clearly explained the reasons for our decision and provided reassurance to Mr X regarding his wife’s sad outcome.

1. We have carefully considered Mr X’s complaint about Mersey and West Lancashire Teaching Hospitals NHS Trust. We have decided that any potential failings in nursing care had no impact on Mrs X’s sad outcome.

2. We recognise that the death of Mrs X has greatly impacted on Mr X and his family, and we are sorry about that. We hope we have clearly explained below why we feel we do not need to carry out a detailed investigation.