Nutrition
14. Mrs H complains that her son had no form of nourishment for several days. She says he could only drink a particular flavour of protein shake and this was unavailable for around four days. She believes if nurses had provided the correct protein shakes her son may not have needed a feeding tube.
15. The Nutrition Guideline explains how clinicians should support people in hospital in terms of nutrition. It says they should screen patients for malnutrition and the risk of malnutrition on admission and then each week afterwards. Those at risk of malnutrition have eaten little or nothing more than five days and are likely to eat little or nothing for five days or longer. It says they should consider using nutrition support for people who need it.
16. The clinical records show nurses assessed Mr R’s risk of malnutrition on 22 August 2022. They established he was at high risk of malnutrition. They referred him to a dietician who assessed him on 26 August and confirmed he was at high risk.
17. The dietician noted that doctors questioned whether Mr R needed intravenous feeding. The dietician said this was not appropriate at that stage. They noted Mr R had lost a significant amount of weight and needed nutritional support. They said nurses should encourage Mr R to eat as much as possible, use food charts and offer him nutritional supplements. They recommended nurses should monitor Mr R’s weight. If the situation did not improve, they suggested clinicians should consider using a feeding tube.
18. The clinical records include food charts. These show Mr R was generally able to eat and drink normally until 31 August 2022. From that point onwards the amount he ate was irregular. On some days he ate all his meals, while on others he refused all nutrition. Nurses reassessed his risk of malnutrition on 3 September and noted he was still at high risk. There were also two occasions over the following three weeks when nurses do not appear to have completed any food charts. Doctors were concerned Mr R was not getting the nutrition he needed.
19. On 22 September 2022 clinicians decided to insert a feeding tube to support Mr R. A dietician reviewed Mr R again on 23 September. They noted the feeding tube should only be used as a short-term measure to improve Mr R’s intake and should not replace eating and drinking. The dietician said nurses should attempt to weigh Mr R and implied he had previously rejected nursing attempts to weigh him. By 25 September doctors decided he should be ‘nil by mouth’ and TPN started two days later.
20. Nurses assessed Mr R’s risk of malnutrition and monitored this throughout. The Nursing Adviser noted he often refused assistance, despite his reduced intake. While there are some gaps in the record our view is there is sufficient evidence to suggest nurses made appropriate attempts to support Mr R with nutrition.
21. The Nursing Adviser said nurses cannot control the availability of specific flavours of protein drinks. They would be expected to communicate with the patient about the unavailability of drinks and offer the best alternatives. There is no reference to any difficulty obtaining the preferred flavour in the clinical records, and the flavour of drinks would not usually be recorded. Nurses offered the supplements each day and there is only one record of Mr R refusing to take it. That said we do not dispute Mrs H’s recollection that her son’s preferred flavour of drink was unavailable.
22. We find nurses followed the Nutrition Guideline. We can see Mrs H was concerned about her son’s nutrition. Clinicians were aware of his reduced nutrition and the evidence suggests they tried to support him. We recognise Mrs H thinks they should have done more, including providing his preferred flavour of protein shake. We cannot say what happened fell below the relevant standards.
Feeding tube
23. Mrs H says clinicians should not have given her son a feeding tube because he was malnourished and at risk of perforation. She also says the way the clinician fitted the feeding tube led to his death. She believes alternative feeding methods should have been considered.
24. The Nutrition Guideline explains that healthcare professionals should consider using a feeding tube for people who are malnourished or at risk of malnutrition but whose gastrointestinal tract (gut) is functioning. The position of all tubes should be confirmed after placement and before use either by testing the pH (a measurement of acidity) of the tube’s contents or carrying out an Xray.
25. We asked the Medical Adviser to explain the differences between TPN (total parenteral nutrition) and NG (nasogastric) feeding.
26. TPN is nutrition given directly into a large vein. It Is used when it is not possible for someone to digest food in the gut, but it carries higher risks. These include the risk of sepsis, blood clots, liver failure and chemical imbalances. It also reduces the body’s ability to fight infection.
27. NG feeding involves placing a fine-bore tube through the nose and into the stomach. It is considered safer as it avoids feeding directly into a large vein and uses the gut to absorb nutrients. It is used when intake by the mouth is not enough to meet someone’s needs, for example when they have poor appetite or cannot swallow easily.
