23. When we consider whether there are indications of service failure, we first look at what should have happened. We use national guidance, local policies, and specialist advice to tell us what the care should have looked like. We then compare that to what did happen. To establish what did happen, we review the medical records and any other contemporaneous records, which includes the family’s account of what happened.
24. If there is an indication of a shortfall between what should have happened and what did happen, we must then consider whether this fell so far short of the expected standards that it could amount to service failure. We are not considering whether a person received perfect care, rather we look at the overall care provided and whether this appears to align, overall, with the standard of care that should have been provided.
25. If we consider an organisation’s actions fell so far below the expected standard that it indicates service failure, we then consider the impact this had and whether the Trust has done enough to put things right. If the organisation has already taken the steps we would expect it to have taken, we will not take further action as there is nothing more we can reasonably achieve for the person bringing the complaint.
Infection
26. Upon admission to hospital on 3 January 2022 the working diagnosis was that Mr E may have an infection in addition to having complications of his congestive heart failure. The recommendation was to commence intravenous (IV) antibiotics; however, upon receiving his blood test results his white cell count was 7, which is considered to be normal for a healthy adult. This indicated he did not have an infection at that time.
27. He had further blood tests on 7 January, which indicated only a slightly raised white cell count of 13. Whilst a raised white cell count can indicate infection, there can also be other causes and our physician adviser confirmed that this is unlikely to be linked to infection or sepsis.
28. Alongside Mr E’s white cell count, we have also considered his National Early Warning Scores (NEWS), which standardises the assessment of acute illness severity. Whilst this scale does not measure infection directly, it does provide some indication as to whether an infection may have been present. It also gives an indication of organ dysfunction, which can occur as a result of sepsis or septic shock.
29. NEWS is a standardised tool developed by the Royal College of Physicians. It measures physiological parameters, such as temperature and blood pressure, to create an aggregate score. This score is then used to inform how often a person should be monitored and whether their care needs to be escalated.
30. On admission to hospital, Mr E’s NEWS score was under five, which does not indicate someone is seriously unwell, and remained relatively stable throughout his admission. We cover his NEWS scores in more detail when we explore deterioration below, and so have not repeated this detailed work here.
31. Our physician adviser said that based on the physiological measurements captured in the NEWS scores, and the clinical narrative from Mr E’s medical records, there was nothing, aside from one instance which we explore below, to indicate he may have had an infection until 17 January.
32. On 17 January, Mr E reported symptoms such as feeling ‘shivery’ and his temperature was high, which could have indicated an infection had developed. His family also reported he was confused on the telephone, which could also have indicated an infection had developed. Sadly, Mr E died that same day, most likely from a sudden cardiac event, before this could be established either way.
33. We note that on 12 January a culture taken from Mr E’s catheter tested positive for e-coli bacteria. However, the pathology department’s report, which was provided to physicians on 15 January, stated that this did not mean Mr E had an e-coli infection, and that this result could represent colonisation (a growth of bacteria) on the catheter itself. The pathology department recommended only commencing treatment if Mr E showed systemic signs of infection. These would include symptoms such as a raised temperature and a raised white cell count.
34. This appears to be in line with the Quality Statements for urinary tract infections published by NICE (NICE QS90). This guidance (Quality Statement two) says: ‘catheters quickly become colonised with bacteria’ and that this can cause ‘positive dipstick results’ (a dipstick is often used to screen for urinary tract infections in the first instance). It adds that ‘this does not indicate that the bacteria are causing an infection in the bladder or kidneys’ and says ‘to ensure urinary tract infections are diagnosed accurately . . . signs and symptoms are assessed to diagnose [them], with urine culture and sensitivity testing to support the diagnosis and guide treatment’.
35. The Trust appears to have acted in line with the NICE QS90 guidance, with the urine culture taking place on the 12 January and the pathology department advising on the type of antibiotic, and to only treat if there were clinical signs of infection. At this stage there were no other indicators of infection other than this positive culture.
36. Our physician adviser explained that based on Mr E’s clinical presentation, there was very little to indicate an infection may be present until 17 January. They added that that in view of the short timescale between these symptoms occurring and Mr E’s death, even if the review had taken place and antibiotics administered at this point, it is unlikely that this would have changed the sad outcome.
37. Based on the evidence we have seen, there is no indication the Trust failed to identify and treat an infection.
Deterioration 38. We recognise the family strongly feels that Mr E was deteriorating during his admission and that his granddaughter, who is a nurse, has highlighted concerns about his medical records. Though it is not proportionate to outline all the detailed comments she provided in this report, we have reviewed her notes alongside the independent advice we received from our nurse and physician advisers.
39. Both our nurse and physician advisers told us that the best indication of whether Mr E was deteriorating during his admission is his NEWS scores. The Royal College of Physicians publishes guidance on how to use the NEWS scale, which is outlined below.
40. NEWS measures patients’ vital signs across six parameters:
• respiration rate • oxygen saturation (the proportion of oxygen saturated haemoglobin relative to total haemoglobin in the blood) • systolic blood pressure (the pressure on the arteries when the heart beats) • heart rate • level of consciousness • temperature.
41. These parameters are then scored from one to three, based on how far outside the expected range the person’s vital signs are. The score for each parameter is added together to make an ‘aggregate score’. This score tells clinicians what level of response (if any) is needed and how often the person should be monitored. The guidance also states that this should not replace the clinical judgement of clinicians.
42. The response and monitoring required for each score is outlined as:
• for a score of zero, 12-hourly monitoring of vital signs should happen, and no escalation is required • patients scoring between one and four (low risk) should be monitored every four to six hours, and a registered nurse should decide whether or not to increase monitoring or escalate to the medical team • when a patient scores five or six (medium risk), their vital signs should be monitored at least hourly, and a registered nurse should inform the medical team caring for the patient • patients who score seven or above (high risk) require an emergency response, continuous monitoring of vital signs, and the patient should be reviewed by an experienced clinician.
• if a patient scores under five, but scores three in one single parameter (low to medium risk) the patient should be monitored hourly and a registered nurse should escalate to the medical team.
43. Our physician adviser brought to our attention the fact that Mr E’s NEWS scores appear to have been overestimated for much of his admission. This happened because the doctors had adjusted his target oxygen saturation levels to 94-98% and this was not reflected in the NEWS scores calculated by the computer software used by the nursing team.
44. Reducing target oxygen saturation levels is common strategy for individuals who are expected to have a lower [than the general population] oxygen saturation level, such as people with chronic respiratory conditions or who have heart failure. This is done to ensure clinicians are responding to an acute deterioration of a patient’s condition, rather than what is normal for them but outside the range generally expected.
45. It is also important to consider that Mr E had been prescribed diuretics. Diuretics are well-known for reducing blood pressure and are used as a treatment for high blood pressure in some cases. Medications such as diuretics can cause higher NEWS scores in the blood pressure parameter that are not the result of an increase in illness severity. In addition, blood pressure and heart rate are closely interrelated, meaning any impact from the diuretics on Mr E’s blood pressure could also have caused his heart rate to change. This means that a reading outside of the expected range may reflect the effect of the diuretics rather than patient deterioration, and clinicians must consider this context for any abnormal physiological parameters. This is one of the reasons why the Royal College of Physicians state that NEWS scores should not replace the clinical judgement of clinicians.
46. We have reviewed Mr E’s NEWS scores and the responses documented when his NEWS scores rose. His scores were, overall, relatively stable; however, there were times when he had acute spikes in the score. We have considered whether these indicated deterioration, and whether the Trust acted on these scores appropriately. To do this, we have focused on the times when Mr E scored five or above, or three in one parameter, as this is the point at which his care should have been reviewed. We have also included NEWS scores of three and above on 17 February, given the importance of this date.
47. Mr E had NEWS scores that required review on the following dates and times:
• on 4 January at 10.19am, his NEWS score had climbed to six. He also scored three in the blood pressure parameter. The nurses immediately referred this to the medical team and a doctor reviewed Mr E at 11.32am.
• at 11.46am on 4 January his NEWS score was six and this was escalated to a doctor again by nursing team.
• the same day, his NEWS score was five at 1.13pm. A doctor reviewed Mr E at 3.59pm, took his vital signs again, and noted his NEWS score had dropped to three. This meant no further action was needed at that time.
• at 10.41am on 5 January, Mr E’s NEWS score was five (four when adjusted for target oxygen saturation). He also scored three in the blood pressure parameter. The nurses escalated this to a doctor and noted their impression that his diuretics were increasing the score by causing low blood pressure. He was reviewed by a doctor at 12.06pm and his blood pressure had stabilised by 12.34pm.
• on 7 January at 3.48pm his NEWS score was five (four when adjusted). The nurse did not escalate this and documented this was because Mr E had just finished on the commode, which can affect physiological readings. The nurse documented they would review this in 30 minutes. When they rechecked his vital signs at 4.32pm his NEWS score had stabilised to three.
• at 8.23pm on 8 January his NEWS score was five. The nurses made no record of escalation, but his score dropped to zero at 9.16pm. This indicates the nurses had decided to repeat his observations, as they had done previously, rather than escalate immediately.
• 6.19pm on 10 January Mr E’s NEWS score was five (four when adjusted). The nurses noted he was on diuretics and the plan was to continue to monitor him. His NEWS score fell to two later that evening.
• On 12 January at 2.11pm Mr E’s NEWS score was six (five when adjusted), scoring three in the respiration rate parameter. The nurses did not escalate this and, instead, repeated his observations again at 2.13pm. His NEWS score had fallen to three (two when adjusted) which meant no escalation was needed.
• on 13 January at 2.13pm he scored five (four when adjusted) and scored three in the blood pressure parameter. The nurse documented that the reason for this high score was due to being on oral diuretics, which were causing consistently low blood pressure.
• at 9.57am on 14 January Mr E’s NEWS score was six (five when adjusted). No escalation was recorded by the nursing team.
• at 6.19pm on 15 January his NEWS score was six again (five when adjusted). The nurses did not document any escalation.