28. We have already referred above to the clinical records relating to Mr R’s nutrition. NG feeding was considered from 26 August 2022, although a tube was first inserted on 22 September. By that stage Mr R was not eating because of nausea. When feeding started Mr R said he felt like he was choking so clinicians stopped it. He then became increasingly unwell, and a scan showed the tip of the feeding tube had perforated the wall of his stomach.
29. The Medical Adviser told us the evidence showed Mr R was malnourished at the time clinicians decided to insert the feeding tube. This was a safer and better alternative to TPN. The Medical Adviser said there was no evidence of an issue with the absorption of nutrients that would have meant a feeding tube being unsuitable for Mr R.
30. The Medical Adviser also noted that doctors carried out an X-ray before using the feeding tube to confirm its position. A radiologist reported the tube was in a ‘satisfactory’ position. There was nothing to suggest that the tube had perforated Mr R’s stomach lining before it was used. Doctors were only able to confirm the perforation following a CT scan on 25 September 2022.
31. We find clinicians followed the Nutrition Guideline when inserting a feeding tube for Mr R and testing whether it was in the correct position. Unfortunately, doctors later found the tube had perforated his stomach lining. This is a rare but recognised risk of using an NG feeding tube. We cannot say this was a failing by the clinician who inserted the tube. We appreciate how upsetting it is for Mrs H to know this incident had such a serious impact on her son. We hope she is reassured that we have looked into the incident and can see no evidence the clinicians fell below the relevant standards.
Surgery decision
32. Mrs H recalled doctors saying her son would have been unlikely to survive surgery. She says she and her son were told there was a 98 per cent chance of him dying during the procedure. She has since found there was an 80 per cent chance of him surviving. The Trust advised her that his chance of major morbidity was 98 per cent, meaning the surgery would likely have been unsuccessful, leaving her son with a major illness.
33. Mrs H says contradictory responses from the Trust have left her questioning whether surgery should have taken place.
34. 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.
35. The clinical records show doctors were considering whether Mr R should have surgery from 26 September 2022. Surgeons did not consider surgery was appropriate. This was because of the risks associated with the procedure. They planned to continue with conservative management and a possible transfer to a different hospital which had a specialist gastroenterology ward. Doctors continued to assess Mr R’s treatment but did not change their views about surgery.
36. The Surgical Adviser noted there is nothing in the clinical records about a calculation relating to the probability of Mr R surviving surgery. They said there are tools available to calculate the risks. Based on Mr R’s blood test results and observations on 26 September 2022, his predicted risk of dying would have been in the region of 66 per cent. By 28 September it would have been around 49 per cent.
37. The Surgical Adviser said there is no doubt that the surgery in question would have been high risk. This was because of Mr R’s multiple illnesses at that point. The Surgical Adviser said it was appropriate for doctors to attempt to manage the condition conservatively rather than attempting surgery.
38. The Medical Adviser said Mr R had several medical problems that contributed to his death. It is likely, following an infection in his digestive system, he developed severe Crohn’s disease. This increased the risk of forming blood clots, causing iron deficiency anaemia and protein loss with very low levels of albumin (a protein which helps the body transport fluids).
39. Mr R developed a large clot and pulmonary embolism (a blood clot in the lungs). The inflammatory bowel disease left him weak and malnourished, and he failed to improve despite nutritional support and medication. The feeding tube added to his problems because it led to a stomach perforation and pneumonia. The perforation probably happened because of the inflammatory bowel disease and his weakened state. The Medical Adviser said the evidence suggested Mr R died because of severe illness and not as a result of medical failings.
40. We find doctors followed Good Medical Practice when they decided not to arrange surgery for Mr R. We can see how confusing it must have been for Mrs H in terms of the different statistics the Trust has provided. The records show doctors based their decisions on appropriate assessments of Mr R, which included examinations, investigations, and consideration of his history. They arranged timely and appropriate treatment and were right not to arrange surgery.
41. We recognise how shocking it must have been for Mrs H to witness her son’s illness and death at such a young age. It is understandable that she has questioned aspects of the care and treatment healthcare professionals at the Hospital gave to him in the last few weeks of his life. We have seen no evidence that clinicians fell below the required standards in the areas we have investigated.
42. We do not uphold Mrs H’s complaint.