• on 16 January at 2.13pm his NEWS score was five (four when adjusted) and he scored three in blood pressure parameter. There was no escalation to a doctor and a nurse noted he was on oral diuretics. Mr E’s nursing notes, as recorded at 3.53pm, indicate his low blood pressure was due to his diuretics.
• at 10.12am on 17 January Mr E’s NEWS score was five (four when adjusted). This was not escalated, and a nurse documented that this was because he was due to be seen by the doctor in ward round.
• later that same day, at 2.19pm his NEWS score was three (two when adjusted). No escalation was required and the nurse noted his observations were improving since that morning.
• At 5.52pm that day his NEWS score was four (three when adjusted), scoring three in respiratory rate parameter. Escalating his care was at the discretion of nursing staff, who decided to repeat his observations three minutes later. Upon doing so, his NEWS score was one, which did not require escalation.
• at 9.37pm on 17 January his NEWS score was three, with that score being solely from the respiratory rate parameter. The nurses escalated this to who reviewed Mr E and recommended he take paracetamol.
48. Our physician adviser explained that when reviewing NEWS scores as an indicator of acute illness severity and clinical deterioration, we must bear in mind any medical conditions or medications that could be causing an increased NEWS score but do not indicate a deterioration. They also explained that ordinarily, when a patient is dying, we would see a consistent downwards pattern or trend of deterioration over hours or days.
49. Mr E’s NEWS scores were overestimated much of the time during his admission because the staff had not factored in his adjusted target oxygen saturation levels. There were times when his oxygen saturation parameter scored zero, which means the rest of the aggregate score had not been overestimated on those occasions. This may have made Mr E appear more unwell than he was at times during his admission.
50. He was also being prescribed oral diuretics, which were causing consistently low blood pressure. This means that higher scores in these parameters would not necessarily indicate a deterioration in his overall condition. Instead, they may have reflected a side effect of the necessary medication Mr E was taking.
51. Our physician adviser told us there was also no consistent trend of deterioration in the physical observations taken, when viewed over time. Mr E experienced spikes in his NEWS scores that quickly resolved on a number of occasions, but there was no overall trend towards deterioration.
52. With regards to taking appropriate action regarding Mr E’s deterioration, the evidence indicates that overall, the nursing team appropriately escalated his care. The nurses had to use their clinical judgement, as advised by the NEWS guidance, to ensure they were escalating an acute deterioration rather than an acute spike in the NEWS score caused by diuretics or other clinical factors. In doing this they, on some occasions, chose to repeat his observations when his NEWS scores spiked to assess whether this was indicative of increasing illness severity. This was appropriate, and usually when the nurses did this Mr E’s NEWS scores dropped to being low risk within a short period of time.
53. There were three occasions, however, where there was no escalation documented and the nurses did not document why. Our nurse adviser explained that this was more likely than not because Mr E’s NEWS scores were rising secondary to his severe heart failure and the use of diuretics to treat this. We can see multiple instances where the nurses documented that they had not escalated his care because of the impact of his diuretics. We do not consider that these instances reflect a failure to act on an acute clinical deterioration, nor do we consider the failure to escalate fell so far short of the Royal College of Physicians’ NEWS guidance that it could amount to service failure, overall. However, the nurses should have kept a more comprehensive record of the decision not to escalate Mr E’s care on these occasions.
54. Overall, the evidence we have seen indicates that there was no evidence of a trend of clinical deterioration whilst Mr E was under the care of the Trust. The evidence also indicates that whilst the nurses should have kept better records on occasion, his care was escalated appropriately most of the time during his admission. For this reason, we have seen no indications of service failure.
Palliative care 55. There is no specific national guidance or standard used to determine whether a person is reaching the end of their life. This is usually identified by clinicians using their clinical judgement. Our physician adviser said that Mr E’s NEWS scores are the best evidence we have to tell us whether or not he appeared to be approaching the end of his life.
56. Our physician adviser said that Mr E’s NEWS scores were consistently stable, overall, even on the final day of his life. They noted some acute spikes in his NEWS score, but that these returned quickly to a low-risk score when his observations were repeated. This indicated the increased score was due an acute change in his observations that was short-term in nature and restabilised quickly. Our physician adviser said this would not indicate that a person was approaching the end of their life.
57. We note that Mr E’s granddaughter queried why a DNACPR was discussed if he was not approaching the end of his life. We can understand why this might cause some concern. Decisions about resuscitation are not the same as considerations around end-of-life care or whether someone is reaching the end of their life. Mr E was 91 years old and had severe heart failure. This does not mean he was actively dying, but it does mean that a cardiorespiratory arrest could easily happen at any time. People can experience a sudden cardiac event at any age, and for those where resuscitation would be unlikely to be of benefit, doctors must carefully consider whether or not to do this.
58. Guidance from the Resuscitation Council says this should happen for all those where cardiorespiratory arrest is ‘reasonably foreseeable’. As Mr E was 91-years old with severe heart failure, this was something that was reasonably foreseeable. However, this does not mean he was actively dying. It is not uncommon for people with a DNACPR in place to live for months or years after this is put in place.
59. Overall, the evidence indicates that there was no clinical indication that Mr E was imminently approaching the end of his life. His physical observations remained stable, with some acute spikes in the NEWS scores that resolved quickly. Mr E died suddenly, most likely from a sudden cardiac event, which can happen at any time in older patients with severe heart failure. Therefore, there is no indication that the Trust missed an opportunity to identify that he was approaching the end of his life and implement palliative care.
Communication 60. We asked both our nurse and physician adviser to review the communication between the clinical staff and Mr E and his family.
61. In line with the NMC Code (section 5.5) the nursing team should have shared information with Mr E’s family, as far as the law allowed. This should have included the information they wanted and/or needed to know about his ongoing health, care and treatment.
62. Similarly, in line with the GMC’s Good Medical Practice guidelines (section 33), doctors should be sensitive to those close to a patient and be sensitive and responsive in giving them information and support. This guidance also outlined that doctors’ first priority is the care of their patients, and our physician adviser explained that this means their priority is to communicate with the patient when the patient has mental capacity. The Trust’s records reflect regular communication with Mr E about his care from the physicians caring for him.
63. Our nurse adviser explained the communication from the multidisciplinary team appears to have been frequent, overall, though we note the family report having a lot of difficulty getting through to the ward for this communication to take place. The Trust has acknowledged and apologised for this.
64. Our nurse adviser highlighted the following instances of communication documented in Mr E’s medical records: • On 4 January at 4.49pm a physician attempted to call the family to obtain a clinical history for Mr E and update them on his care. The call was declined by a call screening service.
• At 6.47pm the same day, Mr E’s family telephoned the ward for an update, which was provided by the nursing staff. Following this call the nurses updated his next of kin to be his daughter and not his wife.
• A doctor spoke with Mr E’s family at 7.42pm on 4 January to obtain a history and updated them on his care.
• On 6 January at 8.36pm Mr E’s daughter telephoned the ward because he had contacted her and told her he may be ready to go home soon. She told the nursing staff they were very concerned because they did not have a package of care in place yet. The nurse documented an update about reducing his diuretics due to low blood pressure.
• At 11.24am on 10 January the nurses documented a conversation with Mr E’s granddaughter about the package of social care needed. The nurse made a note to update her about the discharge plans and documented her telephone number.
• On 11 January at 10.51pm the nurses documented that Mr E’s daughter telephoned the ward to say he seemed confused when speaking with her on the telephone. The nurse documented they went to speak to him and he did not seem confused, and that they would continue to monitor this.
• At 8.43pm on 14 January the nursing team documented that they updated Mr E and his daughter about the availability of support on discharge from hospital.
• On 15 January at 5am the nurses documented a telephone call with one of Mr E’s daughters who had called and was distressed because he had told her on the telephone he was going to die in hospital. The nurse documented that they explained his discharge had been delayed due to a lack of capacity with the home care support.
• At 3.53pm on 16 January the nurses documented that they had updated Mr E’s family about his care.
• At 4.28pm on 17 January the nurse documented they updated Mr E’s daughter as best they could and that she had requested to speak with a doctor.
• At 7.07pm on 17 January the nurses recorded that Mr E’s daughter telephoned the ward and said he seemed confused.
65. We can see from the evidence submitted by Mr E’s family that he was in regular contact with them via telephone. We also know that Mr E’s family struggled to get through to the ward at times and the Trust has already acknowledged this and apologised. When viewed overall, the nurses were updating Mr E’s family about his care. This appears to align with the NMC Code.
66. We recognise there was less communication from the physicians caring for Mr E. We are satisfied the evidence indicates that the physicians were updating Mr E regularly about his care; however, the Trust has acknowledged that there was very little direct communication with Mr E’s family from the doctors caring for him. This could fall short of being sensitive to those close to Mr E and responsive in giving them information and support, as outlined in the GMC’s Good Medical Practice guidance. We recognise this will have caused avoidable worry and distress to Mr E’s family.
67. In its response to the family’s complaint, dated 31 January 2023, the Trust included an improvement plan that outlined the service improvements it had implemented relating to communication. This included a plan to:
• written expectations of the standard of communication the Trust expects being issued to all staff member • use of a communication book whereby family members’ requests for discussions with the medical team are documented.
68. Though the communication with Mr E’s family from the doctors appears to have fallen below the expected standard, the Trust has already acknowledged this and taken appropriate steps to put this right, in line with our Severity of Injustice Scale and NHS Complaints Standards. There is nothing further we could reasonably ask the Trust to do to remedy this.
Fundamental nursing care 69. The family’s concerns about fundamental nursing care relate to three areas: personal hygiene, nutrition, and hydration needs. In line with the NMC’s guidance (Future nurse: standards of proficiency for registered nurses) the Trust’s nursing staff should have:
• observed, assessed and optimised skin and hygiene status and determined the need for support and intervention • assessed the need for and provided appropriate assistance with washing, bathing, shaving, and dressing • observed, assessed and optimised nutrition and hydration status and determined the need for intervention and support • used contemporary nutritional assessment tools • recorded fluid intake and output, where needed, and identified, responded to, and managed dehydration or fluid retention.
70. Additionally, in line with NICE guideline CG32 (nutrition support in adults) the Trust should have:
• screened Mr E for malnutrition, and repeated this weekly where there was a cause for concern • considered nutrition support if Mr E had eaten little or nothing for five days, or was likely to do so • provided appropriate support with eating and drinking, based on Mr E’s needs.
71. On admission to hospital on 3 January, the nurses completed an assessment of Mr E’s nutrition, hydration, and personal hygiene needs. This assessment noted:
• Mr E was able to independently maintain adequate hydration (meaning he did not need help with this) • Mr E’s family had raised a concern about weight loss/change in appetite • he was fully continent (and so did not require continence care) • he was independent with his personal hygiene but needed assistance.
72. The Trust completed a nutrition screen on 4 January, in line with NICE guideline CG32. This screen recorded Mr E was a normal weight; however, our nursing adviser highlighted that he was likely to have been retaining some degree of extra weight due to the fluid retention that was caused by his heart failure.
73. The nurses concluded Mr E was at medium risk of malnutrition due to the concerns that his appetite had been poor in the preceding months. He was weighed again on 5 January and had lost one kilogram, which our nursing adviser said reflected that he may have lost some of the fluid he had been retaining.
74. On 8 January his malnutrition risk was reviewed, in line with NICE guideline CG32. The nurses recorded a two kilogram loss of weight over three days; however, our nursing adviser explained this would be expected as Mr E was being treated with diuretics for fluid retention. This is further supported by the fact his weight remained the same when he was weighed again 11 January.
75. Mr E had no reported difficulties swallowing and could eat and drink an unmodified diet. However, his nutritional intake had previously been reported as being poor and he needed encouragement to take adequate diet and fluids. The nursing team completed a nutrition support care plan from 4 January, which included weighing Mr E regularly, completing food charts, providing nutritional supplements, and implementing the red tray system. The red tray system is used in hospitals to help staff identify which patients need extra support when eating.
76. The evidence from Mr E’s medical records indicates that his food charts were not maintained consistently, and our nursing adviser commented that the nurses did not always record how much of his meal had been eaten. The record-keeping around Mr E’s food charts appears to have been inconsistent and the Trust has acknowledged this and apologised that this was not more closely monitored.
77. Despite the inconsistency in completing the food charts, we can see the reviews of Mr E’s nutritional needs that took place on 8, 9, 13, 16, and 17 January indicated he was ‘eating and drinking fairly well and independently’. The nurses also responded appropriately to a significant drop in Mr E’s weight on 16 January by referring him to the Trust’s dietetics service the following day.
78. Whilst Mr E’s food charts should have been more closely maintained, the evidence overall indicates that he was appropriately assessed and reviewed for his nutritional needs in line with NICE CG32. There is nothing to indicate Mr E had eaten little or nothing for five days or longer, which would have prompted additional nutrition support, and the evidence we do have indicates he was eating and drinking ‘fairly well’. Therefore, the evidence indicates that his nutrition support was in line with NICE guideline CG32, and the Trust has already apologised for the fact it should have kept better records of what he ate, and how much.
79. In addition, although Mr E lost weight, this was more likely than not a loss of fluid due to him being treated for fluid overload. When he lost a significant amount of weight in a short period, he was promptly referred to the Trust’s dietetics team.
80. With regards to Mr E’s hydration, he was assessed by the nursing team as being able to manage his hydration independently on 3 January. This was in line with the NMC’s future nurses guidance, as the nurses had assessed his hydration needs and considered whether he needed help with this.
81. The clinicians’ reviews on 4 and 5 January did not identify dehydration as a concern. His hydration needs were reviewed again by the nursing team on 8 January, who noted he remained able to independently maintain his hydration. Reviews by physicians on 9 and 10 January did not highlight any concern about hydration levels or need for intervention.
82. On 11 January the heart failure service reviewed Mr E and recommended he have 1.5 to 2 litres of fluid per day to avoid dehydration, but did not recommend any monitoring of this.
83. On 12 January a physician associate documented that Mr E’s urine appeared to be dark and that this may be due to dehydration. The associate documented a discussion with Mr E where they advised him that he needed to drink more fluid to avoid becoming dehydrated. The nursing notes the same day reflect the team was encouraging him to drink fluids, which appears appropriate given he was able to manage his own hydration independently.
84. A review from a consultant clinician on 13 January did not document any concerns about dehydration, and a further review by the nurses on 15 January found that Mr E was independent with managing his hydration. A clinician review documented on 17 January that Mr E told them he was ‘drinking lots of water and juices’.
85. The evidence indicates that the nursing team appropriately assessed Mr E’s need for support with hydration and concluded he was able to maintain his hydration independently. This meant there was no indication his intake needed to be monitored. Similarly, the different clinicians who reviewed Mr E throughout his stay did not identify concerns about dehydration, and did not recommend any monitoring of his fluid intake. He appears to have been managing his fluid intake independently, with encouragement from the nursing team, up until his death on 17 January. This appears to be in line with the NMC’s future nurses guidance.
86. Regarding his personal hygiene, in line with the NMC’s future nurses guidelines the nurses assessed his ability to attend to his personal hygiene on 4 January and noted he was independent, but needed assistance. This remained the same when reassessed on 8 and 15 January.
87. Mr E was assessed as continent, and had no documented instances of incontinence during his admission, which meant he did not require continence care. He was documented as able to move independently around his bedside up until his date of death, and the nurses documented that he could mainly wash himself if given the bowl and soap required. The nurses documented that they had provided a call bell and told Mr E how to ask for help with washing himself.
88. There are multiple documented accounts of assisting Mr E with washing on within the clinical notes and he was able to use the call bell to ask for assistance with this when required. As Mr E could wash independently, and had mental capacity, the nurses would have relied upon him to ask for support with his personal hygiene. The evidence indicates that when asked, he was given help to attend to his hygiene. The evidence, therefore, indicates that Mr E’s personal hygiene needs were assessed and managed in line with the NMC’s future nurses guidance.
Dietetics referral 89. The family are concerned that the Trust did not follow the nutritional plan outlined by the Trust’s dietetics team.
90. The evidence does not indicate there was a nutritional plan formulated by the Trust’s dietetics team. The nursing staff referred Mr E to the dietetics team on 17 January due to a sudden loss of weight; however, this was declined because Mr E, sadly, died before they could formulate an assessment. Therefore, we cannot conclude the Trust failed to follow a nutritional plan from the dietetics team.
DNACPR 91. Guidance published by the Resuscitation Council (decisions related to cardiopulmonary resuscitation) outlines what doctors should do to communicate with patients and their families about DNACPR decisions.
92. This guidance is clear that decisions around DNACPR are made by the responsible clinicians, and patients/their family do not have the right to demand treatment that doctors think would not be clinically appropriate. It is also not necessary to obtain the consent of the patient or their family to implement a decision that a person should not be resuscitated.
93. However, the guidance is also clear that clinicians should communicate the reasons for the DNACPR clearly to the patient and take account of their views when making this decision, including, where appropriate, the patient’s family. The guidance states there should be clear, timely, accurate, and honest communication with the patient and those close to them (unless they do not consent to sharing this) about a DNACPR decision.
94. The physicians caring for Mr E documented clear communication with him about the DNACPR decision. He had mental capacity and so it was appropriate for the doctors to have these discussions with him in the first instance.
95. The need for a conversation about resuscitation was first documented in the ED, with a doctor recording they raised the matter with Mr E. Following this, on 4 January, a doctor documented a detailed conversation with Mr E about resuscitation. They clearly documented a discussion about the clinical rationale for not resuscitating him, and Mr E’s views of this. He expressed a wish not to be resuscitated. This documentation indicates the discussion held was in line with the guidance from the Resuscitation Council, which states that the reasons for the decision must be explained to the patient and their views must be taken into account.
96. Following this, the physicians caring for Mr E clearly documented a need to update his family about the DNACPR on the following dates:
• On 4 January a physician documented the need to update Mr E’s family about the DNACPR decision.
• On 5 January the same physician documented the need to update the family on the DNACPR decision again.
• The ward round entry for 5 January also documented the need to update the family on the DNCPR decision.
97. There is no evidence that the family were ever updated on the DNACPR decision by the clinicians. This was not in line with the guidance from the Resuscitation Council, which is clear that the physicians should have communicated the reasons for the DNACPR to those close to Mr E, unless it was not appropriate to do so. There is nothing to indicate this would not have been appropriate. This was important information that they needed to know, and this indicates a failing in the communication about the DNACPR decision.
98. In its response to Mrs O’s complaint, dated 25 July 2022, the Trust acknowledged that it did not communicate with the family about the DNACPR. It apologised for this and committed to discussing this further with the wider clinical team.
99. We consider this appears sufficient to put right the impact of what went wrong. This is because the DNACPR discussion with Mr E was very well documented, and the RESPECT form was completed to a good standard at that time. There is nothing to indicate the decision itself was flawed, and the RESPECT form aligned with Mr E’s wishes. The communication failing, therefore, an instance of poor service that had no wider clinical impact. We recognise that this poor communication caused distress to his family. Our Severity of Injustice Scale says that in such circumstances an apology is sufficient to put things right.
Visiting 100. Our nurse adviser explained that in January 2022 visiting rules were determined locally, based on outbreaks of COVID-19 cases in the community. Therefore, we asked the Trust for its visiting policy as of January 2022.
101. The Trust’s visiting policy for January 2022 states that due to the increased transmissibility of the omicron variant of COVID-19, it had reviewed its previous guidance and restricted in-person visits to special circumstances. The guidance also states it had established the use of electronic devices (iPods and iPads) for use in all ward areas to enable video calls between patients and their loved ones.
102. The visiting policy allowed for carers to attend to provide personal care, or support individuals with dementia or learning disabilities as calming presence. It also allowed for visitors to attend patients who were at the end of their life, and pregnant people were able to have someone attend appointments with them. The policy defers responsibility for managing visitor numbers to the wards, and advises the ward was responsible for identifying how many visitors it was safe to have on the ward. Visitors were to be asked screening questions and had to prebook visits.
103. The policy in place at the time appears to restrict visitors to the Trust, as outlined by the Trust in its complaint response dated 25 July 2022. This meant visiting was restricted to certain circumstances, which Mr E did not meet. Therefore, it appears to have been in line with the Trust’s policy to restrict visiting when Mr E was not on an end-of-life care pathway.
104. However, the Trust’s policy states it should have facilitated additional aids to communication for those patients who could not have visitors under the policy, such as technology to facilitate video calls. The Trust appears to have failed to do this, which was not in line with its policy. This was important for managing the distress to both Mr E and his family at being unable to visit him in hospital, and the failure to facilitate this appears to fall so far short of the Trust’s policy that it could amount to service failure.
105. The Trust has not yet acknowledged that this happened, with its response simply acknowledging that all wards had been provided with video equipment as an alternative to visiting. It has also not yet taken steps to put this right.
106. The impact of this was that the family were not able to have visual communication with Mr E before his death and we understand this will have made the bereavement more difficult. Knowing they could have had more meaningful communication with him prior to his death indicates an injustice to them.
107. We do not consider it proportionate to ask the Trust to undertake systemic service improvements to this area as COVID-19 visiting restrictions no longer apply, and there is nothing to suggest they will be reintroduced in the same way in the near future. The Trust has agreed to apologise for this, in addition to the apologies already offered for poor communication. We consider this is sufficient to put things right, based on the outcomes the family is looking for, in line with our Severity of Injustice Scale.
After death care 108. Our nurse adviser explained that the Trust should have followed NHS England’s guidance for staff responsible for care after death. The guidance is clear that registered nurses are responsible for after death care. In line with this guidance the Trust should have:
• carried out after-death personal care within two to four hours • sensitively informed others in the immediate environment that Mr E had died • packed his personal belongings showing consideration for the feelings of his family members and discussed any soiled clothing sensitively with them • provided written information on the after-death process to his family • let the family sit with him and offered support • closed his eyes, or explained this was not possible to his family sensitively before viewing • supported his jaw by placing a pillow or rolled up towel, removing this before the family viewed his body.
109. According to the nursing notes, Mr E was found unresponsive at 10.36pm. His death was certified at 10.50pm. A nursing record completed at 11.03pm reflects that the nurses had contacted his family.
110. At 2.36am a nurse recorded that four members of Mr E’s family came to the ward to view his body. The notes reflect they were very upset and did not want to speak with the doctors that evening. The family asked if they could close Mr E’s mouth for his dignity and the nurse documented they had tried to do this, without success, but would keep trying. They also documented that they provided the bereavement booklet, but the family declined further support with this.
111. The after-death checklist was completed at 5.47am. The nurse recorded they had completed the last offices, and this included the actions outlined in the NHS England guidance.
112. When the family complained about Mr E’s after-death care, they were concerned that his mouth was left open and that they were invited to view his body whilst other patients were awake in the beds nearby. They were also very upset that cards and a care package sent by his family had been left unopened, and items of Mr E’s clothing were returned to them soiled.
113. The records indicate his after-death care was appropriate and completed in line with the guidance from NHS England, aside from one concerning issue which we address.
114. We understand it must have been very upsetting for Mr E’s family to see his mouth open when they came to say goodbye to him. The nursing notes indicate that the nurses had been unable to close it. Our nursing adviser explained that this is, sadly, not uncommon and whilst nurses should do everything they can to close a deceased patient’s mouth, the NHS England guidance tells staff not to take more forceful measures because this can be distressing to family members. An open mouth after death is reasonably common, and although very upsetting it does not indicate in and of itself that something went wrong.
115. With regards to Mr E’s body being left in a ward bay with other, living patients, we have a lot of compassion for Mr E’s family regarding this. We understand why this was upsetting for them and why they would want privacy at that time. Unfortunately, there are finite resources within NHS hospitals and there is no requirement in the NHS England guidance to move patients to a private space after death. The guidance does mention that those sharing a space with a deceased patient should be offered support, but there is no requirement to move the deceased patient to a more private area.
116. Our nursing adviser explained that whilst staff should do everything they can to facilitate privacy, that this cannot be guaranteed. Unfortunately, if there are no side rooms available, which must be prioritised for infection control reasons, then it is in line with the guidance for a person to remain in a space where there are other living persons. We do not underestimate how upsetting this was, but this does not indicate a failing in the after-death care provided.
117. With regards to Mr E’s belongings, the evidence from the Trust’s responses to the family’s complaint indicate the nurses failed to pack his belongings with consideration for the feelings of his family and failed to explain that some of his items of clothing were soiled. The Trust has stated that this was unacceptable, and we agree with it that this appears to fall far short of the national guidance.
118. The nurses appear to have given little consideration to the unopened care package or the soiled items and that this could cause his family distress. This should have been considered and the nurses should have had a sensitive conversation with the family about this. Not doing so indicates a distressing oversight in Mr E’s after-death care. The Trust has apologised for this, and this has been fed back to the nursing staff on the ward, including the impact statement from each of Mr E’s family members. This appears to align with what we would expect the Trust to have done, in line with our Severity of Injustice Scale.
119. We note there were also delays in Mr E’s body being transferred to the funeral directors. A review of the internal communications at the Trust indicates this was due to the funeral directors not collecting Mr E in a timely manner, as his paperwork had properly been completed on time.
Complaint handling 120. Mrs O and her family are concerned that the Trust lost part of Mr E’s medical records, that it provided incorrect/conflicting information in its complaint responses, and has still not acknowledged the full extent of what went wrong in his care.
121. Our NHS complaint standards set out a framework for how we expect NHS services to administer complaints. In line with these standards, the Trust should have:
• given open and honest answers as quickly as possible • set out what happened and whether any mistakes were made • fairly reflected the experiences of everyone involved 122. Our Principles of Good Administration also say that organisations should make and retain clear and accurate records. This would include not losing parts of a patient’s medical records.
123. The Trust’s records indicate Mr E’s family made a request for Mr E’s records after they raised a complaint about his care. On 16 May Mrs O contacted the Trust to advise that a number of records were missing from those which had been sent as part of the request. The Trust’s internal emails indicate that on 17 May the complaints team asked that the records team process this request urgently.
124. On 23 May Mrs O emailed the Trust to say nobody had contacted her about the missing records. On 24 May internal emails indicate that the records department could not account for why incomplete medical records had been sent. There are no further emails that indicate more records were sent after the family highlighted the missing records.
125. The Trust’s response of 25 July stated that it understood all records had been sent, but the family replied to this to say this was not correct. This was raised again in the local resolution meeting. It appears from the content of this meeting that the records sent to the family were only the paper records and the Trust had overlooked sending the electronic records. The Trust’s response from this meeting, dated 31 January 2023 does not address this in any detail and simply says that the family feels there are gaps in the documentation.
126. The evidence does indicate that the Trust may have failed to send the full medical records, sending only the paper records, and that this was not resolved by the Trust following the local resolution meeting. However, there is nothing to indicate that these were lost by the Trust. Rather, it appears that the Trust initially failed to recognise that part of the records were held electronically and it then did not ensure these were provided to the family following the local resolution meeting.
127. Whilst this appears to fall short of providing the supporting evidence for open and honest answers to the questions the family had as quickly as possible, there is no indication that these have been lost by the Trust. It is disappointing that the Trust has not acknowledged and apologised for the delays in providing these records; however, as the complaint is that they have been lost, we must conclude there is no indication this happened.
128. With regards to incorrect and/or conflicting information in the complaint responses, this appears to relate to disagreement with the conclusions reached by the Trust. We can only consider the information provided in relation to the matters we have considered, as we do not have the evidence to consider the accuracy of clinical matters we have not put to our advisers.
129. With regards to the response issued on 25 July 2022, this appears to align with the medical evidence in the following areas that we have considered:
• communication – the details appear to align with the medical evidence.
• visiting restrictions – the response aligns with the copy of the Trust’s policy at that time.
• nutrition – the response accurately reflects some of his meals were well documented but others weren’t, which aligns with the medical evidence, and accurately reflects the weights and hydration support provided.
• deterioration – the account of deterioration and the events leading up to Mr E’s death appear to align with the medical evidence and the evidence provided by our independent adviser.
• after death care – the response aligns with the advice from our nurse adviser and the medical records.
• medical records – this does not appear to be accurate.
130. Overall, the response appears to have been accurate, in the main, though we note the Trust did not accurately reflect the issue regarding the medical records. It is unclear why this happened.
131. The response of 31 January 2023 reflected the local resolution meeting and covered a number of the concerns the family had about the accuracy of the prior response. It appears the family disagreed with the Trust’s conclusions, but we have seen no evidence of factual inaccuracy or conflicting information being provided in this response, nor in the recording of the meeting.
132. During the meeting, the Trust, appropriately, were compassionate and allowed the family to raise these concerns, but there was no agreement that the response was inaccurate and the comments addressing these in the response of 31 January appear to align with what we have seen during our consideration.
133. It appears the Trust provided open and honest answers and clearly set out where mistakes had been made. This indicates the responses are accurate and they do not appear to conflict with the medical evidence. This appears to be in line with our NHS Complaint Standards.
134. Finally, we can see nothing to indicate that the Trust has failed to acknowledge mistakes or the full extent of what went wrong. In the areas where things may have gone wrong, the Trust appears to have been open and honest in acknowledging this and proactive in taking steps to put things right. This appears to be in line with our NHS Complaint Standards.
135. We recognise that this was a very difficult experience for Mr E and his family, compounded by some delays in facilitating his discharge and his sudden and unexpected death. The visiting restrictions in place at the time, and the apparent failure to provide video communication technology, likely made this unexpected death much more distressing for his family. It is natural to feel very worried when a family member is raising concerns about their care whilst in hospital, and when a person dies soon afterwards it is understandable that the family would have serious concerns about what happened. We hope this independent review helps to reassure Mrs O and her family that there is no indication that Mr E’s care fell far below the expected standards and that his death appears to have been sudden and unexpected.